A service framework and roadmap for the development of care systems for heart attack and stroke in Kyrgyzstan

Prepared for the Ministry of Health of Kyrgyzstan

By the WHO Regional Office for Europe

A service framework and roadmap for the development of care systems for heart attack and stroke in Kyrgyzstan

Prepared for the Ministry of Health of Kyrgyzstan

By the WHO Regional Office for Europe

AbstractCardiovascular diseases (CVD) cause 50% of all deaths in Kyrgyzstan, and premature mortality from CVD is still high. Clinical care of CVD is costly and prolonged. The roadmap aims to create and transform existing networks, implement better clinical guidelines, use resources more effectively, improve infrastructure and improve performance management. Further, mapping the organization of regional centres for specialized care in acute myocardial infraction and stroke will improve the time indicators of specialized treatment. The roadmap outlines core acute care interventions in acute myocardial infraction and stroke with key design of services and proposes strategic directions to accelerate gains in CVD management.

KeywordsCARDIOVASCULAR DISEASES – PREVENTION AND CONTROLSTROKE – PREVENTION AND CONTROLDELIVERY OF HEALTH CARE – METHODSHEALTH SERVICESKYRGYZSTAN

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© World Health Organization 2018All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization.

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ContentsAbbreviations and acronyms iv

Acknowledgements v

Executive summary vi

Introduction 1

Policy context 1

Guiding principles 1

Core interventions 2

Model of care 3

Prehospital care 3

Hospital care 5

Posthospital care 7

Standards of care and quality indicators 8

Transforming services 8

Roadmap 8

Roles and responsibilities 8

Mechanisms 8

Next steps 9

Annex 1. Members of the CVD Working Group 12

Annex 2. Recommendations for ambulances 13

Annex 3. Standards and performance indicators 15

Annex 4. Priorities for interventions 24

Annex 5. Summary of the roadmap 29

Annex 6. Summary diagrams of the roadmap 30

Annex 7. Possible model of stroke care rehabilitation 34

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Abbreviations and acronymsACS acute coronary syndrome

ADL activities of daily living

AMI acute myocardial infarction

CHADSVASC congestive heart failure, hypertension, age, diabetes, stroke/TIA and vascular disease (atrial fibrillation risk score calculator)

CT computed tomography

CVD cardiovascular disease

DALY disability-adjusted life-year

ECG electrocardiography

FAST facial drooping, arm weakness, speech difficulties and time to call emergency services

IHD ischaemic heart disease

IADL instrumental activities of daily living

MRI magnetic resonance imaging

NIHSS United States National Institutes of Health stroke scale/score

NSTEMI non-ST-elevated myocardial infarction

PCI percutaneous coronary intervention

STEMI ST-elevated acute myocardial infarction

TIA transient ischaemic attack

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AcknowledgementsThe authors of the report are: Jill Farrington, WHO Regional Office for Europe, Denmark; Francesca Romana Pezzella, Neurologist, Stroke Unit, San Camillo Forlanini, Rome, Italy and WHO consultant; Alexei Yakovlev, Cardiologist, Federal Almazov North-West Medical Research Centre, St. Petersburg, Russian Federation and WHO consultant. The authors are grateful for the contributions of the working group of Ministry of Health of Kyrgyzstan and to the many cardiologists, neurologists, managers and administrators who supported the development of this Roadmap.

We also extend thanks to David Breuer for text editing.

The evaluation was produced under the overall guidance of Jarno Habicht, WHO Representative of the Country Office in Kyrgyzstan, and Gauden Galea and Bente Mikkelsen, former and current Directors of the Division of Noncommunicable Diseases and Promoting Health through the Life-course of the WHO Regional Office for Europe.

The WHO Regional Office for Europe and WHO Country Office in Kyrgyzstan coordinated the preparation of this report through the biennial collaborative agreements covering 2016-2017 and 2018–2019 between the Ministry of Health of Kyrgyzstan and WHO.

A voluntary contribution from the Ministry of Health of the Russian Federation co-funded the report.

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Executive summaryCardiovascular diseases (CVD) cause more deaths than any other cause in Kyrgyzstan. Four of five CVD-related deaths are caused by heart attacks and strokes. CVD affects individuals in their peak mid-life years and undermines the development of countries by depriving valuable human resources in their most productive years.

Acute coronary syndrome and stroke have been the priority and the major theme of the national health reform programme Den Sooluk (2012–2016). In 2016, WHO reviewed acute and rehabilitative services for heart attack and stroke. It demonstrated fragmentation of the clinical pathways and lack of clear implementation of guideline recommendations, with most patients not being diagnosed or treated on time. Further, opportunities for better use of resources, health personnel, technology, equipment and drugs were observed.

In 2017, Kyrgyzstan’s Ministry of Health established a working group to design a service framework and roadmap for the development of care systems for heart attack and stroke in Kyrgyzstan. Under the coordination of the WHO Regional Office for Europe and the WHO Country Office in Kyrgyzstan, guiding principles were defined and the service framework and roadmap of actions over the short, medium and longer term were developed, drawing on local data, documents and regulations.

The roadmap proposes ways to strengthen care for coronary heart disease and cerebrovascular disease through health system interventions:

• implementing evidence-informed, affordable and sustainable interventions (best buys) for preventing recurrences of myocardial infarction and stroke;

• identifying sustainable strategies for integrating a new model of care into existing health-care infrastructure; and

• building national capacity to meet people’s health-care needs related to heart attack and stroke.

The document was presented to the Ministry of Health, the national working group and the regions in June 2018 and discussed again in September 2018. The latest version of the roadmap received input from recent consultations and letters from the National Centre for Cardiology and Internal Medicine and from the National Hospital for Neurological Care. The Kyrgyz Society of Cardiologists sent comments as well.

Many organizational changes will be required in existing health services to make them more receptive to the needs of people suffering from heart attack and stroke, working in partnership with families, health-care teams and the community, and more effective. This roadmap proposes a way forward for Kyrgyzstan.

