Questions/Answers

Acute ischemic stroke is a frequently detected disease that causes deaths and disabilities. A standard treatment can reduce mortality rates. To illustrate, the prescription of thrombolytic drugs can dissolve blood clots and restore blood flows to the brain. The drug should be prescribed within four hours and a half to patients with symptoms. It can be done by the “Stroke Fast Track” system to provide a convenient patient service. Moreover, a complicated treatment like endovascular thrombectomy for patients with large vessel occlusion is more effective than merely using thrombolysis and is a standard treatment for acute care patients. Nopparat Rajathanee Hospital (NRH) is a community health care center in eastern Bangkok. It is responsible for the population within the areas, in which around 600 to 800 people were found to have an acute ischemic stroke. It is a critical disease that holds third place in the number of patients in an in-patient department. Nevertheless, it is found that access to standard treatment is low because of two main conditions. The first one is the patient conditions such as a distance from facilities, an inconvenient transportation system, lacking knowledge of treatment and medicines, and limitation of medical welfare of migrant workers. The other one is the hospital conditions including insufficient and inexperienced staff. The stroke team of the Nopparat Rajathanee Hospital is developing the system called “Stroke Fast Track” (SFT) as a one-stop and convenient service to help patients equally access a standard treatment.

The NRH Stroke Fast Track project was nominated for the prizes within the first category; ‘Fostering innovation to deliver inclusive and equitable services’. It aims to provide an acute stroke service with equality to every patient. Initially, the cooperative development was among the interdisciplinary units. It started a facilitating innovation and adjusted a service system to be quick and flexible. The project was expanded to affiliated hospitals that lacked potential services. The telemedicine and tele-consultation were supported the system and continually improve services by creating a Mobile Stroke Unit service to equitably access to everyone, comprehensively in eastern Bangkok areas.

The project to develop a Stroke service aligns with the third Development Goal. Good health and well-being mean to especially reduce mortality rates from acute ischemic stroke (3.4 Reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being). Stroke and chronic non-communicable diseases are closely related. Reports of the project found that death rates from an acute ischemic stroke of the patients of the Nopparat Rajathanee Hospital have met the benchmark. Apart from the treatment using standard thrombolytic drugs, a prompt referral of complicated cases, and inclusive patient services, the Nopparat Rajathanee stroke service consists of a multidisciplinary team to continually give physiotherapy, nutrition, and mental health care. It aims to completely rehabilitate patients into society. Moreover, the hospital is in charge of other chronic non-communicating diseases (NCD) that are capable of increasing the risks of heart and vascular diseases. It purposes to prevent the recurrence of stroke.

The NRH stroke treatment service is integrated into other cooperative units. In the beginning, it has built knowledge communication and generated clear treatment guidelines for medical staff. Cooperations were well received. There is a knowledge transfer system among community hospitals, conferences to regularly discuss feedbacks, and joint actions between public and private hospitals. In addition, there is also a benchmarking process of stroke care by universal criteria from state agencies and private organizations. It culminates in a system for sustainable social services.

Standard stroke treatments including thrombolytic drugs, endovascular thrombectomy treatment, and Stroke Unit admission can prevent mortalities and disabilities. Inclusive care with multidisciplinary units can decrease medical complications, duration of hospital admission, and recurrence of a disease. It helps reduce the workload of overall and long-term medical services. Moreover, network co-ordinations make hospitals share vital medical resources such as neurologists, stroke nurses, thrombolytic drugs, and stroke unit wards during acute stroke care. It helps save the costs of medical treatments that are high-priced for people in remote areas and reduce the use of government resources and spending.

A stroke treatment service targets all patients. It is a qualified emergency treatment. It can be provided to every patient for the maximum benefit regardless of patient rights. The Nopparat Rajathanee Hospital is located in an area where a lot of people came for medical services including migrant workers who lack the opportunity or cannot afford the costs. So, they can fully get standard treatment. Besides, the hospital is trying to develop a mobile stroke unit to provide comprehensive services for people at a distance or vulnerable groups that are unable to get to the hospital by themselves.

