Stroke Service Network (SSN)
Prasat Neurological Institute

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Stroke or “brain attack” is a kind of neurological disease often found in adults and the elderly world-wide. It is an emergency condition and there are two main types (ie. ischemic stroke and hemorrhagic stroke). The most common type is ischemic stroke which occurs when blood vessels which supply blood to the brain has been occluded often by blood clot. A hemorrhagic stroke occurs if an artery in the brain leaks blood or ruptures (breaks open). When these happen, brain cells are damaged, deprived of oxygen and begin to die. When brain cells die during a stroke, abilities controlled by that area of the brain such as memory and muscle control are lost and some patients die. Furthermore, more than 2/3 of survivors will have some type of disability, thereby affecting the patients themselves, their families, the economy and the society. Stroke ranks third as cause of death among people in the developed countries after heart disease and cancer. Reports from the World Health Organization (WHO) show that in each year around 15 million people are afflicted by stroke, particularly in developing countries, and averagely in every 6 seconds, there is around one person dying from stroke. In 2020, it is expected that stroke patients will increase by two folds. Moreover, it has been discovered that stroke contributes to being ranked as the second most important cause of Disability-Adjusted Life Year (DALYs) lost among both sexes (WHO, 2015). In Thailand, stroke is a major public health problem. It is the first cause of death in both males and females of all age groups and accounted about 10% in all cause of deaths, and averagely in every 12 minutes, there is one person dying from stroke. In addition, they are first and third ranking of Disability-Adjust Life Years lost in both sexes. The well-established effective treatments of stroke are giving thrombolytic agent to patients with acute ischemic stroke within 4.5 hours after symptoms onset and treating patients in stroke unit, namely, ward specially managed, under the care of medical doctors, nurses and multidisciplinary teams who are knowledgeable and experienced in dealing with stroke. Although there are these well-established effective treatments, most people in Thailand cannot access to these treatment services due to the lack of the services in the country, particularly in rural area, which lead to high in-hospital dead rate of stroke patients (15.1% in 2009). According to a nationwide survey of regional hospitals (having more than 500 beds) and general hospitals (having around 300 to 500 beds) in Thailand in 2009, it has been found that only 28.2% of these hospitals had stroke fast track service for giving thrombolytic drug, and only 12.9% of these hospitals had stroke unit. Based on this survey, the main reasons why these services are not available are lack of neurologist, doctors and medical personnel who have knowledge and experience in these effective treatment service.

B. Strategic Approach

 2. What was the solution?
Prasat Neurological Institute, which is specialized hospital in neurology, has established Stroke Service Network initiative, which is network included 112 hospitals around the country, and facilitated all hospitals in the network to develop effective treatment for stroke, that is, stroke fast track system for giving thrombolytic drug within 4.5 hours after stroke symptoms and stroke unit, by several processes. The processes included providing several short training courses, self evaluation program, site visiting, benchmarking system and service quality certification system to all hospitals in the network. In addition, for sustainable and continuous development, knowledge management process such as creating, sharing, using and managing the knowledge and information have been applied in the network.

