Clinical review of stroke care at National District Hospital, Bloemfontein

Background Stroke is a leading cause of morbidity and mortality affecting sub-Saharan Africa. Studies show that dedicated stroke units improve patient outcomes. National District Hospital (NDH) manages strokes, with the potential of becoming a dedicated stroke unit in Bloemfontein, South Africa. The study aimed to describe the clinical characteristics, management and outcomes of patients presenting with stroke at NDH. Methods In this retrospective descriptive study, emergency department registers were used to identify patients presenting with symptoms of a stroke between 01 January 2019 and 31 March 2019. Relevant data were extracted from hospital files. Results Of the 106 identified patients, 53 were included in the study. The median age was 61 years (range 28–89 years), with an almost equal split between genders. The most common risk factor was hypertension (81.3%). The median time from symptom onset to presentation at NDH was 9 h. No patient received thrombolysis. One patient received neurosurgical intervention. The most prescribed secondary preventative drugs were antihypertensive medication, statins, anticoagulation and antiretroviral therapy. Half (52.8%) of the patients received rehabilitation as in-patients. Final diagnoses were ischaemic strokes (26/53, 49.0%), transient ischaemic attacks (10/56, 22.7%) and haemorrhagic strokes (6/56, 13.6%). The 6-month post-infarct mortality rate was 37.5%. Conclusion Patient outcomes were comparable to similar South African studies. Time delays in stroke management remain a major obstacle. Identified action points include community education, improving emergency medical services and establishing a dedicated stroke unit. Contribution This study underlines the importance of stroke and cardiovascular disease prevention and stresses the value of establishing dedicated stroke units.


e State
Bloem
onteinSouth Africa

Dirk T Hagemeister 0000-0001-9442-3204
Department of Family Medicine
Faculty of Health Science
University of the Free State
BloemfonteinSouth Africa

Cornel Van Rooyen 0000-0002-5092-2957
Department of Family Medicine
Faculty of Health Science
University of the Free State
BloemfonteinSouth Africa

Hagemeister Dt 
Van Rooyen 
C Clinical 

National District Hospital
Bl emfontein

South African Family Practice
(Online) 2078-6204, (Print) 2078-619005 Jan. 2023CE8A0E86D77FBB5AC1C327A66583B18A10.4102/safpReceived: 19 July 2022 Accepted: 19 Sept. 2022strokestroke unitemergency stroke careneurological outcomethrombolysisrehabilitation
Central nervous system infarction is defined as rain, spinal cord, or retinal cell death attributable to ischemia, based on neuropathological, neuroimaging, and/or clinical evidence of permanent injury.Central nervous system infarction occurs over a clinical spectrum: Ischemic stroke specifically refers to central nervous system infarction accompanied by overt symptoms, while silent infarction causes no known symptoms.Stroke also broadly includes intracerebral hemorrhage and subarachnoid hemorrhage.1Stroke is one of the most common causes of death globally, but even more so in developing countries. 2Approximately, 6.55 million lives were lost worldwide in 2019 because of strokes (both ischaemic and non-ischaemic), with a disproportionate number of those deaths occurring in Background: Stroke is a leading cause of morbidity and mortality affecting sub-Saharan Africa.Studies show that dedicated stroke units improve patient outcomes.Nation l District Hospital (NDH) manages strokes, with the potential of becoming a dedicated stroke unit in Bloemfontein, South Africa.The study aimed to describe the clinical characteristics, management and outcomes of patients presenting with stroke at NDH.Methods:In this retrospective descriptive study, emergency department registers were used to identify patients presenting with symptoms of a stroke between 01 January 2019 and 31 March 2019.Relevant data were extracted from hospital files.Results: Of the 106 identified patients, 53 were includ d in the study.The median age was 61 years (range 28-89 years), with an almost equal split between genders.The most common risk factor was hypertension (81.3%).The median time from symptom onset to presentation at NDH was 9 h.No patient received thrombolysis.One patient received neurosurgical intervention.The most prescribed secondary preventative drugs were antihypertensive medication, statins, anticoagulation and antiretroviral therapy.Half (52.8%) of the patients received rehabilitation as in-patients.Final diagnoses were ischaemic strokes (26/53, 49.0%), transient ischaemic attacks (10/56, 22.7%) and haemorrhagic strokes (6/56, 13.6%).The 6-month post-infarct mortality rate was 37.5%.Conclusion:Patient outcomes were comparable to similar South African studies.Time delays in stroke management remain a major obstacle.Identified action points include community education, improving emergency medical services and establishing a dedicated stroke unit.Contribution: This study underlines the importance of stroke and cardiovascular disease prevention and stresses the value of establishing dedicated stroke units.