All of the acute ischemic stroke patients, especially those who registered to the Stroke Fast Track, are a target group of a development project. The expected positive effects are that the patient’s death rates and disabilities are reductive, and their quality of life is improved. Statistics from previous operations show that access rates to the STF and the taking of thrombolytic drugs are increasing (chronologically from 42.2% to 47% in the 2021 budget year). The SFT service with integrated multidisciplinary care affects the death rates from stroke in standard criteria which are 4.3% in 2019, 4.7% in 2020, and 2.5% in 2021 (the goal is less than 5%). Medical complications from thrombolytic drugs are satisfyingly low, which are 2% in 2019, 1.3% in 2020, and 2.5% in 2021 (the goal is less than 6%)

In 2017, the NRH Stroke Unit was set up and the potential development of the Stroke Fast Track team of the Nopparat Rajathanee Hospital was initiated. In 2018, the hospital proceeded with the SFT by becoming an affiliated hospital and providing medical consultation via the telemedicine of King Chulalongkorn Memorial Hospital. There was an interdisciplinary staff undertaking treatment in a stroke unit. In 2019, the Nopparat Rajathanee Hospital developed the SFT, invented the ‘SFT stretcher’, improved the computer tomography (CT) scan result archiving and communication system, and coordinated with the team via Line application. The hospital conducted its own medical team and staff. Moreover, the team fixed systematic delays by reducing time-consuming processes and developed the Patient Care Team Round (PCT) by a multidisciplinary team for treatment planning on stroke unit care. In 2020, the Nopparat Rajathanee Hospital became a community health care center and the original affiliation of stroke network. We received a clinical consultation and referred patients to the hospital. We have two affiliated hospitals which are Wetchakarunrasm Hospital and Khlong Sam Wa Hospital. They coordinate and provide assistance through telemedicine. In October, 2021, the Mobile Stroke Unit was navigated in the hospital’s areas of responsibility.

1) Awareness and service comprehension of staff can be solved by training and presenting patient cases and potential benefits that would bring more understanding and mutual operations. 2) Medical staff insufficiency due to overloaded patients and rapid service expansion can be solved by increasing the number and potential of staff. Still, the problem affects services during a COVID-19 crisis. 3) Mobile Stroke Service Unit service because of an inconvenience in small or restricted service areas can be solved by complying with private enterprises. For instance, affiliated petroleum companies of the PTT provide areas in gas stations to facilitate the service.

NRH’s acute ischemic stroke treatment process is developed to be a regional innovation following the principles of self-dependency and broad beneficence. There is a creation of facilitation equipment and a connected communication system. Furthermore, the lessons learned can be passed to nearby hospitals that still lack the potentials to create acute ischemic stroke networks. There are seminars on consultation and development feedback. And, an innovative service of the Mobile Stroke Unit provides a quick CT scan and can treat stroke by instantly prescribing thrombolytic drugs in an ambulance. The objectives of the project are to expand inclusive and equitable services.

A stroke treatment using the Stroke Fast Track is certified by a universal standard. The NRH proceeds and applies it by initially becoming an affiliate to the King Chulalongkorn Memorial Hospital. It later became a community health care center of eastern Bangkok. In addition, the hospitals are supported by the Department of Medical Services of the Ministry of Public Health to broaden a service. The hospital procures the Mobile Stroke Unit to align with the Stroke Service plan of the 13th Area Health in eastern Bangkok. The innovation is considered to provide public health services for regional human resource development.

Technology is constantly used with a service i.e. an application to connect a medical team and patient information among the co-operating hospitals, an online CT scan result archiving which allows physician to check and consider a timely treatment, telemedicine and teleconsultation on the Mobile Stroke Unit, and a GPS tracking system which helps a medical staff constantly and confidently treat patients.

The Nopparat Rajathanee Hospital has transferred knowledge about development guidelines of stroke treatment to other affiliated hospitals. It is expected that they develop their potentials and independent system such as organizing a workshop on a topic of the Stroke Fast Track on December 16, 2020. As of now, the Wetchakarunrasm Hospital, one of the affiliates, is initiating its own SFT system.

The answer is shared with 7a.