 3. How did the initiative solve the problem and improve people’s lives?
The main objective of the initiative was to reduce in-hospital dead rate of stroke patients in Thailand by facilitating the development of stroke fast track system and stroke unit in hospitals in the network which are hospitals around the country. Apart from being able to save stroke patient’s life, the initiative can also reduce disabilities and improve quality of life of patient. In addition, some patient may get complete recovery with no residual disability. The target audiences who are able to get benefit from this initiative are people living in everywhere in Thailand and having an acute stroke as well as their relatives and their family, regardless of their socioeconomic status. Therefore, the initiative provides benefit to not only individual person but also family, society and the country as a whole. The main strategies to facilitate the development of these effective treatment included academic stroke network establishment by inviting hospital around the country to join the network and using knowledge management processes (eg. essential appropriate knowledge identification, knowledge sharing, benchmarking process, mentoring system, site visiting, etc.) to facilitate the development and provide reward, that is, service quality certification if the hospital has passed the criteria of good quality service.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Prasat Neurological Institute collaborated with the Thai Stroke Society, the Neurological Society of Thailand, and the Royal College of Physicians of Thailand established National Clinical Practice Guidelines for thrombolytic treatment of stroke and how to setup stroke unit, and has distributed to related healthcare professional around the country several years ago. However, just a small number of hospitals in Thailand can provide the service in real practice. Therefore, Stroke Service Network initiative which is an academic network has been established as a tool for engaging stakeholder and Memorandum of Understanding has been signed to develop collaboration between the Prasat Neurological Institute and each hospital. Apart from formal training, a processes of knowledge management have been used to improve the quality of care in each hospital. In addition, quality indicators (e.g. in-hospital dead rate, rate of medical complication, etc.) have been collected and compared among hospitals in the network (ie. benchmarking), the hospitals that have best practices is asked to share experiences among hospitals in the network.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Prasat Neurological Institute implemented the Stroke Service Network initiative, which is academic network included 112 hospitals around the country. The implementation of this initiative has resulted in improving the treatment of stroke patients throughout the country, that is, numbers of hospitals capable of providing fast track service for stroke patients and stroke unit have been increased, particularly in rural region. Because around 168,000 new cases of stroke occur each year in rural region. Therefore, these have resulted in patients of around 168,000 per year in rural region being able to access to fast track service and stroke unit, which lead to reduce the occurrence rate of complications (e.g. chest infection, urinary tract infection, etc.), length of stay in hospital thereby reducing the expenses incurred to the patients themselves, their families and the government. Most importantly, it will go to reduce the in-hospital dead rate and disability of survivors, thereby increasing quality of life of the patients themselves and their families.
 6. How was the strategy implemented and what resources were mobilized?
To reduce in-hospital stroke dead rate in Thailand, it need to establish standard stroke treatment such as stroke fast track for thrombolytic treatment and stroke unit in hospital around the country, particularly in rural area. The implementation steps for establishment of standard stroke treatment services around the country consist of four steps as following 1) network establishment 2) knowledge transference 3) site visiting and 4) service quality certification. Network establishment was done by inviting hospitals in all region of the country to join the network. For sustainable development, Memorandum of Understanding to develop collaboration was signed between Prasat Neurological Institute and each hospital. A set of 29 quality service indicators were developed and recorded in computerized database system for measurement and monitoring the level of development of each hospital and also using as a tool for benchmarking among hospitals in the network. Knowledge transference was performed. Apart from several formal short training courses provided by Prasat Neurological Institute (e.g. 5 days of basic stroke training course for nurse, 5 days of advance stroke training course for nurse, stroke service manager course, pitfalls stroke management for physician, etc.), processes of knowledge management were used to facilitate the development such as creating, sharing, using and managing the knowledge and information have been applied. For seeing the real situation in each hospital, site visiting with walking around each hospital in the network by doctor and multidisciplinary team from PNI were performed. The main purposes of each site visiting were to follow up the level of development, to see the real current situation, to assist performing gap analysis for development, and to give an advice for further development according to context of each hospital. Each hospital was encouraged to do self evaluation periodically by using self assessment form. If the hospital passes those criteria based on self assessment, team from Prasat Neurological Institute will visit those hospital for formal assessment and verification of service quality. Hospitals which fulfilled the standard criteria of the good service will receive service quality certification, that is, stroke unit certification which is valid for 3 years. For sustainable and continuous development, 29 collected indicators have been regularly used for benchmarking among hospitals in the network. The resources for this initiative mainly consist of personnel of Prasat Neurological Institute, namely, the management team, medical doctors specialized in neurology (neurologist), medical doctors specialized in radiology, nurses working in emergency department, nurses working in stroke unit, pharmacists, as well as personnel for administrative work. Budget supporting the initiative come from 3 sources, namely, Prasat Neurological Institute, Department of Medical Services, and the Ministry of Public Health. A greater part of the budget has been spent on conducting training for medical personnel in the network, preparation of documents for training, cost of building the on-line database through the internet, cost of traveling and accommodations in case of conducting site visit to hospitals within the network. At the beginning, the budget was made available by Prasat Neurological Institute only. Later, due to the increase in the number of members of the network, additional budget was supported by Department of Medical Services and the Ministry of Public Health. Hospitals within the network do not pay for the cost of trainings nor the expenses related to visitations.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The initiative was designed by management team and multidisciplinary team related to stroke patient care of Prasat Neurological Institute and of Department of Medical Services after situation of stroke system of care in Thailand and how to improve the quality of care, in term of the whole country, were analyzed. Based on context of developing country as Thailand, the appropriate system of stroke care and appropriate way to implement were determined. The team which contributed to implementation included expert staffs from Prasat Neurological Institute and staffs of the 112 hospitals in the network. Among these 112 hospitals, most hospitals (84.8%) were hospitals affiliated with Ministry of Public Health. Other hospitals included private hospitals (9.8%), medical schools (3.6%), hospitals affiliated with Bangkok Metropolitan (0.9%) and hospitals affiliated with Ministry of Defence (0.9%).

 8. What were the most successful outputs and why was the initiative effective?
The Stroke Service Network initiative has been in operation since 2009 and continuing up to the present. The main outputs of the initiative were 1) trained medical personnel with good knowledge of stroke care (up to present, approximately 3,876 persons) 2) best practice of stroke care in each step of care according to context of each hospital 3) computerized database of indicators for monitoring service quality and for benchmarking 4) increased number of hospitals which had standard of care for stroke, that is, stroke fast track service for thrombolytic drug treatment and stroke unit and 5) learning network for continuous and sustainable improvement. Most of trained medical personnel were nurse. However we also trained medical doctors and other paramedic who involved in the system of stroke care. The context of each hospital are often different from each other. Hospitals that had good performance outcome, evaluated by using quality indicator (e.g. lower rate of complication, lower rate of death, etc.), were asked to share the experience with other hospital by story telling about how to do and then was recorded as best practice for further study by other hospital. Computerized database has been established. Quality indicators (29 indicators) of service care were regularly recorded in the database by each hospital via internet network. We regularly used these data for measurement level of development and also as a tool for knowledge management such as identification of the best practice for sharing, identification of knowledge need, etc. Around the country, the number of hospitals affiliated with Ministry of Public Health, i.e. regional hospitals (having more than 500 beds) and general hospitals (having around 300 to 500 beds), which can provide stroke fast track service for giving thrombolytic drug has increased from 28.2% in 2009 to 98.8% in 2016. Stroke unit service has also significantly increased in these hospitals from 12.9% in 2009 to 61.7% in 2016. Although not all (100%) of these hospitals provided stroke fast track service and/or stroke unit service, these services have covered all regions of the country which lead to decrease in-hospital dead rate of stroke patients in Thailand from 15.1% in 2009 to 8.3% in 2016. For being a learning network, knowledge management processes (e.g. essential knowledge identification, knowledge sharing, mentoring system, etc) have been applied regularly in the network.