Introduction

Stroke, or cerebrovascular accident, is a common and often devastating disease with a high societal cost.The high burden of cerebrovascular disease in South Africa makes it an important topic for research.A thorough assessment of the current situation can help guide clinical governance decisions to advance healthcare services in an effective, equitable and financially prudent manner.

The American Heart Association and the American Stroke Association released a consensus document 1 in 2019 on

Introduction
Stroke, or cerebrovascular accident, is a common and often devastating disease with a high societal cost.The high burden of cerebrovascular disease in South Africa makes it an important topic for research.A thorough assessment of the current situation can help guide clinical governance decisions to advance healthcare services in an effective, equitable and financially prudent manner.
The American Heart Association and the American Stroke Association released a consensus document 1 in 2019 on the updated definition of stroke, intending to include both clinical and tissue criteria into the definition.The term 'stroke' or 'central nervous system (CNS) infarction' can be understood as follows: sub-Saharan Africa and Asia. 2 Stroke-related morbidity and mortality will likely increase further in the future because of the effects of population growth and ageing. 2,3Death, however, is not the only poor outcome to be considered when discussing strokes: disability is a significant permanent consequence affecting some patients (and their families) who survive the neurological insult.
the updated definition of stroke, intending to include both clinical and tissue criteria into the definition.The term 'stroke' or 'central nervous system (CNS) infarction' can be understood as follows: sub-Saharan Africa and Asia. 2 Stroke-related morbidity and mortality will likely increase further in the future because of the effects of population growth and ageing. 2,3Death, however, is not the only poor outcome to be considered when discussing strokes: disability is a significant perma

nt c
nsequence affecting some patients (and their families) who survive the neurological insult.

The timing of medical intervention in the management of stroke is an important factor in improving neurological outcomes and d The timing of medical intervention in the management of stroke is an important factor in improving neurological outcomes and decreasing mortality, particularly the timing of intravenous thrombolytic therapy. 4,5Recent guidelines have set out to extend thrombolytic windows in ischaemic strokes, although the outcomes when giving the thrombolytics within the first 4.5 h remain better than a longer time interval. 4schaemic strokes account for most (> 80%) of the strokes seen, while haemorrhagic strokes account for most nonischaemic strokes.
creasing mortality, particularly the timing o intravenous thrombolytic therapy. 4,5Recent guidelines have set out to extend thrombolytic windows in ischaemic strokes, although the outcomes when giving the thrombolytics within the first 4.5 h remain better than a longer time interval. 4schaemic strokes account for most (> 80%) of the strokes seen, while haemorrhagic strokes account for most nonischaemic strokes.

The Fra The Framingham Heart Study 6 has greatly contributed to what is known today as risk factors for a stroke.The two most significant contributors are hypertension (with mean systolic hypertension playing a more prominent role in strokes than diastolic hypertension) and atrial fibrillation.These two factors greatly increase a patient's risk of stroke, even when correcting for non-modifiable risk factors, such as age and gender.Other risk factors that lead to atherosclerosis also increase the risk for a stroke, such as diabetes mellitus, dyslipidaemia and tobacco smoking. 3,6,7Human immunodeficiency virus (HIV) is also an important risk factor for developing a stroke, especially haemorrhagic strokes and often affects younger HIVpositive patients. 8,9e South African population has a high prevalence of several risk factors predisposing to strokes -including hypertension, diabetes, HIV/AIDS, tobacco use and obesity.About a third of stroke patients die within 28 days with recent estimates putting the death toll from stroke at about 25 000 deaths per year. 10,11,12The incidence of stroke appears to be increasing because of an uptick in non-communicable diseases. 10,11,12The impact of stroke on a population cannot be measured by the mortality rate alone, as many stroke survivors continue to live with moderate to severe disability.This has far-reaching effects, not only on the patient's quality of life but also on the national economy.Bertram et al. 10 estimated the annual cost of cardiovascular disease and its complications in 2011 to be approximately 13-16 billion Rand -excluding the cost of rehabilitation.

