Hospital director office
Maharaj Nakorn Chaingmai Hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
1. What was the problem before the implementation of the initiative? (497 words) Stroke is a sudden attack involving the blood flow in the brain resulting in the loss of the ability to move, speak clearly, etc. affecting “one in six people worldwide…in their lifetime.” (WHO) Cerebrovascular disease, or stroke, is a common, and important, public health problem in Thailand, according to information from the Bureau of Policy and Strategy Ministry of Public Health (MoPH) in 2007 there were 206 stroke victims per 100,000 persons in the general population. Every year there are approximately 250,000 new stroke patients, and 50,000-60,000 individuals die due to stroke. Thai health statistics from 2009 show that stroke was the number one cause of death among Thais, both male and female. It is also the third leading cause of DALY (Disability-Adjusted Life Years) in Thai men and second in Thai women. Many survivors were left with significant disability, but the number of patients able to receive care in a timely manner was less than 10% due to lack of understanding related to cerebrovascular disease (stroke) in both the patient population and in their health care providers in regards to warning signs of stroke and the interventional process that is time-sensitive, an important condition in the care of stroke patients and the fact that patients must seek care at a health care facility that is adequately prepared. Lack of a referral system for this condition and a failure to create preparedness within the system to facilitate rapid treatment in the emergency department, or continuous and quality rehabilitation impact the quality of care given. There are 1.7 million people in Chiang Mai province living in 25 districts in a large, mountainous region on the border with Myanmar, which is a challenge in terms of transportation when transferring patients for medical emergencies. There are also a significant number of minority groups, such as Hmong, Karen, Shan, and Burmese living in the province, both working in the cities and along the border areas. There are 23 community hospitals throughout the province providing care for the general population under the Ministry of Public Health. However, if a patient has symptoms that are beyond the capabilities of one of these facilities, then the patient must be transferred to Maharaj Nakorn Chiang Mai Hospital, which is the tertiary medical center in the province. Prior to setting up this program, Maharaj Nakorn Chiang Mai Hospital had only one patient receive thrombolytics despite the initiation of a referral network from community hospitals in the province. No seminar or educational meetings had yet been done and no formal plan had been officially drafted for patient referrals for stroke victims. The community hospitals themselves had not yet devised an internal action plan for dealing with patients with stroke in the acute setting. Up-to-date medical information had not yet penetrated the daily practice of these community hospitals. In addition to this, the rural population, particularly in the outer reaches and difficult to access mountaintop villages, faced significant obstacles in accessing care in the time frame considered most effective.

B. Strategic Approach

 2. What was the solution?
The Thai FDA approved the intravenous administration of thrombolytic as an acceptable medical standard in 1996 in the treatment of acute stroke. After a 2008 study showed positive results in patients treated within the 3-4.5 hour window after onset of symptoms. Death and disability can be prevented in some cases of stroke if the patient is treated properly within a certain time period and in a facility with the proper equipment and trained personnel. The expression, “time is brain,” is demonstrated in the fact that 30% of patients treated according to the current standard in a timely fashion will have resolution of their symptoms. Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine, Chiang Mai University realized the importance of this issue and, in conjunction with the National Health Security Office, decided to create a comprehensive treatment plan, consisting of making the necessary medications (including thrombolytic) readily available to patients, and created a special emergency treatment unit for stroke patients staffed with specially-trained health care workers. In addition to this, 30 community hospitals were expanded from the 13 already participating in the referral network with an emphasis on complete and comprehensive care, including seeking out and monitoring at-risk individuals, to stroke patients in the acute setting and providing rehabilitation services, in order to prevent recurrence of stroke by establishing a rapid and comprehensive diagnostic, referral and treatment system. The primary goal was to lower the rate of occurrence of stroke in high-risk populations, increase the rate of timely care through the referral network, and lower the morbidity and mortality rates from stroke and its complications.