 9. What were the main obstacles encountered and how were they overcome?
Although thrombolytic treatment and stroke unit service are effective treatment for stroke, these services are quite novel, particularly for developing country. In addition, to establish these services, it need good cooperation from each member of multidisciplinary team. Therefore, the main obstacles in implementing the initiative were that management team of many hospitals did not recognized that these services is essential and certain parts of the personnel in Prasat Neurological Institute and majority of personnel in other hospital in the country did not have knowledge of these kind of services. Some personnel believed that these treatments were not effective, too complicated and too expensive to be established. To overcome these obstacles, we invited management team including director of regional and general hospitals as well as other hospital in network around the country to join the meeting and gave information about huge burden of stroke in Thailand and benefit of standard treatment service compared with traditional treatment service and asked them to join the network for standard services development together. Apart from management team, we also gave information and benefit of these services to working personnel in each hospital, particularly in term of reducing death and disabilities rate of patients. In addition, we showed the effectiveness, that is, patient had been dramatically improved after received thrombolytic treatment by real case demonstration. During implementation, director or management team of some hospitals were changed which lead to discontinuation of development of the services. To ensure the continuation of development, we asked director of each hospital to sign Memorandum of Understanding with Prasat Neurological Institute.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
As results of this initiative, the number of hospitals which can provided standard of care for stroke (i.e. stroke fast track service for thrombolytic drug treatment and stroke unit) has been increased and established in all region of the country, so people living in every region of the country, regardless of their socioeconomic status, can access to these services. Because of the improvement of service care in hospitals, medical complications and the period of hospitalization were reduced thereby resulting in the reduction of expenses for both the patients and the government. More importantly, in-hospital dead rate of stroke patients in Thailand has been decreased from 15.1% in 2009 to 8.3% in 2016. Furthermore, it was found that dead rate within 1 year after onset of stroke patients was reduced from 32.2% in 2007 to 25.1% in 2012.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Before implementation of the initiative, there was substantial disparities in access to standard stroke services, that is, most people in Thailand particularly in rural area, and people with low socioeconomic status can not access to standard stroke service because the services were just available in small number of hospitals such as some hospitals in Bangkok, some private hospitals as well as in hospitals of medical school. This situation leads to high in-hospital dead rate as well as high rate of severe disabilities of the survivors in Thailand. As results of the initiative, the number of hospitals that can provided standard stroke services were significantly increased in rural area which can reduce the disparities in access to standard stroke services and in-hospital dead rate of patients was also significantly decreased. To develop stroke fast track service for giving thrombolytic drug which has to be given to patient within 4.5 hours after onset of symptoms, as well as to develop stroke unit service, the services which can provide emergency response available 24 hours a day 7 days a week are needed. The commitment of personnel of all levels to make substantial improvements in system of service is very important. In addition, several standard written protocols, based on scientific evidence and context of each hospital, have been established in all hospital in the network. Several quality indicators for measurement of structure of care, performance of personnel and clinical outcome have been implemented. Adherence to standard written protocol have been checked by nurse manager of each hospital. Protocol deviations were discussed with the staffs, and were resolved or confirmed after review of all information. Taken together, the initiative can improve integrity and diminished corruption in the public services.

 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)
Stroke can occur in both sexes and in all age group. Thai Epidemiologic Stroke Study found that Thai people with low socioeconomic status, in particular, unemployed/ house work and illiterate were significantly associated with high risk of stroke. The initiative facilitated hospitals in all region of the country, particularly hospitals affiliated with Ministry of Public Health in rural area, in which standard treatment services were lacking. Therefore, stroke patients can access to standard treatment conveniently, promptly and equitably in every region of the country without any discrimination as to sex, age, socioeconomic status, race, or religion. That means that women/girls as well as the poorest can access to such public health services in the same manner as can other citizen groups of Thailand.

Contact Information

Institution Name:   Prasat Neurological Institute
Institution Type:   Government Department  
Contact Person:   Suchat Hanchaiphiboolkul
Title:   Dr.  
Telephone/ Fax:   +(66) 2 354 5357 /Fax number:+(66) 2 354 5357
Institution's / Project's Website:  
Address:   Prasat Neurological Institute 312 Rajavithi Road
Postal Code:   10400
City:   Ratchathewi
State/Province:   Bangkok

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