t Study 6 has
greatly contributed to what is known today as risk factors for a stroke.The two most significant contributors are hypertension (with mean systolic hypertension playing a more prominent role in strokes than diastolic hypertension) and atrial fibrillation.These two factors greatly increase a patient's risk of stroke, even when correcting for non-modifiable risk factors, such as age and gender.Othe

risk factors that lead to athe
osclerosis also increase the risk for a stroke, such as diabetes mellitus, dyslipidaemia and tobacco smoking. 3,6,7Human immunodeficiency virus (HIV) is also an important risk factor for developing a stroke, especially haemorrhagic strokes and often affects younger HIVpositive patients. 8,9e South African population has a high prevalence of several risk factors predisposing to strokes -including hype

ension, diab
tes, HIV/AIDS, tobacco use and obesity.About a third of stroke patients die within 28 days with recent estimates putting the death toll from stroke at about 25 000 deaths per year. 10,11,12The incidence of stroke a

ears to be i
creasing because of an uptick in non-communicable diseases. 10,11,12The impact of stroke on a population cannot be measured by the mortality rate alone, as many stroke survivors continue to live with moderate to severe disability.This has far-reaching effects, not only on the patient's quality of life but also on the national economy.Bertram et al. 10 es imated the annual cost of cardiovasc

ar disease and
its complications in 2011 to be approximately 13-16 billion Rand -excluding the cost of rehabilitation.

A review of stroke outcomes was carried out in 2015 by Maredza et al. 11 on a national scale.The researchers used the Modified Rankin Scale (MRS) 13 to determine the severity of disability after the stroke and A review of stroke outcomes was carried out in 2015 by Maredza et al. 11 on a national scale.The researchers used the Modified Rankin Scale (MRS) 13 to determine the severity of disability after the stroke and found that 58% of stroke victims suffered from some form of disability.
ound that 58% of stroke victims suffered from some form of disability.

Stroke management should ideally take place in a dedicated stroke unit and be protocol-driven. 14,15,16Dedicat Stroke management should ideally take place in a dedicated stroke unit and be protocol-driven. 14,15,16Dedicated stroke units have been found to be cost-effective 17,18 and could improve patient outcomes. 19

cost-effective 17,18
and could improve patient outcomes. 19


Aim

The aim of this study was to describe the clinical characteristics, management and outcomes of patients presenting with stroke at National District Hospital (NDH) in Bloemfontein, from 01 January 2019 to 31 March 2019.

The objective

Aim
The aim of this study was to describe the clinical characteristics, management and outcomes of patients presenting with stroke at National District Hospital (NDH) in Bloemfontein, from 01 January 2019 to 31 March 2019.
The objective of this study was to describe:

f this study was to descr
be:

• the presentation at the emergency department, including time since the on • the presentation at the emergency department, including time since the onset of symptoms, as well as presenting signs and symptoms • initial management of strokes in the emergency department and in-patient setting at NDH • patients' demographic profile • patient risk factors that may contribute to stroke • patient outcomes six months after the incident and final diagnosis.

t of symptoms, as well as presenting signs an
symptoms • initial management of strokes in the emergency department and in-patient setting at NDH • patients' demographic profile • patient risk factors that may contribute to stroke • patient outcomes six months after the incident and final diagnosis.


Methods


Study design

A retrospective descriptive stu

Study design
A retrospective descriptive study was conducted at NDH in Bloemfontein, South Africa.National District Hospital is a level 1 public hospital based in an urban area, servicing patients from the Mangaung Metropolitan area and surrounding small towns.At present, NDH does not have a dedicated stroke unit and therefore there were no clear treatment guidelines, but provides 24-h emergency services.

was conducted a
NDH in Bloemfontein, South Africa.National District Hospital is a level 1 public hospital based in an urban area, ser

from the Man
aung Metropolitan area and surrounding small towns.At present, NDH does not have a dedicated stroke unit and therefore there were no clear treatment guidelines, but provides 24-h emergency services.


Study population and sampling

All patients presenting to NDH emergency department with signs and symptoms suggestive of stroke between 01 January 2019 and 31 March 2019 were included in the sample, retrospectively reviewing their clinical notes in their hospital files.Signs and symptoms used to screen patient files for possible stroke were focal neurological fall-out, first onset seizures and a decreased level of consciousness.


Measurement

Casualty registers were used to identify patients whose presenting complaints could indicate a stroke.Patient and clinical data were extracted from the hospital files using a datasheet designed by the researcher.


Pilot study

A pilot study was performed on the first three patients on the casualty register who presented with signs and symptoms of a stroke to the NDH emergency department in December 2018.After the pilot study, the datasheet was adjusted and resubmitted to the ethics committee for approval.The patients in the pilot study were not included in the final sample.


Data analysis

Data were analysed by the Department of Biostatistics, Faculty of Health Sciences of the University of the Free State using statistical analytics software.Descriptive statistics, namely medians and percentiles, were calculated for continuous data.Frequencies and percentages were calculated for categorical data.

All patient-related information wa

Study population and sampling
All patients presenting to NDH emergency department with signs and symptoms suggestive of stroke between 01 January 2019 and 31 March 2019 were included in the sample, retrospectively reviewing their clinical notes in their hospital files.Signs and symptoms used to screen patient files for possible stroke were focal neurological fall-out, first onset seizures and a decreased level of consciousness.

