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Collaboration works to improve stroke outcomes in Ghana
World Report
Collaboration works to improve stroke outcomes in Ghana A 3-year collaboration between health professionals in the UK and Ghana to improve stroke care is changing day-to-day management and improving multidisciplinary working. Kelly Morris reports.
www.thelancet.com Vol 377 May 14, 2011
points involved in stroke admissions”. Although not ideal, this means that the initial focus of the collaboration is on developing and sustaining core aspects of day-to-day stroke care.
“‘I thought I would be seeing lots of conditions that I wouldn’t have routinely managed before, but I was struck by how some 20% of patients...had had strokes...’” The collaboration was founded by Claire Spice, now consultant in elderly care at Portsmouth Hospital NHS Trust, UK, and Hetty Asare, consultant physician at Ridge Hospital, Accra, Ghana. Spice had moved to Ghana in 2004 and then started working as a consultant physician at Ridge Hospital. “I thought I would be seeing lots of conditions that I wouldn’t have routinely managed before, but I was struck by how some 20% of patients or so coming through the medical wards had had strokes, and that was just the ones who were admitted”, Spice recalls. In Ghana, which is a relatively affluent African country, only the most severely affected stroke patients can be admitted because of a lack of beds. Therapists are also scarce. Additionally, the outcome for stroke is seen as “somewhat inevitable”, Spice explains, “with many other conditions vying for staff time”. On her return to the UK, Spice proposed the collaboration to Asare, who was enthusiastic about the potential for education and improving management, and to Jane Williams, consultant nurse in stroke from Portsmouth Hospitals NHS Trust, who identified a group of skilled professionals in the UK. Since then, the UK group has made three visits to Ghana, to exchange
skills, information, and to open up interprofessional discussion on current and best practice. In March, 2009, the initial visiting team consisted of three physiotherapists, an occupational therapist, a speech and language therapist, and a stroke physician, who gained insights into current practices in stroke care in Ghana, then facilitated workshops for health professionals from inpatient and community settings. “The issues raised in the workshops have been followed up on-the-ground with practical training and individual engagement”, explains Anna Gould, neurophysiotherapist at Salisbury Hospital, Wiltshire, UK. “This has had the biggest impact in terms of finding solutions and sustaining change”, she notes. Clinical development has included the introduction of swallowing assessments, dietetic input, and the correct positioning and handling of patients to improve recovery and prevent secondary complications. The latter task has been especially challenging, says Gould, in view of the lack of moveable beds, appropriate chairs, and other equipment. A major input came from neurophysiotherapist Emily Rogers from
See Editorial page 1625 See Series pages 1681 and 1693 For the International Journal of Stroke paper see DOI:10.1111/j.17474949.2010.00571.x
Clare Gordon
Myriam was unable to move, speak, or swallow; Stella’s arm was affected by severe spasticity despite a prosthesis; Francis required nasogastric feeding; and Emanuel wanted to function better at home. Different clinical pictures, but in common, all these patients had had strokes and were reviewed as part of an international development partnership to improve stroke care (panel), based at Korle Bu Teaching Hospital in Accra, Ghana. The experiences of patients and staff involved show how multidisciplinary working between health professionals from different settings and perspectives can improve stroke care in many dimensions, from acute positioning to neurorehabilitation, and from managing patient expectations of recovery to delivering palliative care. In April, teams from Wessex, UK, and Accra, Ghana, published the first details of the collaboration in the International Journal of Stroke. In Greater Accra, stroke mortality is second only to that from malaria, and is a major burden not only on patients and family, but also on staff and the health-care system. So, the first strategic priority identified was development of a multidisciplinary stroke unit at Korle Bu, linked with community rehabilitation. However, says Korle Bu consultant Albert Akpalu, who was the only neurologist in the hospital at the time the partnership started, “institutional stroke units are a foreign idea as far as most administrators are concerned”. The result, he says, is failure of political and institutional backing. Speaking to The Lancet after discussion with his team, Akpalu relates that “we are trying to overcome this by building a model or a unit within the department, and by scaling up training of staff at all entry
UK speech therapist Sarah Easton talks to students at Korle Bu Teaching Hospital
1639
World Report