1) Interdisciplinary staff from ten different units of the hospital such as neurologist, stroke nurses, emergency medical team, radiological technologists, pharmacists, hospital porters, nutritionists, including staff from affiliated hospitals. 2) The budget for a Mobile Stroke Unit procurement funded by the Department of Medical Services of Ministry of Public Health. 3) The public-private co-operations with the company groups of the PTT providing areas in gas stations for the Mobile Stroke Unit service

Because stroke is a vital disease that the Ministry of Public Health is concerned with the treatment and medical development, policies and supports of the government are essential mechanisms to mobilize a process. It is conducted via coordinated development plans of different Health Areas. Moreover, a stroke service of the Nopparat Rajathanee Hospital is integrated with cooperation from both internal and external units. There are clear codes of treatment guidelines, benchmarking criteria, and public-private stroke treatments with a continual universal standard. They culminated in sustainable social services.

Si

The NRH Stroke treatment system and the Stroke Fast Track are supervised and obtained a quality assurance to establish a Stroke unit from the Department of Medical Services of the Ministry of Public Health in 2019. Furthermore, the hospital is certified with the WSO Angels Award: Thailand on a Gold Status in 2020 and 2021 to provide a stroke service. The evaluation was done by maintaining indicators from patients in the hospital. The awards indicate the potentials of stroke treatment with a universal standard, referring to benchmarking of the European Tier system of the European Stroke Organization (ESO).

The performance indicators consist of: 1) The indicators of treatment processes such as the Stroke Fast Track service access rates, thrombolytic drug access rates, and short prescription periods of thrombolytic drugs to patients 2) The results of treatment such as mortality rates of acute ischemic stroke patients, complication rates from thrombolytic drugs, and proportions of well-recovered patients after being treated. The evaluated equipment which consists of treatment data tracking, medical team operations, and data collection of service satisfaction

The Nopparat Rajathanee stroke care development process suggests that the outcome indicators have reached satisfyingly level. For instance, there are increasing numbers of patient who can access the SFT and get the thrombolytic treatment, 29 to 144 patients per year from the first year to 2021. Patients received faster prescriptions of thrombolytic drugs. The percentage of patients with ‘Door to needle time’ within 60 minutes is increasing from 22% to 87.4%. Mortality and complication rates from thrombolytic drugs meet the standard. In addition, there are continual care and development processes that can expand services to larger and more inclusive areas. Public relations of a stroke service can raise awareness among the locals of the importance of stroke prevention including risk factors from non-communicating diseases (NCD).

The Nopparat Rajathanee Hospital stroke development project was originated by co-operations among the hospital’s different units to analyze problems within the institute. The problems could be solved by improving the skills of staff and creating a network of care services which was cooperated by the King Chulalongkorn hospital as an original affiliated hospital for treatment consultation. There are co-operations among 10 units of the hospital that strengthen the working process. The hospital later expanded such co-operations to lacking affiliated hospitals. Furthermore, the hospital is supported by the Department of Medical Services of the Ministry of Public Health to provide a cutting-edge Mobile Stroke Unit. There are service co-operations with external institutions such as the Erawan Medical Center and the PTT affiliates, which grant places for temporary medical service with thorough and timely manners.

Internal stakeholders are the Nopparat Rajathanee stroke team consisting of more than ten interdisciplinary units. They have tried to comprehensively improve the skills and potentials of staff, and raise awareness of stroke treatment. Moreover, the stakeholders create the hospital’s coordination system and exchange knowledge and mutual problem-solving guidelines. They aim for qualified, maximum working processes and treatment. External stakeholders consist of affiliated hospitals that cooperate with the service development and outer institutions like the PTT affiliates. They participate in facilitating a safe and convenient caring process for patients. Co-operations within every process aim to generate maximum benefits for stroke patients.

The lessons learned of the processes of the Nopparat Rajathanee ischemic stroke treatment come from system development which is the principle of self-dependency. The hospital has developed within contexts of the institution and persuades every subunit to be benefit-oriented and extract maximum potentials of staff in mutual development. Moreover, it transfers knowledge to nearby hospitals to mutually create stroke networks, and expand the benefits to wider areas. The networks of cooperation among different units will be beneficial to the community, especially the groups of the poor and the underprivileged. They will be able to inclusively and quickly access treatment. As of now, even there is an adjunct service as the Mobile Stroke Unit, we have come up with the ideas to extend additional projects for comprehensive stroke treatment. For example, the development of the Hemorrhage Stroke Fast Track system is cooperated by the neurosurgery unit to develop timely hemorrhagic stroke treatment and reduce patients’chances of death. Besides, the hospital has also developed a treatment for in-hospital stroke patients.