Measurement
Casualty registers were used to identify patients whose presenting complaints could indicate a stroke.Patient and clinical data were extracted from the hospital files using a datasheet designed by the researcher.

Pilot study
A pilot study was performed on the first three patients on the casualty register who presented with signs and symptoms of a stroke to the NDH emergency department in December 2018.After the pilot study, the datasheet was adjusted and resubmitted to the ethics committee for approval.The patients in the pilot study were not included in the final sample.

Data analysis
Data were analysed by the Department of Biostatistics, Faculty of Health Sciences of the University of the Free State using statistical analytics software.Descriptive statistics, namely medians and percentiles, were calculated for continuous data.Frequencies and percentages were calculated for categorical data.
All patient-related information was kept confidential, and no identifiable patient details were used in any form of publication.No informed consent from the patients was required.
kept confidential, and no identifiable patient details were used in any form of publication.No informed consent from the patients was required.


Ethical considerations


Results


Patient demographics

For the study period, 106 cases were ident

Patient demographics
For the study period, 106 cases were identified for inclusion.
fied for inclusion.

Only 66 of the 106 files could be retrieved (because of poor record-keeping practices), and eventually, only 53 patients qualified for inclusion in the study.Reasons for exclusion were diagnoses other than stroke.The median age of patients presenting with a stroke was 61 years (range 29-89 years).Just over half (50.9%) of the patients were females while 49.1% were males.Mangaung Metro residents comprised 84.9% of the patients, while 15.1% were from the surrounding smaller towns.Of the 53 patients, 32 (60.4%) used public ambulance emergency medical services (EMS), 15 (28.3%) used transport with a private car or taxi, while only three (5.6%)used a private ambulance service.Three patients had no data recorded on the method of transportation used.

Patients presented to the emergency department on average 9 h after the initial onset of symptoms.Sixteen (37.2%) patients presented within 4.5 h (the thrombolytic window). 4,5,20eventeen (39.5%) patients presented 24 h or more after the initial onset of symptoms.In this emergency department, about 25-30 strokes are seen per month.


Clinical characteristics

Pre-existent risk factors for stroke and their frequency are shown in Table 1.

Twenty


Pat Only 66 of the 106 files could be retrieved (because of poor record-keeping practices), and eventually, only 53 patients qualified for inclusion in the study.Reasons for exclusion were diagnoses other than stroke.The median age of patients presenting with a stroke was 61 years (range 29-89 years).Just over half (50.9%) of the patients were females while 49.1% were males.Mangaung Metro residents comprised 84.9% of the patients, while 15.1% were from the surrounding smaller towns.Of the 53 patients, 32 (60.4%) used public ambulance emergency medical services (EMS), 15 (28.3%) used transport with a private car or taxi, while only three (5.6%)used a private ambulance service.Three patients had no data recorded on the method of transportation used.
Patients presented to the emergency department on average 9 h after the initial onset of symptoms.Sixteen (37.2%) patients presented within 4.5 h (the thrombolytic window). 4,5,20eventeen (39.5%) patients presented 24 h or more after the initial onset of symptoms.In this emergency department, about 25-30 strokes are seen per month.

Clinical characteristics
Pre-existent risk factors for stroke and their frequency are shown in Table 1. Twenty

Patient outcomes 6 months after the incident
ent outcomes 6 months after the incident

Patient outcomes 6 months after the initial event, as recorded in the standard follow-up notes in the patient files, were also assessed using the MRS. 13 As shown in Figure 1, 29 (54.7%)patients were lost to follow up.Of the remaining 24 patients who had available follow-up notes, nine (37.5%) patients died.


Final diagnosis

The final diagnosis of 44 patients was recorded.Twenty-six (59.9%) patients suffered an ischaemic stroke, while six


Discussion


Demographics

The demographic profile of patients presenting with stroke indicates that most of the patients are middle-aged or elderly, but 11 (20.8%) of the strokes occurred in patients younger than 49 years. 21A high percentage (88.9%) of the so-called 'young st Patient outcomes 6 months after the initial event, as recorded in the standard follow-up notes in the patient files, were also assessed using the MRS. 13 As shown in Figure 1, 29 (54.7%)patients were lost to follow up.Of the remaining 24 patients who had available follow-up notes, nine (37.5%) patients died.