Panel: Project partners in the UK-Ghana stroke collaboration UK link coordinators Claire Spice (consultant geriatrician, Queen Alexandra Hospital, Portsmouth); Sarah Easton (speech and language therapist, Queen Alexandra Hospital, Portsmouth); Emily Rogers (neurophysiotherapist, Glenside Manor Healthcare Services, Salisbury); Anna Gould (neurophysiotherapist, Salisbury District Hospital, Salisbury); Louise Johnson (neurophysiotherapist, Christchurch Hospital, Christchurch); Clare Gordon (consultant nurse, stroke care, Royal Bournemouth and Christchurch Hospitals, Bournemouth); Colleen Lloyd (stroke liaison nurse, Portsmouth Hospitals NHS Trust, Portsmouth) Ghana link coordinators Albert Akpalu (consultant neurologist, Korle Bu Teaching Hospital, Accra); Hetty Asare (consultant in medicine, Ridge Regional Hospital, Accra); Faustine Okine (identified stroke lead for nursing, Korle Bu Teaching Hospital, Accra); Cynthia Cudjoe (identified stroke lead for physiotherapy, Korle Bu Teaching Hospital, Accra); Kwadwo Nkromah (identified stroke lead for medicine, Korle Bu Teaching Hospital, Accra)
Glenside Manor Healthcare Services, Salisbury, UK, who led the second visit and extended her stay for 2 months. “Initially, it was very difficult not to try and directly apply UK methods into the Ghanaian health-care environment”, Rogers told The Lancet. “It took time to identify what are differences in purely stroke care rather than the overall structure within which it sits.” Each barrier identified became part of a larger issue, she says, which meant “a focus on very small and specific goals was absolutely key”. Support from senior staff in the UK and Ghana, and an independent, voluntary consultant, Alexandra Tobin of Alexandra Tobin & Partners, UK, was crucial, says Rogers. The major recommendations from the first two visits were: to improve communication and establish stroke teams—for wards, polyclinics, and the emergency room; encourage multidisciplinary working between doctors, nurses, and therapists; foster ongoing education and training for all staff involved with stroke patients; and improve equipment needs, particularly for positioning. Establishing a stroke unit at Korle Bu Teaching Hospital remains the ideal goal, and Peter Langhorne, professor 1640
of stroke care at the University of Glasgow, UK, comments that “establishing functioning stroke units is very challenging but, if possible, stroke-unit care promises the greatest population impact of any stroke treatment”. Tobin, an independent quality improvement consultant who coached and supported the UK team, comments that “in fact, much can be achieved by improving basic care first”. Spice notes that this approach has helped to identify and start implementing “building blocks” for future development. With medical, nursing, and physiotherapy clinical leads now identified, and link nurses in polyclinics and the emergency room, the nursing and physiotherapy directorates are essential for a paradigm shift towards a multidisciplinary approach, says Akpalu. “We are now looking to the future to introduce specialised services by stroke nurses and physiotherapists in the hospital and community, taking away the emphasis from the traditional doctor-based care”, he explains. Previously, says Spice, “therapists and nurses were not aware that they might have something to offer, and now they see that they can have leadership and take primary roles in management”. Now, she relates, these changes have been broadly welcomed. The Ghanaian multidisciplinary team now meets weekly, and a core outcome has been development of an acute stroke checklist by the Ghanaian team, which is now being piloted. Data gathering, audit, and training are ongoing, and Korle Bu staff are advocating for, and disseminating knowledge of, best practice more widely. The collaboration has taken more time and commitment than expected, and Langhorne comments that “this initiative is very challenging but very worthwhile”. Participants describe the partnership as mutually beneficial, sharing experiences of the challenges of stroke care, learning how to overcome barriers, and to implement
change through clear, agreed goals and open communication. Rogers stresses how “changes in awareness have been big, changes in thinking have been medium, and changes in practice have been very small”. But, the partnership is working because all partners have been involved from the outset, and have adapted to local environment and culture. “The bane of several partnerships is that ideas are imported/ imposed on developing countries which eventually fail or become white elephants”, says Akpalu, whereas this collaboration has a strong mutual sense of ownership and respect, with “infectious enthusiasm and the results of improvement in stroke care”, he notes. The wider challenge continues to be funding—for the collaboration and from donors and the Ghanaian Government to support stroke care nationally. More advocacy and lobbying are needed in parliament and at the ministry of health to give non-communicable diseases, especially stroke, greater attention as compared with the heavy investments in communicable diseases, say the Ghanaian team. “It is too early to quantify the impact of the work carried out”, comments Louise Johnson, neurophysiotherapist at Christchurch Hospital, UK. However, the learning gained through the partnership can provide insights that are useful to other groups, on developing and maintaining clinical skills, nurturing leadership, and how to organise service delivery from the ground up—an approach that works in the UK too, notes Tobin. Johnson concludes: “If there are sufficient pressures and motivation for change from the organisation, and from those offering external support, then it is certainly possible to bring about local improvements to stroke care without significant resource investment.”
