Managing acute ischaemic stroke in a small island developing state: meeting the guidelines in Barbados.

BACKGROUND: We describe hospital-based management of acute ischaemic stroke patients in 2010-2013 in Barbados, by comparing documented treatment given in the single tertiary public hospital with international guideline recommendations. METHODS: Evidence-based stroke management guidelines were identified through a systematic literature search. Comparisons were made between these guidelines and documented diagnostic practice (all strokes) and prescribed medication (ischaemic stroke only), using a combination of key informant interviews and national stroke registry data for 2010-2013. RESULTS: Several published international guidelines for the acute management of ischaemic stroke recommended patient management in a dedicated stroke unit or nearest hospital specialised in stroke care. Further, patients should receive clinical diagnosis, CT brain scan, specialist evaluation by a multidisciplinary team and, if eligible, thrombolysis with alteplase within 3-3.5 h of symptom onset. Subsequent secondary prophylaxis, with a platelet aggregation inhibitor and a statin was advised. Barbados had no stroke unit or stroke team, and no official protocol for acute stroke management during the study period. Most of the 1735 stroke patients were managed by emergency physicians at presentation; if admitted, they were managed on general medical wards. Most had a CT scan (1646; 94.9%). Of 1406 registered ischaemic stroke patients, only 6 (0.4%) had been thrombolysed, 521 (37.1%) received aspirin within 24 h of admission and 670 (47.7%) were prescribed aspirin on discharge. CONCLUSIONS: Acute ischaemic stroke diagnosis was consistent with international recommendations, although this was less evident for treatment. While acknowledging the difficulty in implementing international guidelines in a low-resource setting, there is scope for improvement in acute ischaemic stroke management and/or its documentation in Barbados. A stroke unit was established in August 2013 and written clinical protocols for acute stroke care were in development at the time of the study; future registry data will evaluate their impact. Our findings have implications for other low-resource settings with high stroke burden.

Predicting the burden of acute myocardial infarction in a country with limited resources: combining data from routine sources.

BACKGROUND: Prior to implementation of a national surveillance system for cardiovascular disease in Barbados, a small island state with limited health resources, the national burden of acute myocardial infarction (MI) was unknown. METHODS: We retrospectively estimated national acute MI incidence rates (IRs) per 100,000 during the decade before registry implementation (1999-2008), using easily accessible routine data from different sources, assessing changes over time through Poisson regression. Future events (2009-2013) were estimated using simple sensitivity analysis to incorporate prediction uncertainty. Model predictions were compared with actual IRs from initial years of the registry. RESULTS: In 2000, crude IR was 85.5 (95% CI: 74.9-97.2), rising to 92.1 (81.2-103.9) in 2008. Accounting for population ageing, the model anticipated IR of 115.9 in 2010 (99.7-132.1), vs actual crude IR 129.7 (115.9-144.6). CONCLUSIONS: Despite no electronic medical record system in Barbados, data were simple to collect, and provided a rough baseline for acute MI burden. We show that, in countries with small populations, limited resources and in absence of surveillance, national mortality statistics and routine hospital data can be combined to adequately model national estimates of acute MI incidence. This cheap and simple, yet fairly accurate method could be a key tool for other low-resource countries with ageing populations and increasing cardiovascular disease levels.

Should I call an interpreter?-How do physicians with second language skills decide?

Very little is known about how and when clinicians use their second language skills in patient care and when they rely on interpreters. The purpose of this study was to identify the factors most relevant to physicians' decision-making process when confronting the question of whether their language skills suffice to communicate effectively with patients in particular encounters. We conducted 25 in-depth, semi-structured telephone interviews with physicians in different practice settings who, while not native speakers, routinely interact with LEP patients using second language skills. Physicians consider a variety of factors in deciding whether to use their own language skills in clinical care, including their own and their patient's language proficiency, costs, convenience, and the clinical risk or complexity of the encounter. This study suggests the need for practical guidance and training for clinicians on the appropriate use of second language skills and interpreters in clinical care.

Using a risk assessment approach to determine which factors influence whether partially bilingual physicians rely on their non-English language skills or call an interpreter.

BACKGROUND: Partially bilingual physicians may weigh a number of factors in deciding whether to use their own limited non-English language skills or call an interpreter when caring for patients with limited English proficiency. Yet little is known about this decision process or how it might fail. In a patient safety approach to exploration of this complex, potentially high-stakes decision, key risk factors that may contribute to miscommunication during health care encounters in non-English languages were identified. METHODS: The Healthcare Failure Mode and Effects Analysis (HFMEA) method was adapted to examine the decision process. An initial set of possible decision factors was presented to a national expert panel of eight physicians, who modified and expanded the list of factors and then rated each according to four scales: Frequency, Importance, Amenability to Intervention, and Detectability. A "5 Whys" approach was used to examine underlying causes of these failure modes and generate potential interventions. FINDINGS: Nine factors were described that could lead physicians to use their own skills rather than an interpreter when that decision might pose unacceptable risk. The highest-priority factor was lack of knowledge regarding the value of using a trained interpreter and how to work with a trained interpreter effectively. For the top failure mode, a sample hypothetical 5 Whys exercise shows how to examine potential underlying causes and produce recommendations. CONCLUSIONS: A variety of discrete factors can have important effects on physicians' decisions to use their own non-English language skills or an interpreter. Because this decision can affect patient safety, organizations and policy makers should use these factors to guide local efforts to examine these issues and develop quality improvement and safety activities.