Final diagnosis
The final diagnosis of 44 patients was recorded.Twenty-six (59.9%) patients suffered an ischaemic stroke, while six

Demographics
The demographic profile of patients presenting with stroke indicates that most of the patients are middle-aged or elderly, but 11 (20.8%) of the strokes occurred in patients younger than 49 years. 21A high percentage (88.9%) of the so-called 'young strokes' had either or both hypertension and HIV as a comorbidity.This number of young strokes is significantly higher than the global incidence of strokes in young adults, estimated to be around 10% -15%. 21les and females were roughly equally affected in this study sample, which is not in keeping with global statistics, which tend to show that men are about 1.5 times more likely to be affected than women. 22The reason for this is unclear and likely multifactorial.One of the postulated reasons is a higher prevalence of obesity among South African women versus men. 23Men in this study were more likely to be affected at a younger age than women.The median age of stroke was 55 years for men versus 63 years for women.This trend is supported by global data. 22e majority (84.9%) of patients resided within the Bloemfontein sub-district, in a roughly 15 km radius from the hospital.The median time from the onset of symptoms to presenting at the hospital was 9 h, with a wide range from less than an hour to 168 h.This delay is worrying, as it reduces the number of patients who potentially qualify for thrombolytic therapy.Sixteen patients did present in time for possible thrombolytics.Still, because of the nature of the referral system to obtain a CT scan at another hospital, not a single patient could be thrombolysed.

kes' had ei
her or both hypertension and HIV as a comorbidity.This number of young strokes is significantly higher than the global incidence of strokes in young adults, estimated to be around 10% -15%. 21les and females were roughly equally affected in this study sample, which is not in keeping with global statistics, which tend to show that men are about 1.5 times more likely to be affected than women. 22The reason for this is unclear and likely multifactorial.One of the postulated reasons is a higher pr

alence of obe
ity among South African women versus men. 23Men in this study were more likely to be affected at a younger age than women.The median age of stroke was 55 years for men versus 63 years for women.This trend is supported by global data. 22e majority (84.9%) of patients resided within the Bloemfontein sub-district, in a roughly 15 km radius from the hospital.The median time from the onset of symptoms to presenting at the hospital was 9 h, with a wide range from less than an hour to 168 h.This delay is worrying, as it reduces the number of patients who potentially qu lify for thrombolytic therapy.Sixteen patients did present in time for possible thrombolytics.Still, because of the nature of the referral system to obtain a CT scan at another hospital, not a single patient could be thrombolysed.

Thaddeus and Maine describe the 'Three Delays Model', 24 which would also apply to this situation.The delays are: (1)  delay in the decision to seek care, (2) delay in arrival at a health fa Thaddeus and Maine describe the 'Three Delays Model', 24 which would also apply to this situation.The delays are: (1)  delay in the decision to seek care, (2) delay in arrival at a health facility and (3) delay in the provision of adequate care.

lity and (3)
elay in the provision of adequate care.

Patients (and their families) may not realise the seriousness of the symptoms they are experiencing and because most strokes are painless, they might delay seeking help.The South African Guideline for the management of ischaemic stroke and transient ischaemic attack 25 puts education (of the patients and community) as one of the top priorities to improve knowledge to recognise the signs and symptoms of a stroke.Community education programmes have shown to be successful in decreasing the pre-hospital delay and ultimately improving the prognosis of patients. 26,27,28e second delay described is the delay to arrive at the facility.Most patients (60.4%) used public EMS to reach the hospital.The specific time delays involved with the EMS services were not explored as part of this study but could be explored in future studies of this nature.Notably, the three patients who used a private ambulance service arrived within 4 h after the onset of symptoms.The third delay described is the delay in receiving appropriate care at the hospital.Unfortunately, no patients received thrombolytic therapy during the 3-month study period because of the delays discussed here, as well as further delays at the hospital itself.

The referral system is wrought with inefficiencies, such as delays in getting hold of the registrar on call for internal medicine, who needs to discuss the scan with the registrar on call for radiology.In addition, some patients must be transported from one hospital to the other using Patients (and their families) may not realise the seriousness of the symptoms they are experiencing and because most strokes are painless, they might delay seeking help.The South African Guideline for the management of ischaemic stroke and transient ischaemic attack 25 puts education (of the patients and community) as one of the top priorities to improve knowledge to recognise the signs and symptoms of a stroke.Community education programmes have shown to be successful in decreasing the pre-hospital delay and ultimately improving the prognosis of patients. 26,27,28e second delay described is the delay to arrive at the facility.Most patients (60.4%) used public EMS to reach the hospital.The specific time delays involved with the EMS services were not explored as part of this study but could be explored in future studies of this nature.Notably, the three patients who used a private ambulance service arrived within 4 h after the onset of symptoms.The third delay described is the delay in receiving appropriate care at the hospital.Unfortunately, no patients received thrombolytic therapy during the 3-month study period because of the delays discussed here, as well as further delays at the hospital itself.
The referral system is wrought with inefficiencies, such as delays in getting hold of the registrar on call for internal medicine, who needs to discuss the scan with the registrar on call for radiology.In addition, some patients must be transported from one hospital to the other using an overburdened and inefficient EMS system.It is logistically impossible to get a CT scan within 20 min of the patient arriving at the facility because of these problems.For those who received rehabilitation as in-patients, the median time from admission to the initiation of rehabilitation was 40 h and 42 min.This delay could be attributable to patients awaiting a bed in the emergency department and rehabilitation services not being available after-hours or over weekends.
an overburdened and inefficient EMS system.It is logistically impossible to get a CT scan within 20 min of the patient arriving at the facility because of these problems.For those who received rehabilitation as in-patients, the median time from admission to the initiation of rehabilitation was 40 h and 42 min.This delay could be attributable to patients awaiting a bed in the emergency department and rehabilitation services not being available after-hours or over weekends.