Kelly Morris www.thelancet.com Vol 377 May 14, 2011
Collaboration works to improve stroke outcomes in Ghana A 3-year collaboration between health professionals in the UK and Ghana to improve stroke care is changing day-to-day management and improving multidisciplinary working. Kelly Morris reports.
www.thelancet.com Vol 377 May 14, 2011
points involved in stroke admissions”. Although not ideal, this means that the initial focus of the collaboration is on developing and sustaining core aspects of day-to-day stroke care.
“‘I thought I would be seeing lots of conditions that I wouldn’t have routinely managed before, but I was struck by how some 20% of patients...had had strokes...’” The collaboration was founded by Claire Spice, now consultant in elderly care at Portsmouth Hospital NHS Trust, UK, and Hetty Asare, consultant physician at Ridge Hospital, Accra, Ghana. Spice had moved to Ghana in 2004 and then started working as a consultant physician at Ridge Hospital. “I thought I would be seeing lots of conditions that I wouldn’t have routinely managed before, but I was struck by how some 20% of patients or so coming through the medical wards had had strokes, and that was just the ones who were admitted”, Spice recalls. In Ghana, which is a relatively affluent African country, only the most severely affected stroke patients can be admitted because of a lack of beds. Therapists are also scarce. Additionally, the outcome for stroke is seen as “somewhat inevitable”, Spice explains, “with many other conditions vying for staff time”. On her return to the UK, Spice proposed the collaboration to Asare, who was enthusiastic about the potential for education and improving management, and to Jane Williams, consultant nurse in stroke from Portsmouth Hospitals NHS Trust, who identified a group of skilled professionals in the UK. Since then, the UK group has made three visits to Ghana, to exchange
skills, information, and to open up interprofessional discussion on current and best practice. In March, 2009, the initial visiting team consisted of three physiotherapists, an occupational therapist, a speech and language therapist, and a stroke physician, who gained insights into current practices in stroke care in Ghana, then facilitated workshops for health professionals from inpatient and community settings. “The issues raised in the workshops have been followed up on-the-ground with practical training and individual engagement”, explains Anna Gould, neurophysiotherapist at Salisbury Hospital, Wiltshire, UK. “This has had the biggest impact in terms of finding solutions and sustaining change”, she notes. Clinical development has included the introduction of swallowing assessments, dietetic input, and the correct positioning and handling of patients to improve recovery and prevent secondary complications. The latter task has been especially challenging, says Gould, in view of the lack of moveable beds, appropriate chairs, and other equipment. A major input came from neurophysiotherapist Emily Rogers from
See Editorial page 1625 See Series pages 1681 and 1693 For the International Journal of Stroke paper see DOI:10.1111/j.17474949.2010.00571.x
Clare Gordon
Myriam was unable to move, speak, or swallow; Stella’s arm was affected by severe spasticity despite a prosthesis; Francis required nasogastric feeding; and Emanuel wanted to function better at home. Different clinical pictures, but in common, all these patients had had strokes and were reviewed as part of an international development partnership to improve stroke care (panel), based at Korle Bu Teaching Hospital in Accra, Ghana. The experiences of patients and staff involved show how multidisciplinary working between health professionals from different settings and perspectives can improve stroke care in many dimensions, from acute positioning to neurorehabilitation, and from managing patient expectations of recovery to delivering palliative care. In April, teams from Wessex, UK, and Accra, Ghana, published the first details of the collaboration in the International Journal of Stroke. In Greater Accra, stroke mortality is second only to that from malaria, and is a major burden not only on patients and family, but also on staff and the health-care system. So, the first strategic priority identified was development of a multidisciplinary stroke unit at Korle Bu, linked with community rehabilitation. However, says Korle Bu consultant Albert Akpalu, who was the only neurologist in the hospital at the time the partnership started, “institutional stroke units are a foreign idea as far as most administrators are concerned”. The result, he says, is failure of political and institutional backing. Speaking to The Lancet after discussion with his team, Akpalu relates that “we are trying to overcome this by building a model or a unit within the department, and by scaling up training of staff at all entry
UK speech therapist Sarah Easton talks to students at Korle Bu Teaching Hospital
1639
World Report
