Describe an evidence-based approach to locally contextualized guideline adaptation for stroke unit development in Zambia.

Stroke units are the global standard for stroke care and improve outcomes independent of thrombolysis and thrombectomy.  However, they are largely absent in many resource-limited settings, especially in sub-Saharan Africa.  Before October 2023, Zambia had no stroke units.

Because directly translating stroke clinical practice guidelines (CPGs) from high-resourced settings to Zambia would be impractical, we undertook a three-step systematic approach to adapt American Stroke Association (ASA) CPGs on ischemic and hemorrhagic stroke care for stroke unit development in Zambia.

First, we conducted a 300-person prospective observational cohort study of consecutive adults with stroke admitted to the University Teaching Hospital in Lusaka in order to identify areas of focus for a future stroke unit.  This study revealed high rates of urinary catheterization (47% of participants), low rates of mobilization (19% of participants were mobilized on any day during their hospitalization), insufficient rates of neuroimaging (20% of participants without neuroimaging), and high mortality (21%).  Second, these data were used to provide context for a multi-disciplinary stakeholder meeting in which the Adopt-Contextualize-Adapt approach was used to categorize ASA CPGs into those that could be directly translated to the Zambian setting, those requiring adaptation, and those that could not be easily implemented/adapted with current resources.  Discipline-specific focus groups were then used to identify implementation priorities and additional resources (training, personnel and physical resources) that would be required for successful adaptation.  Finally, results from focus groups were used to inform the development of locally contextualized Zambian CPGs and final protocols for Zambia’s first stroke unit.

Zambia’s first stroke unit opened in October 2023.  Next steps include repeating the observational cohort study in the post-implementation period to evaluate CPG uptake and impact on outcomes.