Management

Patients were triaged according to the South African Triage Scale (SATS) and received priority in the emergency room to be stabilised.many strokes can be attributed to dysrhythmias, such as atrial fibrillation.Blood pressure and blood glucose management were carried out in patients who required pharmacological support.

Thrombolysis is the backbone of ischaemic stroke management, but as none of the patients in this group received it, this study could not evaluate its administration.One out of the six patients who presented with a haemorrhagic stroke received neurosurgical intervention; the rest were managed conservatively or palliated depending on the severity of the stroke.

All patients admitted to NDH received rehabilitation in the form of physiotherapy and occupational therapy, which is available on site.There was a significant time delay in receiving rehabilitation because of such services being unavailable after hours and over weekends.No data are available for this group of patients on speech therapy, as it is not available on site and only available at Pelonomi Tertiary Hospital.


Risk factors

According to the World Health Organization, roughly 27.4% of men and 26.1% of women in South Africa have hypertension. 29The risk factor profile of the patients presenting with stroke is also in keeping with prior studies on the subject, showing that hypertension is by far the most critical risk factor in the development of strokes. 6,8,9,11,21,25ypertension as the only risk factor was present in 37.7% of cases, while 35.9% of patients had hypertension combined with other risk factors.Only 18.7% of patients who presented with stroke did not have hypertension as a risk factor.Systolic hypertension is of greater concern than diastolic hypertension, 21 but this study did not differentiate between the two entities.Blood pressure control should be of great priority in primary healthcare, as risk reduction could dramatically decrease the burden of disease. 21,25other major risk factor for the development of stroke (especially thromboembolic strokes) is the presence of atrial fibrillation.Global stroke statistics estimate that 9.3% -19.0% of ischaemic strokes are because of atrial fibrillation, 6,30 yet only 1.9% of patients presenting with stroke at our facility had documented atrial fibrillation.This could be because of the lower mean age of the first stroke (as the prevalence of atrial fibrillation increases with increasing age) that the attending clinician missed the diagnosis, or that the episode of atrial fibrillation was intermittent and not present at the time the patient was seen in the emergency department.

Twelve (22.6%) patients presenting with stroke had other manifestations of major target organ damage, such as ischaemic heart disease, peripheral vascular disease or previous strokes.Manifestations of cardiovascular disease often point to widespread atherosclerotic changes in the entire cardiovascular system, not just in a confined area.Patients with one manife

Management
Patients were triaged according to the South African Triage Scale (SATS) and received priority in the emergency room to be stabilised.many strokes can be attributed to dysrhythmias, such as atrial fibrillation.Blood pressure and blood glucose management were carried out in patients who required pharmacological support.
Thrombolysis is the backbone of ischaemic stroke management, but as none of the patients in this group received it, this study could not evaluate its administration.One out of the six patients who presented with a haemorrhagic stroke received neurosurgical intervention; the rest were managed conservatively or palliated depending on the severity of the stroke.
All patients admitted to NDH received rehabilitation in the form of physiotherapy and occupational therapy, which is available on site.There was a significant time delay in receiving rehabilitation because of such services being unavailable after hours and over weekends.No data are available for this group of patients on speech therapy, as it is not available on site and only available at Pelonomi Tertiary Hospital.