Panel: Project partners in the UK-Ghana stroke collaboration UK link coordinators Claire Spice (consultant geriatrician, Queen Alexandra Hospital, Portsmouth); Sarah Easton (speech and language therapist, Queen Alexandra Hospital, Portsmouth); Emily Rogers (neurophysiotherapist, Glenside Manor Healthcare Services, Salisbury); Anna Gould (neurophysiotherapist, Salisbury District Hospital, Salisbury); Louise Johnson (neurophysiotherapist, Christchurch Hospital, Christchurch); Clare Gordon (consultant nurse, stroke care, Royal Bournemouth and Christchurch Hospitals, Bournemouth); Colleen Lloyd (stroke liaison nurse, Portsmouth Hospitals NHS Trust, Portsmouth) Ghana link coordinators Albert Akpalu (consultant neurologist, Korle Bu Teaching Hospital, Accra); Hetty Asare (consultant in medicine, Ridge Regional Hospital, Accra); Faustine Okine (identified stroke lead for nursing, Korle Bu Teaching Hospital, Accra); Cynthia Cudjoe (identified stroke lead for physiotherapy, Korle Bu Teaching Hospital, Accra); Kwadwo Nkromah (identified stroke lead for medicine, Korle Bu Teaching Hospital, Accra)
Glenside Manor Healthcare Services, Salisbury, UK, who led the second visit and extended her stay for 2 months. “Initially, it was very difficult not to try and directly apply UK methods into the Ghanaian health-care environment”, Rogers told The Lancet. “It took time to identify what are differences in purely stroke care rather than the overall structure within which it sits.” Each barrier identified became part of a larger issue, she says, which meant “a focus on very small and specific goals was absolutely key”. Support from senior staff in the UK and Ghana, and an independent, voluntary consultant, Alexandra Tobin of Alexandra Tobin & Partners, UK, was crucial, says Rogers. The major recommendations from the first two visits were: to improve communication and establish stroke teams—for wards, polyclinics, and the emergency room; encourage multidisciplinary working between doctors, nurses, and therapists; foster ongoing education and training for all staff involved with stroke patients; and improve equipment needs, particularly for positioning. Establishing a stroke unit at Korle Bu Teaching Hospital remains the ideal goal, and Peter Langhorne, professor 1640
of stroke care at the University of Glasgow, UK, comments that “establishing functioning stroke units is very challenging but, if possible, stroke-unit care promises the greatest population impact of any stroke treatment”. Tobin, an independent quality improvement consultant who coached and supported the UK team, comments that “in fact, much can be achieved by improving basic care first”. Spice notes that this approach has helped to identify and start implementing “building blocks” for future development. With medical, nursing, and physiotherapy clinical leads now identified, and link nurses in polyclinics and the emergency room, the nursing and physiotherapy directorates are essential for a paradigm shift towards a multidisciplinary approach, says Akpalu. “We are now looking to the future to introduce specialised services by stroke nurses and physiotherapists in the hospital and community, taking away the emphasis from the traditional doctor-based care”, he explains. Previously, says Spice, “therapists and nurses were not aware that they might have something to offer, and now they see that they can have leadership and take primary roles in management”. Now, she relates, these changes have been broadly welcomed. The Ghanaian multidisciplinary team now meets weekly, and a core outcome has been development of an acute stroke checklist by the Ghanaian team, which is now being piloted. Data gathering, audit, and training are ongoing, and Korle Bu staff are advocating for, and disseminating knowledge of, best practice more widely. The collaboration has taken more time and commitment than expected, and Langhorne comments that “this initiative is very challenging but very worthwhile”. Participants describe the partnership as mutually beneficial, sharing experiences of the challenges of stroke care, learning how to overcome barriers, and to implement
change through clear, agreed goals and open communication. Rogers stresses how “changes in awareness have been big, changes in thinking have been medium, and changes in practice have been very small”. But, the partnership is working because all partners have been involved from the outset, and have adapted to local environment and culture. “The bane of several partnerships is that ideas are imported/ imposed on developing countries which eventually fail or become white elephants”, says Akpalu, whereas this collaboration has a strong mutual sense of ownership and respect, with “infectious enthusiasm and the results of improvement in stroke care”, he notes. The wider challenge continues to be funding—for the collaboration and from donors and the Ghanaian Government to support stroke care nationally. More advocacy and lobbying are needed in parliament and at the ministry of health to give non-communicable diseases, especially stroke, greater attention as compared with the heavy investments in communicable diseases, say the Ghanaian team. “It is too early to quantify the impact of the work carried out”, comments Louise Johnson, neurophysiotherapist at Christchurch Hospital, UK. However, the learning gained through the partnership can provide insights that are useful to other groups, on developing and maintaining clinical skills, nurturing leadership, and how to organise service delivery from the ground up—an approach that works in the UK too, notes Tobin. Johnson concludes: “If there are sufficient pressures and motivation for change from the organisation, and from those offering external support, then it is certainly possible to bring about local improvements to stroke care without significant resource investment.”
Kelly Morris www.thelancet.com Vol 377 May 14, 2011