Barriers to the implementation of prehospital thrombolysis in the treatment of ST-segment elevation myocardial infarction in South Africa: An exploratory inquiry

Abstract

Introduction: Evidence-based guidelines advocate percutaneous coronary intervention (PCI) as the mainstay reperfusion strategy for ST-segment elevation myocardial infarction (STEMI). However, the South African health system is not well positioned to provide PCI as a 'mainstay strategy'. In response, the Health Professions Council of South Africa approved the use of prehospital thrombolysis (PHT) for emergency care practitioners in 2009. However, since its approval, prehospital thrombolysis has failed to reach a level of systematic uptake indicative of successful implementation. The current study aimed to explore, through a qualitative inquiry, barriers to PHT for the treatment of myocardial infarction within a South African context.

Methods: A qualitative single-case study design was used where a series of semi-structured interviews were conducted involving purposefully selected participants. The case comprised a nationalised private emergency medical service, and participants were selected in view of relevant experience and knowledge. Requisite data was conceptualised through the consolidated framework for implementation research, and thematic analysis outlined the data coding procedures of the study.

Results: The study identified potential barriers to the implementation of PHT. These comprised cost, logistics, inter-professional collaboration, leadership engagement, and beliefs or scepticism associated with PHT.

Conclusion: A lack of strategic implementation has resulted in a poor introduction of evidenced-based prehospital cardiac care, affecting vulnerable populations who may have otherwise benefited from receiving this level of care. Given the time-sensitive nature of STEMI management, and severely limited access to 'primary reperfusion', PHT resembles not only a logical but also appealing solution in the South African context.

Keywords: Acute myocardial infarction; Implementation; Prehospital coronary care; Prehospital thrombolysis; St-segment myocardial infarction.