Risk factors
According to the World Health Organization, roughly 27.4% of men and 26.1% of women in South Africa have hypertension. 29The risk factor profile of the patients presenting with stroke is also in keeping with prior studies on the subject, showing that hypertension is by far the most critical risk factor in the development of strokes. 6,8,9,11,21,25ypertension as the only risk factor was present in 37.7% of cases, while 35.9% of patients had hypertension combined with other risk factors.Only 18.7% of patients who presented with stroke did not have hypertension as a risk factor.Systolic hypertension is of greater concern than diastolic hypertension, 21 but this study did not differentiate between the two entities.Blood pressure control should be of great priority in primary healthcare, as risk reduction could dramatically decrease the burden of disease. 21,25other major risk factor for the development of stroke (especially thromboembolic strokes) is the presence of atrial fibrillation.Global stroke statistics estimate that 9.3% -19.0% of ischaemic strokes are because of atrial fibrillation, 6,30 yet only 1.9% of patients presenting with stroke at our facility had documented atrial fibrillation.This could be because of the lower mean age of the first stroke (as the prevalence of atrial fibrillation increases with increasing age) that the attending clinician missed the diagnosis, or that the episode of atrial fibrillation was intermittent and not present at the time the patient was seen in the emergency department.
Twelve (22.6%) patients presenting with stroke had other manifestations of major target organ damage, such as ischaemic heart disease, peripheral vascular disease or previous strokes.Manifestations of cardiovascular disease often point to widespread atherosclerotic changes in the entire cardiovascular system, not just in a confined area.Patients with one manifestation of atherosclerosis should be initiated on the best medical therapy to decrease their risk of suffering a stroke. 12,18,20man immunodeficiency virus is considered an important risk factor for the development of stroke because of widespread vasculitis and systemic inflammation. 8,9In this study population, 15.1% of patients had HIV as comorbidity.This is marginally higher than the overall HIV prevalence for South Africa, which is estimated at 13%. 31 However, the HIV percentage in our study population was much lower than the 25.5% reported in 2018 after the 2017 survey. 32abetes, disorders of lipid metabolism and tobacco smoking were also recorded and are known risk factors for the development of cardiovascular disease. 3,6,7In this study population, 17.0% of the patients were diabetic, 17.0% admitted to tobacco smoking and 7.6% had known dyslipidaemia.Metabolic risk factors play a major role in the development of atherosclerotic disease, which contribute to developing both ischaemic and haemorrhagic strokes. 3,6,7roke prevention should be a key priority in the district health plan and strengthening the primary healthcare system is essential to improve outcomes for stroke patients.Stroke prevention can be divided into five stages: primordial prevention, primary prevention, secondary prevention, tertiary prevention and quaternary prevention. 33imordial prevention would include laws and policies to improve the social and environmental conditions that contribute to the disease.Sugar tax has already been implemented to try and address the obesity epidemic and decrease cardiovascular risk factors. 34Increased taxation on tobacco products also falls into this category.Primary preventative measures include preventing hypertension, dyslipidaemia and diabetes and non-pharmacologic strategies and lifestyle changes, such as stopping smoking, restricting alcohol consumption, maintaining healthy body weight, increasing regular aerobic physical activity and adopting a healthy plant-based diet with limited sodium intake. 21Secondary prevention would be targeted to at-risk individuals to adequately treat their diseases to prevent them from suffering a stroke -ensure good blood pressure control, treat with a statin and aspirin or anticoagulants such as warfarin and rivaroxiban, if indicated in atrial fibrillation. 35It is vital to have HIV-positive patients on antiretroviral treatment to suppress their viral load.Tertiary prevention would target the clinical and outcome stages of the disease, such as a dedicated stroke unit with the facilities to thrombolyse patients with an acute ischaemic stroke. 28,35inally, quaternary prevention, as described by the World Organization of Family Doctors (WONCA) International Dictionary for General/Family Practice, can be interpreted as activity taken to detect patients at risk of overmedication, to safeguard them against additional medical intrusion and to recommend interventions that are morally acceptable. 36his principle can also be linked to the ethical concept of 'Do no harm', as medical intervention may lead to unintended sequelae.

ation of atherosc
erosis should be initiated on the best medical therapy to decrease their risk of suffering a stroke. 12,18,20man immunodeficiency virus is considered an important risk factor for the development of stroke because of wide pread vasculitis and systemic inflammation. 8,9In this study population, 15.1% of patients had HIV as comorbidity.This is marginally higher than the overall HIV prevalence for South Africa, which is estimated at 13%. 31 However, the HIV percentage in our study population was much lower than the 25.5% reported in 2018 after the 2017 survey. 32abetes, disorders of lipid metabolism and tobacco smoking were also recorded and are known risk factors for the development of ca diovascular disease. 3,6,7In this study population, 17.0% of the patients were diabetic, 17.0% admitted to tobacco smoking and 7.6% had known dyslipidaemia.Metabolic risk factors play a major role in the development of atherosclerotic disease, which contribute to developing both ischaemic and haemorrhagic strokes. 3,6,7roke prevention should be a key priority in the district health plan and strengthening the primary healthcare system is essential to improve outcomes for stroke patients.Stroke prevention can be divided into five stages: primordial prevention, primary prevention, secondary prevention, tertiary prevention and quaternary prevention. 33imordial prevention would include laws and policies to improve the social and environmental conditions that contribute to the disease.Suga tax has already been implemented to try and address the obesity epidemic and decrease cardiovascular risk factors. 34Increased taxation on tobacco products also falls into this category.Primary preventative measures include preventing hypertension, dyslipidaemia and diabetes and non-pharmacologic strategies and lifestyle changes, such as stopping smoking, restricting alcohol consumption, maintaining healthy body weight, increasing regular aerobic physical activity and