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IntroductionThis roadmap is prepared to follow up the WHO Review of acute care and rehabilitation services for hear attack and stroke in Kyrgyzstan (1), which was presented to the Ministry of Health in spring 2017. Ischaemic heart disease (IHD) and stroke are major causes of premature mortality and years of life lost in Kyrgyzstan, and the prevalence of cardiovascular risk factors is high. The review identified both strengths and weaknesses within the present services, with significant avoidable mortality and disability and lost opportunities for reducing the disease burden and costs. Its 16 recommendations were grouped into three key messages: manage the existing resources effectively; design the system and direct further investment; and demonstrate success.

The main audience for this document is policy-makers within Kyrgyzstan. Therefore, it seeks to be concise and to refer to other more detailed reports where necessary. It focuses on prehospital, hospital and post-hospital care for heart attacks (acute myocardial infarction (AMI)) and stroke (ischaemic and haemorrhagic).

The document was developed in conjunction with a CVD Working Group appointed by the Ministry of Health. Annex 1 presents the members of the Working Group and meeting dates. The process was led by WHO: the WHO Country Office in Kyrgyzstan, WHO Regional Office for Europe and WHO consultants.

Policy contextThis is not a stand-alone document. It is prepared within (and benefits from) a broader policy context and dynamic process of change within the health sector of Kyrgyzstan. The national health reform programme 2012–2016 Den Sooluk (extended to 2018) will soon be replaced by the Health Sector Strategy for Kyrgyzstan (the Programme for Health System Development until 2030, currently in draft form). A service delivery master plan will be developed during 2018. The eHealth strategy was approved in 2016, and the eHealth architecture was developed in 2017. A ministerial decree on emergency care services, with an action plan, was approved in December 2017. National clinical guidelines for AMI (with ST-elevation (STEMI); without ST-elevation (NSTEMI)) and stroke were updated and approved in late 2017 (2–4). Health system changes are also underway: a review of the State Guaranteed Benefit Package; broader consideration of performance- and results-based financing by the Mandatory Health Insurance Fund; improvement in pharmaceutical policies, including price regulation, pharmacovigilance and procurement practice to improve access to essential drugs, such as centralized procurement at the regional level through hospital or pharmacy chains; and improvements to the quality system and service delivery (recent WHO reviews for both are nearing completion).

Guiding principlesThis document is consistent with guiding principles within relevant international and national policy documents, such as those within the draft Health Sector Strategy for Kyrgyzstan of universal health coverage, reducing inequalities in health and state guarantees ensuring quality-assured, safe and effective health care and population health services. In addition, specific guiding principles for this roadmap are:

• evidence-informed practice;

• improving quality, with data driving the improvement;

• consistency of services across the country, reducing variation in care;

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• a unified model of care, common principles of organization and coordination, with emergency services, the hospital services, clinical networks and primary care teams planning services together;

• an integrated approach – effective collaboration between personnel providing assistance at different stages and effective communication of health-care providers across boundaries, with patients at the centre; and

• efficient use of resources: for example, sharing such facilities as an angiography suite, especially when resources are limited.

Core interventionsIn conjunction with the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020, WHO has published a set of cost-effective (“best buys”) and effective interventions, which was updated in May 2017 (5). In addition to preventing risk factors such as tobacco and alcohol use, this contains a limited list of interventions for the acute care of acute coronary syndrome (ACS) and stroke and secondary prevention and rehabilitation following acute events:

• drug therapy (including glycaemic control for diabetes mellitus and control of hypertension using a total risk approach) and counselling for individuals who have had a heart attack or stroke and to people with: high risk (≥30%) of a fatal or non-fatal cardiovascular event in the next 10 years or a moderate to high risk (≥20%) of a fatal or non-fatal cardiovascular event in the next 10 years;

• treating new cases of AMI with either: acetylsalicylic acid; acetylsalicylic acid and clopidogrel; thrombolysis; or primary percutaneous coronary interventions (PCI);

• cardiac rehabilitation after myocardial infarction;

• anticoagulants for medium-and high-risk non-valvular atrial fibrillation and for mitral stenosis with atrial fibrillation;

• treating acute ischaemic stroke with intravenous thrombolytic therapy;

• low-dose acetylsalicylic acid (acetylsalicylic acid) for ischaemic stroke; and

• care of acute stroke and rehabilitation in stroke units.

Only one of these interventions is also a WHO best buy (shown in bold): that is, an effective intervention with cost–effectiveness analysis ≤100 international US dollars per disability-adjusted life-year (DALY) averted in low- and middle-income countries. The rest are WHO “effective interventions”, with cost–effectiveness analysis >100 international dollars per DALY averted in low- and middle-income countries.

In support of the management of hypertension and other cardiovascular risk factors, WHO has issued a set of treatment protocols for use in primary health care (6). WHO also publishes a Model List of Essential Medicines (7) that contains lists of drugs recommended for ACS and stroke care. WHO is also preparing a list of priority medical devices for cardiovascular disease, but it has not been published yet.

Other bodies, such as the European Society of Cardiology (8) (and its specific groups) and the European Stroke Organisation (9) have published evidence-informed clinical guidelines relevant to acute care of ACS and stroke, their secondary prevention and rehabilitation that are widely followed within many countries in the WHO European Region. Although not all follow WHO cost–effectiveness and effectiveness criteria, these clinical practice guidelines and scientific literature promote cornerstone interventions for acute care and rehabilitation. Stroke cornerstones in reducing death and disability are: comprehensive and multiprofessional clinical pathways within a stroke network (10–12); endovascular thrombectomy (11); hemicraniectomy (13) in selected cases; standardized nursing protocols such as the fever, sugar and swallowing protocol (14); and comprehensive pharmaceutical and non-pharmaceutical control of vascular risk factors and rehabilitation (11,15–

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18). ACS care cornerstone interventions in reducing death and disability are: coronary unit care; emergency reperfusion (PCI or fibrinolysis); treatment of acute complications; antithrombotic therapy; cardiac rehabilitation; and secondary prevention.