 3. How did the initiative solve the problem and improve people’s lives?
This program addressed the problem of stroke in several new ways: • We created a system within the hospital that would facilitate the timely treatment of stroke patients that did not exist before • We used an established call center for those outside the hospital to communicate with the hospital effectively and efficiently • We developed a network among the peripheral community hospitals so that treatment could reach patients in a more timely manner • We took a proactive approach to providing knowledge to network hospitals and their communities in order to find at-risk persons, increase monitoring and prevent stroke from occurring. • We developed an electronic communication system to provide immediate access to patient information to increase the quality of care for transfer patients. The system completely changed from an old, tertiary-centered approach where Maharaj Nakorn Chiang Mai Hospital was the center to a community-centered approach, where the community identifies at-risk patients and provides treatment. The network was created to strengthen community hospitals in providing patient-centered care and so that transfer patients would be effectively cared for, following medically established standards, and enabling patients to receive appropriate medical care as rapidly as possible.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine, Chiang Mai University, in conjunction with the National Health Security Office (NHSO) and 13 hospitals in Chiang Mai, Lamphun, Prae and Maehongson province created a network as follows: Step 1: Develop internal systems within each hospital in conjunction with the multi-disciplinary team. To develop a manual and patient care guidelines, or care map, for acute stroke and set up a fast track for treatment of stroke patients for all patients who develop symptoms of stroke whether in-patient or outside the hospital. Step 2: Establish a stroke unit in Maharaj Nakorn Chiangmai Hospital. Step 3: Implement stroke education through an awareness campaign concerning treatment guidelines through training sessions for health care workers, professional development meetings and informational programs for the general public to increase understanding related to stroke and the services available at the local hospitals. Step 4: Network development: a stakeholders meeting was held to come to a working agreement between the involved hospitals and the NHSO, area 1, and the Neurological Hospital in order to divide the hospitals into zones of responsibility and to develop the 13 hospitals from Chiang Mai, Lamphun, and Prae province into an organized network as well as establish a network level board. Step 5: Proactive development and extending providers beyond the reach of Maharaj Hospital by leading informational sessions about stroke and offering to act as a “mentor” to the community hospitals in the network by developing and training their health care workers in their ability to detect, monitor, and rehabilitate at-risk individuals within the community and helping hospitals learn how to train community health volunteers to further branch out and reach a broader segment of the population. Every year, the community hospitals in the network were given the opportunity to present their results back to the educators from the sponsoring institution. Step 6: Set up a specialty clinic to detect patients at high-risk in order to give advice on how to lower risk, offer treatment, and give patient education about stroke at the internal medicine clinic starting in 2009. Step 7: Set up a comprehensive follow-up clinic for recovering stroke patients providing continuous care and counseling on the 3rd and 4th Fridays of the month starting in 2011.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
1. Those involved in the development of the processes and procedures for creation and management of the emergency treatment ward for stroke patients included the entire health care team, nurses, support staff, diagnostic radiology, Rehabilitation department, Faculty of Allied Health of Chiang Mai University, Northern Thailand Brain Disease Center, Sriphat Medical Center, and the Faculty of Medicine, Chiang Mai University. 2. In terms of development of the network for stroke, the supporters include Maharaj Nakorn Chiang Mai Hospital and NHSO, starting with 13 hospitals in Chiang Mai, Lamphun, Prae, and Maehongson provinces and expanding to 30 community hospitals 3. NHSO sponsored the training for hospital workers, community health workers and the training of the general population. 4. NHSO supported, through the health promotion office, the training of community health workers who visit patients in the home, as well as workers at the community hospital, to provide screening services, treatment and primary prevention, as well as referrals from the network community and public hospitals to develop identification, monitoring and rehabilitation services in their community. 5. Maharaj Nakorn Chiang Mai Hospital and the Faculty of Medicine, Chiang Mai University established a comprehensive care clinic for high-risk and stroke patients in terms of providing personnel and facilities.
