Questions/Answers

Heart/cardiovascular attack is the world's leading cause of death (23.3%), most of which occurs during productive age. Indonesia is no exception with heart and blood vessel disease ranked as the number one at 35%. Referring to the calculation used by European Society of Cardiology (ESC), Tulungagung Regency with a population of 1,089,775 is estimated to have the incidence of heart attacks at 469 to 1,569 people per year. Death from a heart attack occurs due to delayed handling, where patients are treated more than the golden (critical) period, under 180 minutes. The response time in 2015 was 250 minutes, and death rate of 19.3%. In 2015, only 88 patients experiencing heart attack brought in to Dr. Iskak Hospital, far below the estimates. This is due to several things, namely low public knowledge on the signs/ symptoms of heart attack, geographical factors, socio-economic status of the community varies, the high cost of intervention and 65,000 poor people in Tulungagung Regency are not covered by government insurance. These cause all patients to arrive late so that the treatment exceeds the golden period. Iskak Hospital made a breakthrough in the form of Integrated Acute Coronary Syndrome Service (Laskar) which implements special strategies to get a fast response time in pursuit of "golden period" cases of heart attack. First, educating public and other stake holders outside the hospital; Secondly the formation of an integrated team that collaborates between pre-hospitals (active action to treat patients from before arriving to the hospital) with intra-hospital (a hospital team that coordinates with the prehospital team and performs treatment preparations in the hospital based on the initial diagnosis). The challenge that LASKAR innovation aims to overcome is how to most efficiently and effectively provide certainty of access, speed, accuracy and quality of service to people with heart attacks.

It is relevant to the fostering innovation category to deliver inclusive and equitable services Medical services provided are carried out by expert cardiologists based on the international guide line, free for the poor (26% of patients), focusing on ease of access, speed , the accuracy and quality of service regardless of socioeconomic status or gender of the patient. Public safety center (PSC) 119 provides easy and equal access. Anyone can call or press the emergency button, and to reach the remote area, LASKAR is cooperating with Indonesian Resident Amateur Radio network and Amateur Radio Organization of the Republic of Indonesia

LASKAR's innovation focuses on treating Acute Coronaria Syndrome which is the leading cause of death in Indonesia which occurs because of the late treatment and low level of public knowledge on coronary syndrome. LASKAR Innovation aims to accelerate the response time of heart attack patients handling by integrating all facilities and health workers actively from the beginning before arriving at the hospital (pre-hospital) to conducting collaboration between the prehospital team with intra hospital in accordance with international standards. Therefore, when the patient is referred to the hospital it only takes zero minutes for the patient to get the right treatment. LASKAR innovation actively disseminates and educates the public about the signs and symptoms of a heart attack, how to provide first aid and how to get help with health facilities. This increases the understanding of people who are willing to go to the hospital from only 88 people in 2015 to 451 in 2020. Through a collaboration approach, this system managed reduce the heart attack mortality rate from 19.3 % (2015) to 10.8 % (2020). This is in line with the SDGs Goal Indicator 3.4.1. Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease.

1. Social term; The Increased public understanding of the symptoms of heart attack and ease of access to services make the community increasingly aware of the importance of handling in golden period time to prevent disability and the risk of death, shown by the increasing number year by year. 2. Local government and Dr. Iskak Tulungagung Hospital guarantee citizens who are unable and not covered by insurance to get free services. Dr Iskak Hospital managed to become the hospital with the cheapest service tariff in Indonesia in Percutaneous Coronary Intervention and thrombolytic with the best service and still earned profit.

In general, hospital services in Indonesia are passive and this can cause heart attack patients to lose a golden period of only 180 minutes and cause fatal events, disability or death. LASKAR innovation encourages hospitals to be proactive by providing pre-hospital services in 2 ways: Firstly, educating to the community on how to recognize and overcome heart disease and how to get the hospital. Secondly, providing Public Safety Center (PSC) 119, people simply call 119/0355-320119 or press the android-based emergency button. For those who do not have a phone can ask for help from amateur radio organizations of Indonesian residents. PSC will instantly response, diagnose, give temporary treatment to provide mobile EKG and ambulance pickup. People who cannot afford and do not have insurance will get free assistance and services from Dr. Iskak Tulungagung General Hospital and the district government. This makes the less fortunate group not hesitate to seek treatment. The collaboration between the pre-hospital team and the intra-hospital team makes the response time of heart attack in golden periode can be achieved. Response time for thrombolytic is 70 minutes, and PCI response time is 131 minutes, which is still far below ESC standard of 180 minutes.