Kyrgyzstan has published several relevant evidence-informed clinical guidelines: STEMI (2); NSTEMI (3); and stroke (4). Local recommendations do not describe the principles of organization of care and quality control. Some of the WHO cost-effective and effective interventions (listed above) and the proposed cornerstones for ACS and stroke are included, but not all. Otherwise, they appear to be evidence-informed and also reference the relevant European Society of Cardiology and European Stroke Organisation guidelines. Step-by-step introduction of the best interventions into practice should be supported by national recommendations, documents and instructions and orders of the Ministry of Health, and have implementation monitoring tools.

Model of carePrehospital careSummary of the current situation

The previous report (1) describes the current situation in more detail. In general, the public poorly recognizes the early symptoms and signs of AMI and stroke, and the knowledge and skills for appropriate responses are poor, even among health-care professionals.

The ambulance service does not meet modern standards or the population need. It was not planned countrywide according to important criteria such as population density and the location of emergency health facilities and transport routes, so there is unequal distribution of service and poor access in remote areas. Although some specialized cardiological ambulance teams exist that have been trained in acute cardiac care and have electrocardiography (ECG) equipment and defibrillators, generally vehicles are not equipped with life-saving drugs and equipment and ambulance crews are not trained to carry out key investigations such as ECG or to provide immediate emergency care for acute cardiovascular events.

Future situation

According to the national guidelines for stroke and transient ischaemic attack (TIA) and ACS, public information campaigns are needed to raise awareness among laypeople and health-care personnel of the early signs and symptoms of heart attack and stroke and what to do. These can be promoted by government and nongovernmental institutions such as patient and professional organizations such as the Kyrgyz Association of Neurologists and the Kyrgyz Association of Cardiologists. Some materials are already available and being used within the country, such as facial drooping, arm weakness, speech difficulties and time to call emergency services (FAST); other materials are available internationally and can be adapted.

A single emergency care number needs to be promoted so that members of the public call to get an ambulance. Dispatchers need to be trained to give immediate advice to people calling with symptoms of suspected ACS or stroke, maintaining telephone contact with the caller and providing advice on patient management and on cardiopulmonary resuscitation in the event of cardiac arrest until appropriately trained and equipped help arrives. Kyrgyzstan’s stroke and TIA guidelines recommend establishing a stroke care service network, establishing a stroke code, a 15-minute prenotification system (19) and a protocol whereby people with suspected strokes are brought to the nearest hospitals that can provide specialized care.

Emergency funding mechanisms should be designed to stimulate the proper application of the best interventions with proven effect to discourage malpractice, providing support for the proper and high quality of health-care services.

In remote areas, where emergency care is difficult to access and the main health provider may be only a feldsher, the nurse needs to be trained and supported (with handbook and telemedicine support) to assess the patient, perform and interpret ECG and give appropriate first response (such as aspirin, pain relief and oxygen) before transporting the patient to an

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emergency care centre. Kyrgyzstan’s new clinical guideline on STEMI establishes a treatment window of 120 minutes from STEMI diagnosis to primary PCI. This could involve a prehospital setting with a tele-ECG network to select and direct the patient to effective treatment.

There are already plans to modernize emergency care services following adoption of the law, and it is also highlighted as an important topic for action within the draft health-care programme. Emergency services for trauma, ACS and stroke can be planned together. The ambulance response to out-of-hospital medical emergencies can provide basic life support or advanced life support. Basic life support emphasizes rapid transport to the hospital, so basic life support ambulance crews provide only minimal treatment at the scene (“scoop and run”) (20). Ambulance crews using advanced life support are trained and equipped to provide sophisticated care on site (“stay and play”). Apart from improving the ratio and distribution of ambulance to population, the ambulances need to be better equipped to respond to an acute event. Annex 2 lists the equipment and drugs to be included within the ambulance for care of heart attack and stroke.

The road map offers a justified plan of the development of emergency assistance systems for ACS and stroke, which should simultaneously be implemented in the regions for synchronous development and the absence of inequality. In terms of the roadmap, a short-term development (within one year) is to equip ambulances to be able to provide basic life support at a standard level (see Annex 2 for the list of supplies and equipment) and to train ground ambulance personnel to recognize suspected stroke (FAST test) and ACS and start the recommended clinical pathway. A standard ambulance equipped for basic life support seems to offer benefits for nonfatal and longer survival (21) of people with stroke, whereas a specialized cardiological team able to perform thrombolysis for STEMI patients <6 hours after symptom onset in a prehospital setting reduces mortality and disability among people with ACS (see Annex 2 for both the equipment and the medication standard recommended). Therefore, a medium-term development (1–3 years) is to equip ambulances to be able to perform thrombolysis remotely using specialist advanced life support ambulances supported by telemedicine.

A long-term development for stroke care in the prehospital setting would be to develop mobile stroke units if their cost–effectiveness can be demonstrated. A mobile stroke unit is an ambulance dedicated to treating people with acute stroke and similar time-sensitive brain ailments. It contains, in addition to the normal ambulance equipment, a device for brain imaging such as a computed tomography (CT) scanner, a point-of-care laboratory and telemedicine interaction between the ambulance and the hospital (videoconferencing, exchange of videos of patient examination and CT scans). Thus, this specialized ambulance includes all the tools necessary for hyperacute treatment of people with stroke and diagnosis-based triage directly at the emergency site. The use of stroke ambulances increases the percentage of people receiving thrombolysis within the golden hour (22,23). The cost of building and fully equipping a functional mobile stroke unit is estimated to be between US$ 600 000 and US$ 2 million (24). Although currently available cost–effectiveness studies suggest that the expenditure pays off in the long term (25,26), conclusive evidence from clinical trials to support mobile stroke units as being cost effective and improving clinical outcomes is still needed.

Telemedicine support is provided as needed, with a recognized role especially in rural areas. There must be an agreed pre-admission protocol between appropriately trained emergency medical services and the specialist services, with algorithms on dispatch time, assessment, transport strategies within the catchment area and pre-notification that includes: onset time, symptom and sign recognition using a validated tool such as FAST and pre-alert systems. The ambulance crew should provide and record the delivery of appropriate prehospital treatment to people with suspected ACS or stroke and ensure that a defibrillator and someone trained in its use remain at the patient’s side for the whole of the journey from the initial response to the handover in the hospital. Time is heart, time is brain, time is life. The person should be transported to hospital with acute specialist services as quickly as possible and always within a maximum of 1 hour for stroke and 120 minutes for ACS (for STEMI or NSTEMI from diagnosis to reperfusion with complications, for non-complicated NSTEMI 24 hours (time to angiography). The acute stroke service should immediately assess on arrival, enabling timely expert triage of people with acute stroke and the potential for thrombolysis (27).