dopting a h
althy plant-based diet with limited sodium intake. 21Secondary prevention would be targeted to at-risk individuals to adequately treat their diseases to prevent them from suffering a stroke -ensure good blood pressure control, treat with a statin and aspirin or anticoagulants such as warfarin and rivaroxiban, if indicated in atrial fibrillation. 35It is vital to have HIV-positive patients on antiretroviral treatment to suppress their viral load.Tertiary prevention would target the clinical and outcome stages of the disease, such as a dedicated stroke unit with the facilities to thro

olyse patients w
th an acute ischaemic stroke. 28,35inally, quaternary prevention, as described by the World Organization of Family Doctors (WONCA) International Dictionary for General/Family Practice, can be interpreted as activity taken to detect patients at risk of overmedication, to safeguard them against additional medical intrusion and to recommend interventions that are morally acceptable. 36his principle can also be lin

Patient outcomes
Stroke survivor outcomes were measured in this study using the MRS 13 and are discussed and compared in Table 2 with the outcomes that were found in the 2008 study by Bertram et al. 10 on South African stroke survivors.
Serious neurological sequelae for patients who survived their strokes are still a major problem at NDH.There are clear, published, cost-effective guidelines 14,15,19,20,28  Regarding the final diagnoses made for the patients who presented with signs and symptoms suggestive of stroke to the emergency department, 59.9% were diagnosed with an ischaemic stroke and 22.7% had transient ischaemic attacks, which is roughly in keeping with previous studies on the topic.Haemorrhagic stroke accounted for 13.6% of patients and 4.6% were classified as 'other'.These results align well with other published data, which puts the prevalence of haemorrhagic strokes at 10% -15%. 7,37,38The risk factor that most prominently contributed to a haemorrhagic stroke was hypertension, with 66.7% of patients who had a haemorrhagic stroke also having previously diagnosed with hypertension.In addition, 16.7% of patients with a haemorrhagic stroke had HIV as the only risk factor.This study's strengths lie in the detailed data that were collected, but it is limited by the study size.The study size was primarily limited by poor record-keeping practices as less than half of the files could be retrieved.The hospital still uses a paper-based filing system.The study was also limited by its retrospective nature.Because of the limited amount of data that could be retrieved as well as missing data, misclassification bias is a distinct possibility.

Conclusion
Stroke remains a significant clinical and public health concern in Bloemfontein and the broader South African population.
Improving patient outcomes should be a high priority for the Free State Department of Health to adhere to international standards of practice.All these problems trickle down to impact patient outcomes.Establishing a dedicated stroke unit at NDH is just one of the ways to improve the lives and livelihoods of patients affected by the devastating consequences of cerebrovascular accidents but should not be the only way we strive to improve our healthcare delivery.

Recommendations
This study underlines the importance of stroke and cardiovascular disease prevention and stresses the value of establishing dedicated stroke units in South Africa, particularly at NDH. Future research could explore outcomes after the intervention (such as applying dedicated stroke protocols) was applied and the role that EMS plays in patient outcomes when presenting with medical emergencies, such as a stroke.
Ethical approval was obtained from the Health Sciences Research Ethics Committee at the University of the Free State [UFS-HSD2020/0164/2710-0001].The Free State Department of Health gave permission to conduct the study.

TABLE 1 :
Frequency of pre-existing risk factors for stroke (N = 53).
(13.6%) patients suffered a haemorrhagic stroke, which did not require thrombolysis.Transient ischaemic attacks made up 10 (22.7%) cases, while one (2.3%)patient had Todd's paresis, and one (2.3%)patient had an infective intracranial mass (tuberculoma).None of the patients had conversion syndrome or a malignant intracranial mass.
available, which can significantly improve outcomes, but need stringent implementation and application.Factors limiting the clinicians' ability to improve patient care include clinical governance issues such as poor record-keeping, poor healthcare planning and a lack of priority patient transport.

TABLE 2 :
10roke survivor outcomes: Comparison between this study and Bertram et al.10