Cardiac emergency services do not distinguish gender, because Laskar Innovation prioritizes patient center care and patient safety. Anyone who has a heart attack is treated with established standard operating procedures so that the services provided are the same and there is no difference between men and women, rich or poor. The Tulungagung local government and Dr. Iskak Tulungagung General Hospital even budgeted service costs for 65,000 poor people in Tulungagung Regency who do not have health insurance.

The target group is the entire community of Tulungagung regency, especially 65,000 destitutes in Tulungagung Regency who have not been covered by National Health Insurance. The LASKAR innovation has succeeded in reducing the death rate of heart attack patients from 19.3.% in 2015 before its establishment to 10.8 in 2020 and shortened the response time handling according to European Society of Cardiology (ESC) standards. LASKAR innovation system that integrates the pre-hospital with the Intra hospital team using information technology-based telemedicine practices has also succeeded in saving lives of 1,560 people per in 5 years and 52% among them are the productive age group of 30 – 60 years of age. Not only people who live close to the city / hospital get the services but also those who live in the suburbs of Tulugagung,32% of these include patients without national health insurance. People who used to neglect heart attack symptoms were educated through programs conducted in all sub-districts, schools, NGOs and boarding schools about the signs and symptoms of a heart attack and provides first aid and ways to get assistance in health facilities as well as information on providing free services for the low income group without health insurance.

In December 2015, the Public Safety Centre (PSC) was built. It is a development of telemedicine based Modern Emergency Department Installation integrated with 32 Community Health Centers,11 Private Hospitals, Police, Regional Disaster Management Agency, Fire Department, The Indonesian Red Cross. People who contact the PSC will be followed up by Call taker who responds based on health protocol guidelines. Dispatcher discusses with the supervisor's doctor to determine the next step. There are two types of responses that dispatchers give: First, non-severe condition patients are directed to the nearest primary care health facility that has become a provider or picked up by the nearest pre-hospital team for help and assistance. The heart record is sent online to the Call centre and to the cardiologist. Based on the results of the heart record, the cardiologist decides whether the patient only needs to be advised and monitored at a primary health care facility or he/she should be sent immediately to the hospital. Second, patients with severe condition is immediately picked up by the nearest pre-hospital team of the nearest health facilities or to be taken directly to the hospital's emergency department. LASKAR monitoring and evaluation are carried out every 6 months. Based on the December 2019 evaluation, a weakness was found in the system, that it is not able to know the location of the patient accurately. This weakness is overcome by the addition of the Emergency Button feature utilizing the Global Positioning System (GPS). When the emergency button is pressed for three seconds, the guard at the Call Centre will know the patient's position to facilitate help. Since December 2019, it has been equipped with post hospital services to monitor patient consumption after discharge from the hospital. During the Covid-19 Pandemic LASKAR is useful for reducing Covid-19 transmission and protecting Co-morbid patients.

The implementation of LASKAR Innovation both with drugs and the installation of heart rings is a costly health service, so it becomes an obstacle for the poor who do not have a social insurance. To overcome these obstacles, Dr. Iskak Tulungagung General Hospital provides a budget of three billion rupiah per year for operations and finances guarantees for poor patients without insurance. Other obstacles are low public knowledge of the symptoms of heart attacks and the use of information technology, addressed by providing education on heart attack symptoms and training in the use of information technology to the public.

In developed countries, the treatment of coronary heart attack patients with primary PCI according to international standards of less than 180 minutes from the start of symptoms is not difficult. However, in the context of Tulungagung regency , the handling of heart attack patients by the LASKAR Team of Dr. Iskak Tulungagung General Hospital is very innovative because by utilizing a simple heart recording tool, electrocardiography, telemedicine-based practice on simple information technology and collaboration between pre-intra hospital teams with primary health services , plus guarantees for the poor, it is able to achieve PCI response time according to international standards.