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Hospital careSummary of the current situation

There are resources (institutions, equipment, trained personnel, training opportunities etc.) that can be considered as the basis for the formation of the structure of regional networks of care in ACS and stroke. The possibilities are described in the WHO report Review of acute care and rehabilitation of myocardial infarction and stroke in Kyrgyzstan (1). Table 1 gives an overview of the current facilities in the public sector for acute care.

Table 1. Hospital facilities (public sector) for acute care: current situation

Hospital CityACS care

PCIHeart

surgeryStrokecare

CT scan Neurosurgery

National Centre for Cardiology and Therapy

Bishkek + + – – – –

Research Institute of Cardiac Surgery and Organ Transplantation

Bishkek + + + – – –

National Hospital Bishkek – – – + – +

City Hospital No. 1 Bishkek – – – + – –

Chuy Joint Regional Hospital Bishkek – – – + – –

Osh Regional Clinical Hospital Osh + – – + – –

Southern Centre for Cardiovascular Surgery

Jalal–Abad + + – – – –

Naryn Regional Hospital Naryn + – – + – –

Issyk–Kul Regional Hospital Karakol + – – + – –

Talas Regional Hospital Talas + – – + – –

Batken Regional Hospital Batken + – – + – –

For PCI, currently a limited number of patients can be treated because of limited resources: that is, catheters and equipment and physician availability round the clock. Stroke unit care is only partly available, and stroke care pathways and multidisciplinary teams are not fully in place. Currently only a limited number of people with ACS can be treated because of limited resources and expertise.

Future situation

Both stroke and myocardial infarction (ACS) are time-dependent diseases that require an integrated care system approach based on a hospital network and protocols that enable rapid diagnosis and timely access to acute-phase therapy within a well-defined therapeutic window.

To optimize resources, both the ACS and stroke networks should be embedded within a broader emergency care system to homogenize their development, implementation and quality monitoring.

It is proposed that the provision of acute care be reorganized based on a hub-and-spoke arrangement (28) whereby the hub centres would have more advanced equipment, more personnel and more diversified and larger resources.

Multiprofessional collaboration and admission to a dedicated department is critical for clinical outcome related to mortality and disability for both ACS and stroke: patients who receives a package of organized inpatient care are more likely to survive, return home and regain independence than those who receive conventional care in general wards.

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Where possible, the hubs for ACS and stroke care should be co-located to facilitate the sharing of staff and equipment and care of comorbidities. For stroke, the principle would be one hub (24/7) for 1.5 million population, with 3–4 spokes per hub depending on population density, geographical location and transport routes between centres, as stated by Kyrgyzstan’s prehospital stroke guideline (2017). For ACS, it has been suggested that one PCI hub centre (24/7) is needed per 300 000 to 500 000 population, performing about 600 primary PCI per million population per year (29).

For both ACS and stroke, telemedicine and phone consultation with brain imaging and ECG transmission should be used to empower spokes, triage patients and review cases (as established in Kyrgyzstan’s stroke and TIA guidelines). Given the burden of CVD disease, a similar number of hubs and spokes for ACS as for stroke would be expected.

Final decisions about the distribution of services might be taken once the service delivery master plan is complete. The CVD Working Group initially thought that the proposed service model for delivering acute services should involve four main providers and the local ambulance service. These four main providers would be placed in Bishkek, Jalal-Abad, Osh and Karakol (Fig. 1). This will also need to fit with the Concept for the Development of the Regions of Kyrgyz Republic 2018–2022, which supposes economic development and employment growth in Chui, Jalal-Abad, Issyk-Kul, Osh and Bishkek in 2018–2019 and sees these regions as a priority for developing health care and emergency cardiovascular care.

Fig. 1. Perspective for development of ACS and stroke services: full implementation of hospital and ambulance master plan level

Legend: blue – ACS care; green – stroke care; red – ACS and stroke care.

Ideally, the four main centres and regional and local hospitals should be part of an ACS and/or stroke service network that has agreed protocols for acute patient triage, assessment, transport and possibly for the use of telemedicine to support the appropriateness of diagnosis, thrombolysis and other acute interventions if senior personnel are not available on site to conduct face-to-face assessment.

The principles of service development are that:

• PCI facilities should be available;

• health insurance models are developed with 100% coverage of emergency care in ACS and stroke including thrombolytic therapy and/or PCI (ACS) or thrombectomy (stroke) and models of payment;

• a programme is developed for educating and certifying health-care professionals for the ACS and stroke care system;

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• prehospital care and logistical models are developed;

• a multilevel system of monitoring, quality control and operational management is created; and

• a public campaign supports early access to emergency specialized medical care.

The barriers to effective ACS care (30), which are also likely to apply to stroke care (31), are as follows:

• patient – social, personal, cultural, financial and religious barriers;

• insurance barrier: low penetration of insurance;

• transport barrier: lack of a centralized ambulance system;

• physician barriers: skills, 24/7 availability and ethics;

• technology barriers: lack of devices, drugs and infrastructure; and

• economic and legislative barriers: lack of legislation supporting infrastructure and resources and reimbursement policies to hospitals and providers.

Posthospital carePeople with stroke and ACS need access to effective rehabilitation services. Stroke rehabilitation is a multidimensional process designed to facilitate the restoration of or adaptation to the loss of physical or mental function when reversal of the underlying pathological process is incomplete. Rehabilitation aims to enhance functional activities and participation in society and thus improve the quality of life. Key aspects of rehabilitation care include multidisciplinary assessment, identification of functional difficulties and their measurement, treatment planning through goal setting, delivery of interventions that may either effect change or support the person in managing persisting change and evaluation of effectiveness.

