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Objective:Quality of neurologic emergency management in an under-resourced country may be improved by standard operating procedures (SOPs).Methods:Neurologic SOPs were implemented in a large urban (Banjul) and a small rural (Brikama) hospital in the Gambia. As quality indicators of neurologic emergency management, performance of key procedures was assessed at baseline and in the first and second implementation years.Results:At Banjul, 100 patients of the first-year intervention group exhibited higher rates of general procedures of emergency management than 105 control patients, such as neurologic examination (99.0% vs 91.4%; p < 0.05) and assessments of respiratory rate (98.0% vs 81.9%, p < 0.001), temperature (60.0% vs 36.2%; p < 0.001), and glucose levels (73.0% vs 58.1%; p < 0.05), in addition to written directives by physicians (96.0% vs 88.6%, p < 0.05), whereas assessments of other vital signs remained unchanged. In stroke patients, rates of stroke-related procedures increased: early CT scanning (24.3% vs 9.9%; p < 0.05), blood count (73.0% vs 49.3%; p < 0.01), renal and liver function tests (50.0% vs 5.6%, p < 0.001), aspirin prophylaxis (47.3% vs 9.9%; p < 0.001), and physiotherapy (41.9% vs 4.2%; p < 0.001). Most effects persisted until the second-year evaluation. SOP implementation was similarly feasible and beneficial at the Brikama hospital. However, outcomes did not significantly differ in the hospitals.Conclusions:Implementing SOPs is a realistic, low-cost option for improving process quality of neurologic emergency management in under-resourced settings.Classification of evidence:This study provides Class IV evidence that, for patients with suspected neurologic emergencies in sub-Saharan Africa, neurologic SOPs increase the rate of performance of guideline-recommended procedures.

We thank Dr. Chin for the comments on our article.1 We agree that the study was performed under experimental conditions. This limitation, aimed to be minimized by assessment conditions that were similar before and after standard operating procedure (SOP) implementation and by the absence of provision of additional resources, was discussed.1 The statement that sub-Saharan African countries face crucial challenges that are, in the end, associated with the severe financial constrains is true. This was documented in our study,1 including the problem of CT performance due to unsettled payment questions. SOPs are only one of several steps, among which are long-term international financial support and cooperation, structural measures (such as health insurance systems), and systematic training of neurologists (thereby avoiding brain drain). Yet, what can be done today? As long as the financial support and the structural frameworks remain suboptimal, SOPs to make better use of the still available, although limited, personnel and technical resources (e.g., adjustment of physiologic measures, aspirin prophylaxis, or physiotherapy) are a relevant step towards guideline-recommended stroke management. As suggested by Dr. Chin, these might be complemented by further SOPs that focus on postemergency management and measures for prevention.2