The innovation is inspired by 911 emergency services and the application of innovation of Modern Emergency Installation. It is modified by organizing proactive emergency services equipped with pre hospital care with patient Acuity Category System adapted from modern emergency department. This innovation is the first in Indonesia and is very relevant to be applied in other regions in Indonesia and developing countries. What is needed is the dissemination of understanding, collaborative teamwork systems utilizing telecommunications and existing health resources. Another innovative approach is that hospital not only perform curative and rehabilitative services, but actively provide promotive services by educating communities.

The integration of LASKAR innovation with the Public Safety Centre system is made possible by the utilization of information technology, telecommunications and telemedicine practices towards single data on heart attack cases in the community. This integration allows all health facilities in Tulungagung Regency to exchange patient information which enables faster and easier patient care. By integrating health care facilities using this information technology, space and time limitations are no longer an inhibitory factor in efforts to provide help to patients who have a heart attack. In addition, data integration and information disclosure can also ensure accountability for health services.

LASKAR Innovation transfer has been carried out in Mataram City, Nusa Tenggara Barat Province, and Malang Regency. Mataram transferred the whole idea, set up Emergency units and PSC and use the same application as Tulungagung Regency. NTB Province hospital is currently conducting modern IGD and PSC set-ups with help from experts and supervisors from Dr.Iskak General Hospital. Malang Regency implements the overall innovation model of LASKAR into a sister hospital, even an Emergency Specialist from Dr. Iskak General Hospital was assigned in Malang regency hospital. To date, Riau Province and Central Java province have visited Dr. Iskak Hospital and studied LASKAR innovation. The Indonesian Society of Cardiovascular Specialists (PERKI) established Dr. Iskak Tulungagung General Hospital as a benchmark for cardiac emergency services and used it as a learning center for cardiologists from all over Indonesia by organizing a national seminar and Live Demo Proctorship system to implement the LASKAR model every year since 2017. There have bee 107 both government and private hospitals that have visited and learned about LASKAR innovation. Dr.Iskak General Hospital makes itself a home of cardiac emergency innovation learning and provides assistance for other regions wishing to adapt LASKAR Innovation.

has been transfer

Resources needed for LASKAR Innovation: 1. Financial resources: a. APBD (Local Budget) worth Rp 8.5 billion for the purchase of cardiac catheterization tools. b. Dr. Iskak Tulungagung General Hospital Budget to educate cardiologists and nurses, education to the community and operational costs, worth 550 million per year. 2. Human resources LASKAR Innovation human resources : a. Cardiologist, as the leader b. Emergency specialist c. Trained general practitioners d. Trained nurses e. Trained ambulance driver f. Doctors, nurses and ambulance drivers at local health centers as a network g. Call taker and Dispatcher Officers

Key factors of Laskar Innovation are: a. Strengthening institutions: Tulungagung Regency Local Regulation number 6 of 2018 on Public Service. Decree of the Regent of Tulungagung Number: 188.45 / 80 /013/2016 Management Team Response Time Of Acute Coronary Syndrome (ACS) Cases in the Community and local regulations that require hospitals and local governments to bear public health financing such as and operational costs of LASKAR teams. b. Operational Standards of LASKAR team procedures c. Monitoring and periodic evaluation d. Support from the Regional Representative Council and local government to allocate the budget in the Regional Revenue and Spending budget.

Yes

LASKAR innovation is evaluated periodically by: 1. Internal parties by the Acute Coronary Syndrome team and hospital management in the form of analysis and evaluation of monthly reports, annual semesters on response time, adequacy of infrastructure and human resources, community complaints. 2. External Parties a. Indonesian Society of Cardiology Intervention in the form of a detailed report on condition of the patient after reperfusion. And then they will evaluate outcomes of reperfusion on proctorship activities every years in Dr. Iskak Tulungagung General Hospital. b. The Independent Institute (University) conducts a patient satisfaction index survey periodically every 6 months.