Summary of the current situation

In Kyrgyzstan, some components of the post-stroke and cardiac rehabilitation process are already in place, but these are limited to Bishkek city. Not all the available interventions are evidence informed. Cardiac rehabilitation facilities are even more limited, and neither post-stroke nor cardiac rehabilitation facilities are organized in a comprehensive clinical pathway.

Future situation

Rehabilitation services are the primary mechanism by which functional recovery and the achievement of independence are promoted among people with acute stroke and ACS. A full comprehensive evaluation (motor, swallowing, cognitive and mental aspects) should be done when the condition of the person with stroke is stable to plan discharge to the proper setting of post-acute care. It has been demonstrated that earlier admission to rehabilitation results in improved overall functional outcomes. People with stroke who are candidates for post-acute rehabilitation should receive organized, coordinated, interprofessional care. Early supported discharge services may be reasonable for people with mild to moderate disability who may attend a rehabilitation programme in outpatient or day service. Evidence indicates that the functional outcomes achieved through stroke rehabilitation are maintained and actually improve for up to one year; by five years after a stroke, functional outcomes plateau and may decline; by 10 years, overall functional outcome scores significantly decline, although it is unclear to what extent the natural ageing process and comorbidity may contribute to these declines. Nevertheless, stroke rehabilitation may be delivered in different settings and with different levels of intensity (see Annex 7 for a possible organization model of setting of care).

Cardiac rehabilitation is a medically supervised programme in which people who experienced heart attack, heart failure, angioplasty or heart surgery receive: exercise counselling and training, education for heart-healthy living to reduce vascular risk factor behaviour and empower cardiovascular-healthy habits. It may be delivered in different settings of care by multiprofessional teams. Primary health care has an important role to play in secondary prevention and preventing further

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heart attacks and strokes. This requires good communication with specialist care on discharge and systematically identifying and following up patients to control CVD risk factors.

Drug therapy with the main groups of medicines (antiplatelets, statins, beta-blockers and angiotensin-converting enzyme inhibitors) for secondary prevention is a method of preventing recurrent myocardial infarction with proven efficacy and should be widely used for all patients. Measures need to be planned to increase the accessibility of therapy (registration, price regulation and benefits) and increase adherence to treatment.

Standards of care and quality indicatorsAnnex 3 suggests a list of evidence-informed standards of care for ACS and stroke together with a set of indicators that can be used for monitoring the achievement of these standards. These are listed alongside the indicators in Annex 3.

Several documents and agencies within Kyrgyzstan propose indicators for monitoring the quality of care for heart attacks and strokes within Kyrgyzstan. These include the Mandatory Health Insurance Fund (12 indicators drafted by 19 March 2018) and national clinical guidelines (eight suggested indicators for implementation). A roadmap for quality systems is also being prepared. A general concern is that the indicators suggested may be: difficult to collect routinely and/or may be open to manipulation; not very useful; too complex and comprehensive to be meaningful; or unclear (such as the indicator on door-to-brain CT: private facility CT? Public hospital neuroimaging service?).

Transforming servicesRoadmapAnnex 4 outlines a roadmap for transforming services for ACS and stroke over the next five years, starting with immediate priorities for the first year, medium-term priorities (1–3 years) and then longer-term priorities by five years. Annex 5 summarizes the roadmap in one page, and Annex 6 contains infographics to overview the roadmap in pictorial format.

Roles and responsibilitiesThe list of stakeholders for agreeing and implementing the roadmap includes: the Ministry of Health; Mandatory Health Insurance Fund; regional and local health administrations; professional and scientific societies and academia; directors, managers and clinicians within public hospitals and health-care facilities; key opinion leaders in the cardiovascular and stroke field; health promotion and public health institutions; and patients, survivors and their families. Several of these are already represented within the CVD Working Group.

The system needs to be designed and implemented at the national, regional and local levels. National and subnational steering groups could comprise the Ministry of Health, the Mandatory Health Insurance Fund, the lead clinician, a hospital manager and public health and patient representatives. Clear lines of responsibility and accountability need to be designated.

MechanismsPolicy and regulations

The broader policy context has already been described. There seems to be a real opportunity to link this work with that for developing the emergency systems, the service delivery master plan, eHealth system, performance monitoring and

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the quality systems, so that the health system response is comprehensive and aligned with Ministry of Health instructions, orders, government decrees and decisions of the Coordination Council on optimizing care in AMI and stroke.

Structural investment

Bilateral donors have invested considerably recently in building hospitals and health facilities; some are in the private sector such as the Hospital of Kyrgyz-Turkish Friendship in Bishkek. There are likely to be multiple opportunities for investment, including in digital health solutions, but these need to be coordinated to achieve optimal outcomes. This should also fit with the regional development policy.

Training of personnel

A group of local experts appointed by the Ministry of Health has produced new stroke and ACS guidelines, and disseminating and implementing these is also part of this roadmap. Medical education reforms are underway. A Swiss-funded project produces distance-learning courses. Extending the use of telemedicine facilities is also a possibility. The CVD Working Group made the following suggestions: regular conferences presenting the results of work; educational programmes for postgraduate education, including distance and residential education; internships; international exchange programmes; participation in international projects – registries, clinical research and trials; advanced training (and education in the workplace) according to specialty, including for nurses; preparing emergency specialists and training specialties that are needed but absent such as neurorehabilitation physician, speech therapist and occupational therapist.

Materials that may need to be developed are: extension of the national clinical practice guidelines; clinical protocols on ACS and stroke for nurses (such as FeSS); pocket books and billboards with stroke and ACS protocols, clinical scales such as NIHSS, Rankin scale, CHADSVASC etc.; a pocket book for emergency ambulances; and a module for drivers, dispatchers and ambulances. The action plan for emergency services already includes suggestions regarding training for emergency ambulance crews and dispatchers.

Health-care funding

A comprehensive and aligned health system response also needs to ensure that system enablers are in place to facilitate this change. Health-care funding is a critical part of this and needs to consider how domestic funding can start to broaden the benefit package and coverage.

Next stepsThis roadmap has been presented to the Ministry of Health and widely consulted with national and regional partners, including the medical profession. The document is intended to inform the Ministry of Health in taking the next steps in developing its own roadmap for improving services.

