| 4. In which ways is the initiative creative and innovative?
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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.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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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.
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| 6. How was the strategy implemented and what resources were mobilized?
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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.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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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.
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| 8. What were the most successful outputs and why was the initiative effective?
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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.
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| 9. What were the main obstacles encountered and how were they overcome?
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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.
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