During my first two weeks in Nepal’s buzzling capital, Kathmandu, I had the opportunity to visit the project’s hospitals in Kathmandu. These hospitations were important for me to get an understanding of what stroke care looks like in the tertiary care centers in Kathmandu. Furthermore, these visits gave me the opportunity to analyze with the experienced neurologists where they felt there was a need for improvement.
Three hospitals I visited are private multidisciplinary hospitals (Grande International Hospital, Norvic International Hospital and Mediciti) and one private hospital is a dedicated neurological center (Annapurna Neurological Institute). The fifth hospital I visited was the governmental Tribhuvan University Teaching Hospital (TUTH). As all of these hospitals are certainly the best hospitals in Kathmandu these hospitals are very well- equipped and provide all necessary diagnostic services, available 24/7. The hospitals each treat approximately 30 to 50 acute stroke patients per month – and the neurologist see even many more stroke patients for follow-up in their out-patient departments.
Once a stroke patient arrives, the usual stroke care pathway begins in the emergency department, where the patient is initially examined by an emergency physician – most of the emergency physicians have received stroke trainings by neurologists. Mostly, the neurologist is called for consultancy then. Two hospitals (Annapurna & TUTH) do acute CT scan, in the other hospitals the preferred acute brain imaging is MRI, as that can exclude stroke mimics. Since thrombolysis is very expensive it is important for the patient/family, to know that the treatment “is worth it”…they have to pay for all medication out of their own pocket. Whether Alteplase or Tenecteplase is used depends on availability at the pharmacy or the preference of the physicians and patient’s relatives. It’s great to see, that all of the visited hospitals do give thrombolysis. Unfortunately, right now, only one hospital is providing endovascular treatment – there are only two neuro- interventionalists for 30 million people in Nepal.
An acute stroke patient (especially after recanalization) is admitted to ICU (or Stroke Unit) – and if the clinical situation allows for that – transferred to general ward after 24 hours. The ICU stay includes cardiac monitoring, FeSS protocols (fever, sugar, swallowing) and neurological assessments. Since all the hospitals have a department of physiotherapy attached and provide a speech&language therapist, the early rehabilitation starts right away on ICU/ HDU.
The diagnostics for stroke etiology comprise cardiac workout (ECG, Holter-ECG, echocardiography), vessel diagnostics (carotid doppler, DSA) and lab diagnostics (HbA1C, LDL, homocysteine) – everything on individually decided basis (according to the patient’s risk profil, type of stroke etc). Since there are only a few rehabilitation clinics, patients mostly stay in the hospital until it is possible to discharge them home again – and this is quite approximately 7-10 days. The only challenge is that despite the good treatment, few data has been written down so far. And we all know that any improvement starts with sharing good experiences and recognizing our own gaps.
However, my impression of the hospitals rather tells me that Quality Monitoring will mainly serve as a role model for other hospitals to follow – and to show worldwide that Nepal provides high quality stroke care!