Important information in coming months will be the results of an exercise to test the feasibility of collecting the proposed indicators and costing of all the recommendations (one-time investment and concurrent costs). The analysis should also feed into the State Guaranteed Benefit Package discussion in the coming months.

References

1. Farrington J, Pezzella FR, Yakovlev A, Rotar O. Review of acute care and rehabilitation services for heart attack and stroke in Kyrgyzstan. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro.who.int/en/countries/kyrgyzstan/publications/review-of-acute-care-and-rehabilitation-services-for-heart-attack-and-stroke-in-kyrgyzstan-2017, accessed 14 November 2018).

2. Beishenkulov MT, Toktosunova AK. Clinical protocol on acute coronary syndrome with ST elevation. Bishkek: Ministry of Health, Kyrgyzstan; 2017.

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3. Toktomushev C, Turgunbaev DD, Kaliev OC et al. Management of patients with acute disturbance of cerebral circulation. Clinical guidelines for prehospital care. Bishkek: Ministry of Health, Kyrgyzstan; 2017.

4. Toimatov SS, Omorov NK, Turgunbaev DD, Smith B. Ischemic stroke and transient attack. Clinical guidelines for hospital care. Bishkek: Ministry of Health, Kyrgyzstan; 2017.

5. Tackling NCDs. “Best buys” and other recommended interventions for the prevention and control of noncommunicable diseases. Geneva: World Health Organization; 2017 (http://www.who.int/ncds/management/best-buys/en, accessed 14 November 2018).

6. Evidence-based treatment protocols. HEARTS technical package for cardiovascular disease management in primary health care. Geneva: World Health Organization; 2018 (http://apps.who.int/iris/bitstream/handle/10665/260421/WHO-NMH-NVI-18.2-eng.pdf;jsessionid=8FB9FEC6E61A12277C75CE8F8D6D7595?sequence=1, accessed 14 November 2018).

7. WHO essential medicines list. 20th edition. Geneva: World Health Organization; 2017 (http://www.who.int/medicines/publications/essentialmedicines/en, accessed 14 November 2018).

8. Clinical practice guidelines. Sophia Antipolis, France: European Society of Cardiology; 2018 (https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines, accessed 14 November 2018).

9. ESO Guideline Directory. Basle: European Stroke Organisation; 2018 (https://eso-stroke.org/eso-guideline-directory, accessed 14 November 2018).

10. Langhorne P, Williams BO, Gilchrist W, Howie K. Do stroke units save lives? Lancet. 1993;342:395–8.11. Kim CH, Jeon JP, Kim SE, Choi HJ, Cho YJ. Endovascular treatment with intravenous thrombolysis versus endovascular

treatment alone for acute anterior circulation stroke: a meta-analysis of observational studies. J Korean Neurosurg Soc. 2018;61:467–73.

12. Ganesh A, Lindsay P, Fang J, Kapral MK, Côté R, Joiner I et al. Integrated systems of stroke care and reduction in 30-day mortality: a retrospective analysis. Neurology. 2016;86:898–904.

13. Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007;6:215–22.

14. Middleton S, McElduff P, Ward J, Grimshaw JM, Dale S, D’Este C et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet. 2011;378:1699–1706.

15. Guidelines 2008. Basle: European Stroke Organisation; 2008 (https://eso-stroke.org/eso-guideline-directory, accessed 14 November 2018).

16. European Stroke Organization guideline on glycaemia management in acute stroke. Basle: European Stroke Organisation; 2017 (https://eso-stroke.org/eso-guideline-directory, accessed 14 November 2018).

17. Teasell R, Foley N, Hussein N, Cotoi A. The efficacy of stroke rehabilitation. In: Teasell R, Cotoi A, Chow J, Wiener J, Iliescu A, Hussein N, Salter K. The stroke rehabilitation evidence-based review. 18th edition. Toronto: Canadian Stroke Network; 2018 (http://www.ebrsr.com, accessed 14 November 2018).

18. Mendis S. Stroke disability and rehabilitation of stroke: World Health Organization perspective. Int J Stroke. 2013;8:3–4.19. Heikkilä I, Kuusisto H, Stolberg A, Palomäki A. Stroke thrombolysis given by emergency physicians cuts in-hospital delays

significantly immediately after implementing a new treatment protocol. Scand J Trauma Resusc Emerg Med. 2016;24:46.20. Ryynänen OP, Iirola T, Reitala J, Pälve H, Malmivaara A. Is advanced life support better than basic life support in

prehospital care? A systematic review. Scand J Trauma Resusc Emerg Med. 2010;18:62.21. Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes of basic versus advanced life support for out-of-hospital

medical emergencies. Ann Intern Med. 2015;163:681–90.22. Ebinger M, Kunz A, Wendt M, Rozanski M, Winter B, Waldschmidt C et al. Effects of golden hour thrombolysis: a

Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke (PHANTOM-S) substudy. JAMA Neurol. 2015;72:25–30.

23. Ebinger M, Winter B, Wendt M, Weber JE, Waldschmidt C, Rozanski M et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA. 2014;311:1622–31.

24. Bowry R, Grotta JC. Bringing emergency neurology to ambulances: mobile stroke unit. Semin Respir Crit Care Med. 2017;38:713–7.

25. Gyrd-Hansen D, Olsen KR, Bollweg K, Kronborg C, Ebinger M, Audebert HJ. Cost–effectiveness estimate of prehospital thrombolysis: results of the PHANTOM-S study. Neurology. 2015;84:1090–7.

11

26. Dietrich M, Walter S, Ragoschke-Schumm A, Helwig S, Levine S, Balucani C et al. Is prehospital treatment of acute stroke too expensive? An economic evaluation based on the first trial. Cerebrovasc Dis. 2014;38:457–63.

27. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870–947.

28. Moynihan B, Davis D, Pereira A, Cloud G, Markus HS. Delivering regional thrombolysis via a hub-and-spoke model. J R Soc Med. 2010;103:363–9.