 6. How was the strategy implemented and what resources were mobilized?
1. Maharaj Nakorn Chiang Mai Hospital provided the infrastructure for services needed as follows: • Professional personnel support • Facilities to provide services, including various clinical services and emergency room patient care to stroke patients • Basic medical and specialized care equipment required for diagnosis, intensive care monitoring, radiological services, laboratory facilities, and others • Miscellaneous practical systems for additional internal support, such as an intranet-based radiology viewing system CMU PACS created an electronic medical records system to make appointments on line (SMI) and provide access to patient discharge summaries to the network hospitals, a service system to manage clinically high-risk patients through a call center with EMS and trained EMS throughout Chiang Mai. The financial source for training came out of the National Budget and the hospital maintenance budget. 2. NHSO supported the following • Thrombolytic medications were made available to all social security patients and all treatment costs were covered for all stroke patients for the entire extent of their encounter • Coordinated and underwrote all costs associated with the development of the comprehensive stroke care network • Underwrote the costs associated with activities involved in promoting awareness and understanding related to stroke by giving annual payments to the tertiary hospital to support educational activities for hospital personnel and others outside the hospital, including medical seminars, and informing the general public under NHSO budget as a part of the National Budget.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
1. System results a. Creation of a stream-lined acute stroke care process, stroke fast track, and care maps b. Established a call center for seamless referral to the tertiary care center and for return of the patient back to the community c. Creation of a stroke care network 2. Service results 2.1 People became more aware of the fact that stroke is a preventable condition, by lowering risk factors, and that it is treatable if care is sought in a timely fashion. Not only that, but one can recover after a stroke if treated correctly, including following a course of rehabilitation. 2.2 High-risk groups were screened in their communities. 2.3 Results from the development of the patient-care network are as follows: • Patients were given rtPA within 3 hours in greater numbers and in shorter time frames year by year. At Maharaj Hospital, ten patients (10.70%) received rtPA in 2008, followed by 27 (23.07%) in 2009, then 52 (27.27%) in 2010, 97 (38.90%) in 2011, 81 in 2012, increasing every year. In 2012, Prae Provincial hospital was able to administer the thrombolytic directly to stroke patients, decreasing the number of patients needing care at Maharaj Hospital. • There was an improvement in the door to needle time (DNT) up to the international standard, which is within 60 minutes. In 2008, the DNT was 88.3 minutes, in 2009 it was down to 77 minutes, in 2010 the DNT was down to 56 minutes, in 2011 it was 53 minutes and in 2012 it was 59.45 minutes. • Bleeding complications from the thrombolytic decreased (standard is less than 6% of cases) from 15% in 2008, 14.81% in 2009, 5.88% in 2010, 2.06% in 2011, and 2.47% in 2012. The rate of stroke patients who were able to care for themselves one month after the event increased from 52.81% in 2010, 62.6% in 2011, and up to 68.51% in 2012. Three months after receiving thrombolytic, 41% of patients in 2010 were independent, 64% in 2011 and 90% in 2012. The referral network of 13 hospitals increased to 30 hospitals, and one of the hospitals was able to administer thrombolytic at their own facility and another hospital is now in process to do the same.

 8. What were the most successful outputs and why was the initiative effective?
There was close follow up and monitoring of the various institutions involved at multiple stages of the program: 1. Maharaj Nakorn Chiang Mai Hospital as the sponsoring institution of the project, monitored two components as follows: 1.1 Internal surveying: tracking key indicators at various stages along the way, from the time the patient first presented for care in the emergency room until the time of discharge to home. This information was gathered and analyzed and presented to the relevant departments if there was a concern. 1.2 Network hospital monitoring for key indicators, such as delayed referrals or failure to make a referral, the number of patients referred per hospital, the mortality and complication rates, as well as the rate of disability, the number of projects and activities done for patients, monitoring for following referral procedures correctly from the community hospital to Maharaj Hospital. Feedback was given on a monthly basis when an incident occurred. 2. The financial sponsor, NHSO, also monitored the progress of the program by evaluating both the tertiary and the community hospitals annually by gathering various key indicators on a quarterly basis giving feedback continuously. 3. The Thai Stroke Society monitored quality control by, acting as a consulting body and guarantor of the development of the stroke unit, reviewing the program’s relevant data and key indicators as well as conducting site visits on a periodic basis. 4. The Healthcare Accreditation Institute (Public Organization) also monitored the program for maintaining minimum standards for hospital care in the treatment of stroke patients at the tertiary hospital, Maharaj Nakorn Chiang Mai Hospital annually.