Indicators used in the evaluation are: 1. Number of heart attack incident calls in the community received by the call centre 2. Thrombolytic response time, instrumen; time from diagnosis to initiation of thrombolytic drug 3. Number of fibrinolytic patients undergoing thrombolytic 4. Fibrinolytic response time 5. Number of primary PCI actions 6. Primary PCI response time,instrument; the time it takes from the time the diagnosis is made until the puncture of the vein 7. Number of STEMI patients without reperfusion 8. Number of community complaints 9. Level of Community Satisfaction (questioners) 10. Number and type of technical problems and coordination

1. Improved public knowledge proven by the increase of visits of heart attack patients from 88 (2015) patients to 451 (2020), and access to PSC Call Centres increased from 707 (2015) to 4,352 (2020) 2. Thrombolytic referral response time, from 250 minutes average (2015) to 70 minutes average (2020) 3. Number of Primary PCI actions before innovation: 0 and after innovation until 2020: 505 4. Primary PCI response time before innovation: NA; after innovation averages 139 minutes 25 seconds 5. Mortality rate of heart attacks decreased from 19.3% (2015) to 10.8% (2020). 6. Public Satisfaction Survey result on public services from 77.66 (2015) to 85.63 (2020) (see appendix 2020 LASKAR Executive Summary) Some of the evaluation results followed up are: 1. Should to add 1 intervention consultant cardiologist, and 1 imaging consultant cardiologist.In January 2021 had been sent to fellowship. 2. Based on the results of evaluation and analysis there was a need to add catheterization tool and it was purchased in June 2021.

The vision of Indonesia Go Healthy 2025 Ministry of Health of the Republic of Indonesia is the achievement of healthy living rights for all levels of society through a health system that can ensure living in a healthy environment, proactive community in maintaining health and equal access to quality health services. Heart and blood vessel attacks became the main cause of death in Indonesia, and to address the achievement of health development goals and vision, Tulungagung regency established LASKAR innovation based on the Decree of the Regent of Tulungagung Number: 188.45 / 80 / 013/2016 Management Team Response Time Of Acute Coronary Syndrome (ACS) Cases in the Community. Education and counseling efforts by the LASKAR team to the public about the symptoms/signs of heart attack and first aid in cases of heart attack are in accordance with the preventive and promotive task of community health center. Collaboration of pre-hospitas, intra- hospital and post hospital becomes the backbone to achieve healthy Tulungagung Regency. One of the forms of regency support for the national policy is to open itself into a home of learning and willing to become a facilitator, trainer and supervisor in encouraging the transfer process to other areas.

Parties that have contributed to the development of LASKAR (Integrated Acute Coronaria Syndroma Service) are: 1. Tulungagung Regency Parliament is involved in the discussion and endorsement of budget/financing. 2. Regent of Tulungagung, making a Laskar Team Decision Letter 3. Head of Tulungagung District Health Office as coordinator of provider Community Health Centres 4. Head of Tulungagung Regency Regional Development Planning Agency as Budget/financing planner 5. Head of The Office of Financial and Asset Management Tulungagung Regency provides budget/financing and inventory of assets. 6. Director of Dr. Iskak Tulungagung General Hospital is responsible for LASKAR Innovation operations 7. 32 Community LHealth Centers in Tulungagung Regency as a provider 8. Medical staff, nurse’s and ambulance driver’s in health centers as implementers 9. 2 Emergency specialists and nurse’s of Emergency Departmen at Dr. Iskak hospital as the implementer of LASKAR innovation 10. 6 Cardiovascular Specialists with nurse’s as implementers of LASKAR innovation 11. The general public accessing LASKAR innovation services 12. Local print and electronic media are involved in controlling the implementation of LASKAR innovation 13. Evaluation conducted by: Regent of Tulungagung Regency Regional Head, Director of Dr. Iskak Tulungagung Hospital, Head of Tulungagung District Health Office, All doctors and staff involved

Collaboration is the key word to the success of LASKAR innovation. 1. Other important lessons that can be learned from LASKAR innovation include; to achieve goal 3 target 4 Indicator 1 SDGs is to reduce mortality due to heart attacks, Indonesia has a target of lowering to one-third by 2030. Tulungagung Regency has managed to reduce deaths caused by heart attacks by 44% within 5 years. This achievement is made with a simple and low-cost strategy as long as it is done collaboratively, building partnerships with all stake holders and communities. This strategy is very suitable to be applied in developing countries. 2. To improve the performance and benefits of this innovation, periodic monitoring and public awareness of their rights and obligations is required. Public control is indispensable to maintain awareness of the performance of hospitals an all stake holders involved in innovation. 3. In the future, LASKAR will continue to educate people about the symptoms/signs of a heart attack, how to provide first aid in cases of heart attack and how to access Heart attack service centers to all levels of society through schools, community organizations both formal and informal.