29. The Stent Save a Life initiative (https://www.stentsavealife.com, accessed 14 November 2018). 30. Mehta S, Granger C, Grines CL, Jacobs A, Henry TD, Rokos I et al. Confronting system barriers for ST-elevation MI in low

and middle income countries with a focus on India. Indian Heart J. 2017;70:185–90.31. El Khoury R, Jung R, Nanda A, Sila C, Abraham MG, Castonguay AC et al. Overview of key factors in improving access to

acute stroke care. Neurology. 2012;79(13 Suppl. 1):S26–34.

12

Annex 1. Members of the CVD Working GroupThe Working Group was established in June 2017 and had 16 meetings by March 2018.

N.S. Ibraeva: National Coordinator on Noncommunicable Diseases, Ministry of Health, Department of Management of Health Care and Drug Policy

A.S. Sarybaev: Senior Cardiologist, Ministry of Health, National Centre for Cardiology and Internal Medicine; Head, Department of High Altitude Medicine

V. Zventsova: Cardiologist and Scientific Secretary, National Centre for Cardiology and Internal Medicine, Department of AMI

Z. Chazymova: Senior Doctor of Urgent Cardiology, National Centre for Cardiology and Internal Medicine, Department of Urgent Cardiology

A.B. Dzhumanazarov: Deputy Director, Research Institute of Cardiac Surgery and Organ Transplantation

S.A. Makhmuthodjaev: consultant on CVD, Den Sooluk

G. Tumenbaeva, Senior Cardiologist, Emergency Ambulance Service of Bishkek

A.S. Artykbaev: Senior Neurologist, Ministry of Health, Head of Department, City Hospital No. 1

I.A. Sverdlova: Neurologist, Kyrgyz State Medical Institute of graduate education

N. Asanova: Neurologist, FMC No. 7 Post

B.B. Kulov: Head of Department, Scientific Institute of Rehabilitation

I. Luzenko: Assistant, Department of Neurology, Kyrgyz State Medical Academy

13

Annex 2. Recommendations for ambulances2.1. Equipment for ambulances

Table A2-1 shows the suggested core equipment for an ambulance providing prehospital basic life support that is relevant for ACS and stroke, in addition to any other standard basic life support equipment the ambulance contains for other conditions (see the section on model of care).

Table A2-1. Suggested equipment to be in all ambulances to support basic care of ACS and stroke

Availability requirements Equipment Current availability for ambulances

RequiredVentilation and airway equipment (suction apparatus; oxygen supply; manual resuscitator and mask)

No

Required Pulse oximetry monitor Yes

Required ECG recorder and monitor Yes

Required (in the absence of doctor)Recommended (when there is a team of doctors)

The device for transmitting ECG results (telemedicine)

Not in ambulancesYes, in some tertiary-level hospitals

Required External cardioverter (defibrillator) Yes

In addition to the basic equipment, an ambulance that provides more advanced life support for ACS would need additional equipment as shown in Table A2-2 (1).

Table A2-2. Suggested equipment to be in specialized ambulances providing more advanced care for ACS

Availability requirements Equipment Current availability for ambulances

Required (in the absence of doctor)Recommended (when there is a team of doctors)

The device for transmission of ECG (telemedicine)

Not in ambulancesYes, in some tertiary-level hospitals

Strongly recommended External electrocardiostimulator (pacemaker)

No

Recommended Invasive ventilation No

Recommended Portable ultrasound diagnostic device No

May be considered Chest compression device No

May be consideredPoint-of-care biomarker systems (troponin test)

No

Source: Beygui et al. (2). Key: the priorities are: (1) required; (2) strongly recommended; (3) recommended; and (4) may be considered.

2.2. Medicines for ambulances

These are the suggested core medicines for an ambulance with a doctor onboard that provide prehospital care (3) for ACS and stroke (see the section on model of care). Kyrgyzstan’s prehospital clinical guidelines do not list any specific medicines, but these suggestions come from international evidence-informed guidelines and the WHO essential medicines list.

14

Table A2-3. Suggested medicines for ambulances providing prehospital care for ACS and stroke in ambulances

Requirements Medicines for ACS and strokePresence in WHO essential medicines list

Presence in national formulary

Current availability for ambulances

Required

Morphine Yes Yes Yes

Furosemide Yes Yes Yes

Adrenaline Yes Yes Yes

Diazepam Yes Yes Yes

Strongly recommended

Amiodarone Yes Yes Yes

Atropine Yes Yes Yes

Blood pressure–lowering drugsBisoprololAmlodipineEnalapril

BisoprololAmlodipineEnalapril

Yes

Recommended

Nitroglycerin Yes Yes Yes

Lidocaine Yes Yes Yes

Dobutamine Yes Yes Yes

Magnesium sulfate Yes Yes Yes

As described in the section on model of care, a specialized ambulance for ACS would be able to perform thrombolysis. Table A2-4 lists the additional medicines that would be needed.

Table A2-4. Additional medicines needed for performing thrombolysis

Medicines to support prehospital thrombolysis

Presence in WHO essential medicines list

Presence in nationalFormulary

Current availability for ambulances

Alteplasea No No No

Unfractionated heparins and/or enoxaparin

Yes Yes Not

Acetylsalicylic acid (aspirin) Yes Yes Yes

Clopidogrel Yes Yes Yes

Beta-blockers YesBisoprololCarvediolMetoprolol

Yes

Source: Beygui et al. (2). aStreptokinase is currently available in hospitals but not ambulances. Currently, only streptokinase is available, this drug is not recommended by international guidelines anymore. Within international guidelines (2), alteplase may be considered and tenecteplase is recommended but the latter is not in the WHO essential medicines list.

References

1. WHO essential medicines list. 20th edition. Geneva: World Health Organization; 2017 (http://www.who.int/medicines/publications/essentialmedicines/en, accessed 14 November 2018).

2. Beygui F, Castren M, Brunetti ND, Rosell-Ortiz F, Christ M, Zeymer U et al. Eur Heart J Acute Cardiovasc Care. 2015 DOI: 10.1177/2048872615604119

3. Equipment for ambulances: ACEP policy statement. Irving (TX): American College of Emergency Physicians and Medical Direction of Emergency Medical Services; 2018 (http://www.acep.org, accessed 14 November 2018).

15

Ann

ex 3

. Sta

ndar

ds a

nd p

erfo

rman

ce in

dica

tors

3.1.