 9. What were the main obstacles encountered and how were they overcome?
1. Problems outside the hospital included: 1.1 Uninformed segments of the population were slow to seek treatment, leading to missed treatment opportunities. Therefore, we promoted an on-going informational campaign about stroke and treatment guidelines. Patients were given a platform to communicate their feelings and experiences to the public and other public media campaigns were used to easily reach the general population in their every-day lives, such distributing calendars, refrigerator magnets, and CDs with popular music, for example. 1.2 Slow referral rate due to private ambulance team did not cooperate to the program. We did discuss with provincial authority on Emergency Medical Service to set a common transfer protocol among both government and private ambulance. 1.3 Not following the patient care guidelines, which could have been a result of turnover of coordinators at the community hospitals due to resignations, transfers, and new hires. In order to overcome this barrier, a systematic approach was needed. A guideline handbook was created and training sessions with review and new updates were required annually to improve the care of patients in accordance with the guidelines. This was done at yearly problem-solving exchanges for providers in the network. 2. Problems within the organization: Administering the medication outside of the target period was due to delays in several steps in the process. Because the service provider was a health-care teaching facility, training physicians rotated on-call duty and the person responsible for patient care was constantly changing. To solve this problem, physicians-in-training were given information regarding stroke patient care during orientation prior to beginning their service on the relevant wards. We also monitored outcomes by tracking patient records selected randomly, following patient feedback questionnaires, and evaluating the physicians’ practices.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
1. High-risk individuals and the public were familiar with stroke, including symptoms and how to respond, resulting in a population that is accessing care in increasing numbers. The public also knows how to avoid or lower risk factors for stroke, and we should see decreases in incidence of stroke in the future. 2. Community hospitals in the network have gained more information about stroke, gaining the ability to evaluate, screen and refer stroke patients as needed in order to provide high quality care. Also, the hospitals are more proactive in identifying at-risk patients, promoting stroke prevention and education to the general public. Looking at the results of a systematic review of the network before and after joining the program in 2010-11, improvements were achieved in every aspect, such as hospitals that had appointed a committee to manage stroke patients (23% to 71%), created a patient care flow chart increased (46% to 71%), increased awareness of “stroke alert” increased (54% to 71%), used a provincial level plan of action (55% to 71%), used secondary stroke prevention guidelines (46% to 77%), and developed a primary prevention plan in at-risk patients (62% to 86%). In the future, it is hoped that the network hospitals will develop the capability to administer thrombolytic themselves. 3. Maharaj Nakorn Chiang Mai Hospital and the healthcare team now have guidelines in patient management, health care workers have increased their knowledge of how to refer patients to the appropriate health care setting where they can receive the most timely and effective care. 4. For patients, efficient referrals have led to more rapid and timely care due to the development of the call center and the stroke fast track system, risk has decreased, mortality lowered, rates of patient independence increased after receiving care, which can be seen in the chart below. The number of patients receiving thrombolytic increased each year from 2008 to 2012, starting with 10, then 27, 51, 97, and 81 respectively. In terms of the percentage of stroke patients receiving thrombolytic in the three provinces per estimated number of stroke patients eligible to receive thrombolytic, there were 90% in 2008, 96.42% in 2009, 96.07% in 2010, 97.90% in 2011, and 98.39% in 2012. 5. Percent of patients at 3 months after treatment can take care themselves and do not need help from family member increase from 41% to 64% to 90% during 2010-2011-and 2012. Thus, the community has less burden of taking care of paralytic patients.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The comprehensive stroke patient care program under the Maharaj Nakorn Chiang Mai Hospital network is sustainable due to the following: 1. There is a culture of working cooperatively between organizations in order to achieve targets that are perceived as significant. 