Key result
Cluster-randomized trial tests implementation of the ACT package across 48 Kenyan emergency departments.
Why the study?
Emergency cardiac care in Kenya is fragmented, with only 53.8% of emergency departments reporting AMI management guidelines, and no trial on AMI care has previously been conducted in an African emergency department.
Does the ACT (AMI Clinical pathway and Training) package improve fidelity of implementation of evidence-based AMI care components compared to standard care across emergency departments in Kenyan referral hospitals?
RCT
1:1 cluster-randomized
Yes
Does the ACT (AMI Clinical pathway and Training) package improve fidelity of implementation of evidence-based AMI care components compared to standard care across emergency departments in Kenyan referral hospitals?
Answers are grounded in this paper and cite their sources.
This protocol describes the first cluster-randomized trial of emergency department acute myocardial infarction care in Africa, aiming to decentralize and integrate standardized emergency cardiovascular care across 48 referral hospitals in Kenya.
Background Cardiovascular disease causes one in ten deaths in Africa. In Kenya, the emergency department (ED) is often the first, and sometimes only, point of contact with the health system, yet emergency cardiac care is fragmented. In our prior work, only 53.8% of Kenyan EDs reported having AMI management guidelines despite publicly available national protocols, and no trial on AMI care has been conducted in an African ED. Through the ACT (AMI Clinical pathway and Training) package, and our trial, we seek to address this gap. Methods This hybrid type 3 effectiveness-implementation study spans 48 EDs (all 47 public, county referral hospitals and one national referral hospital). The ACT package has four components: a context-specific AMI care pathway and form co-designed with a Community Advisory Board; clinical training across staff; visual reminders in clinical areas; and a defibrillator per site. Sites will be randomized 1:1 to ACT versus standard care in a two-arm cluster-randomized trial over 12 weeks with prospective chart data abstraction. The primary outcome is fidelity of implementation of five evidence-based components: history and physical, EKG, risk-stratification score, defibrillator use when applicable, and referral when indicated. Process evaluation follows RE-AIM, with maintenance assessed at 3 and 6 months. A closing Shiffman-Smith–guided stakeholder symposium will produce a national policy brief. Results Pathway adaptation and site engagement are underway, building on preliminary data showing higher ED hypertension prevalence (35.8%) than national estimates (24.5%) and gaps in guideline and defibrillator access. We hypothesize ACT will increase adoption of evidence-based AMI care; the protocol will be presented. Conclusion ACT is the first cluster-randomized trial of AMI care in an African ED. By decentralizing standardized cardiac care to county referral hospitals and tying it to referral networks and Ministry of Health policy, it offers a replicable model for integrating emergency cardiovascular care into low-resource health systems.
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Ngaruiya et al. (2026) conducted an RCT in Acute myocardial infarction (AMI). Acute Myocardial Infarction Clinical pathway and Training (ACT) package vs. Standard care was evaluated on Fidelity of implementation of five evidence-based components: history and physical, EKG, risk-stratification score, defibrillator use when applicable, and referral when indicated. The ACT package is being evaluated against standard care across 48 Kenyan emergency departments in a 12-week cluster-randomized trial; outcome results are not yet reported in this study protocol.
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