2. The government-funding source, the NHSO, is a strong supporter of continuing the program. The system will be fully covered under the NHSO starting in 2012, which should make the program more stable. Nevertheless, the NHSO will continue to play a supporting role in the program, whether by providing funding or equipment as needed to continue to meet the patient care demand (the program has moved from being a special project to a routine service) 3. There was a monitoring system for each step of the process to make sure that goals were reached on a continuous basis both from NHSO, an independent quality assurance board for hospitals and an internal self-evaluation by program itself. The referral system, with NHSO support, would be transferrable, with some minor adjustments, to management of any chronic disease. There is also a committee that meets regularly to oversee practice guidelines and a patient care manual that could be adapted for use at other hospitals. 4. Hospital administration supported the program by making it a high priority and facilitating patient care by providing personnel, facilities and equipment. 5. The Ministry of Public Health designated the stroke unit as a high national priority in the plan to develop the national public health policy, edition 7, which is released this year. The comprehensive stroke patient care plan could be a model for other health institutions to implement or copy in the management of patients with any chronic illness due to the following features: 1. Clear practice guidelines and steps in case management 2. A standardized manual with a care map could be adapted for use in any hospital 3. An electronic support system for facilitating communication between network hospitals The resulting network development and dissemination of information through the network for stroke patient care in the community hospitals by introducing practice guidelines and a patient care service manual with a patient care map and standing orders, could be adapted and used to formulate comprehensive stroke patient care at the local level. Health care facilities that can administer thrombolytic and provide complete care and, in the future, become sponsoring care centers for other local health care facilities. Currently, Phrae Provincial Hospital has become such a facility and in the next year there will be two hospitals, NakornPing and Lumpun Provincial Hospital, which will also be able to completely manage stroke patients. Maharaj Hospital will provide temporary support during the initial phase. This is further evidence demonstrating the transferability of the initiative to other hospitals.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
1. We learned how to manage patients systematically, establishing procedures both outside and inside the hospital, using two-way communication that had not been done before, involving a multi-disciplinary team including non-medical personnel, such as elevator operators and transporters, for example. Every part of the process is significant for successfully providing timely care for stroke patients and it is important that every person involved understand that their role is significant because efficient time management leads to success in treating stroke patients. Making every component understand the goal of the organization will make everyone work together as a team voluntarily, which is the heart of success. 2. Patient testimonials of recovery after stroke treatment shared with others in the community and returning to normal life attest to the success of the care received after stroke. This showed that the program was accepted by those with experience in it as patients, which increased confidence in the rest of the community. This led to the network hospitals being more successful in establishing patient care units which then builds on further success increasing the program’s success even more. 3. Knowing roles and responsibilities, and capabilities of the hospital in the network led to seamless, quality care. If hospitals and individual units work independently without regard for working together, then targets will not be achieved. 4. The strength of communities and their members was seen when they received information and raised awareness that led to improved screening and referral of stroke patients in a timely manner. Patient rehabilitation and recovery after discharge from the hospital was educational as well, showing that the brain is able to recover, at least partially. One patient initially in a comatose state, unable to care for themselves for 40 days, recovered consciousness, which led to the sense that the efforts to provide care and the courage of the patient together lead to better outcomes.

Contact Information

Institution Name:   Maharaj Nakorn Chaingmai Hospital
Institution Type:   Government Agency  
Contact Person:   Dr. Nisit Wattanatchariya
Title:   Vice director of the hospital  
Telephone/ Fax:   + (66) 53 945154
Institution's / Project's Website:  
Address:   110 Intavaroros Road
Postal Code:   50200
City:   Muang
State/Province:   Chiangmai

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