Pre

hosp

ital

car

e: a

cute

cor

onar

y sy

ndro

me

(ACS

)

Stan

dard

of c

are

Impl

emen

tati

on

phas

eIn

dica

tors

Impl

emen

tati

on to

ols

Leve

l (ho

spit

al,

regi

onal

or

nati

onal

)

Avai

labi

lity

of b

asic

leve

l of c

are

at th

e pr

ehos

pita

l sta

ge: c

ardi

opul

mon

ary

resu

scita

tion,

defi

brill

ation

, ana

lges

ics,

an

tithr

ombo

tic d

rugs

(hep

arin

, an

tipla

tele

ts),

diur

etics

, cat

echo

lam

ines

(1)

1 ye

ar

• %

of a

mbu

lanc

e te

ams

equi

pped

with

ECG

m

achi

ne, d

efibr

illat

or a

nd s

et o

f med

icati

ons

• %

of a

mbu

lanc

e te

ams

certi

fied

in b

asic

and

ad

vanc

ed li

fe s

uppo

rt

• %

of r

esus

cita

tion

case

s su

cces

sful

ly

resu

scita

ted

• %

of a

mbu

lanc

es e

quip

ped

with

bot

h EC

G

and

defib

rilla

tor (

ambu

lanc

es e

quip

ped

with

de

fibril

lato

r/al

l am

bula

nces

tim

es 1

00)

• %

of n

eed

cove

red

(act

ual n

umbe

r of

avai

labl

e de

vice

s/to

tal d

evic

es n

eede

d to

co

ver t

he p

opul

ation

tim

es 1

00)

Plan

for d

evel

opin

g em

erge

ncy

care

Ambu

lanc

e an

nual

repo

rts

Trai

ning

pro

gram

mes

Ambu

lanc

e st

aff c

ertifi

catio

n pr

ogra

mm

e

Regi

onal

Patie

nts

with

sus

pect

ed A

CS re

quiri

ng

ambu

lanc

e in

terv

entio

n sh

ould

rece

ive

it as

so

on a

s po

ssib

le (i

deal

ly w

ithin

20

min

utes

) fr

om c

allin

g, E

CG s

houl

d be

regi

ster

ed

with

in th

e ne

xt 1

0 m

inut

es a

fter

clin

ical

as

sess

men

t and

, if i

ndic

ated

, pati

ents

sh

ould

rece

ive

antit

hrom

boly

tic d

rugs

in

the

preh

ospi

tal s

etting

if a

vaila

ble

1–3

year

s

• %

of p

atien

ts w

ith A

CS re

ceiv

ing

ambu

lanc

e he

lp w

ithin

20

min

utes

from

cal

ling

(ACS

pa

tient

s re

ceiv

ing

ambu

lanc

e he

lp w

ithin

20

min

utes

/all

ACS

patie

nts

calli

ng a

mbu

lanc

e tim

es 1

00)

• %

of p

atien

ts re

ceiv

ing

EKG

in a

pre

hosp

ital

setti

ng (a

ll pa

tient

s re

ceiv

ing

EKG

in

preh

ospi

tal s

etting

s/al

l pati

ents

with

clin

ical

ly

diag

nose

d AC

S tim

es 1

00)

• %

of p

atien

ts w

ith A

CS re

ceiv

ing

thro

mbo

lysi

s in

a p

reho

spita

l setti

nga (p

atien

ts re

ceiv

ing

thro

mbo

lysi

s/al

l pati

ents

with

clin

ical

di

agno

sis

of A

CS ti

mes

100

)b

Ambu

lanc

e re

gist

ry a

nd A

CS re

gist

ry

• Av

aila

bilit

y of

thro

mbo

lytic

dru

gs

• EK

G a

nd d

efibr

illat

or a

vaila

bilit

y

• Ch

eckl

ist a

nd A

CS p

reho

spita

l tr

eatm

ent p

roto

col

• Am

bula

nce

pers

onne

l tra

inin

g

Regi

onal

and

na

tiona

l

16

Stan

dard

of c

are

Impl

emen

tati

on

phas

eIn

dica

tors

Impl

emen

tati

on to

ols

Leve

l (ho

spit

al,

regi

onal

or

nati

onal

)

The

preh

ospi

tal c

are

of p

eopl

e w

ith

susp

ecte

d AC

S sh

ould

incl

ude

an A

CS p

re-

aler

t by

ambu

lanc

e cr

ews

to th

e re

ceiv

ing

emer

genc

y de

part

men

t or i

nten

sive

car

e un

it if

the

patie

nt is

ECG

pos

itive

or A

CS is

su

spec

ted

to e

xped

ite s

peci

alis

t ass

essm

ent

and

trea

tmen

t. T

hese

pati

ents

sho

uld

be

hosp

italiz

ed d

irect

ly in

an

inte

nsiv

e ca

re

unit

1–3

year

s

• %

of p

atien

ts w

ith p

reho

spita

l sus

pect

ed A

CS

(EKG

don

e) h

ospi

taliz

ed d

irect

ly to

inte

nsiv

e ca

re u

nit/

all A

CS p

atien

ts a

dmitt

ed to

hos

pita

l tim

es 1

00)

Prot

ocol

of r

egio

nal c

oord

inati

on o

f AC

S ca

reAm

bula

nce

conn

ectio

n w

ith h

ospi

tal

(dire

ct c

all o

r cal

l thr

ough

am

bula

nce

disp

atch

er)

Preh

ospi

tal A

CS p

roto

col a

nd c

heck

list

Ambu

lanc

e an

d em

erge

ncy

serv

ices

tr

aini

ngAm

bula

nce

regi

stry

and

ACS

or

hosp

ital r

egis

try

Hos

pita

l

Defi

brill

ation

at t

he p

reho

spita

l sta

ge; E

CG

at th

e pr

ehos

pita

l sta

ge s

houl

d be

ava

ilabl

e1–

3 ye

ars

• %

of a

mbu

lanc

es e

quip

ped

with

bot

h EC

G

and

defib

rilla

tor (

ambu

lanc

es e

quip

ped

with

de

fibril

lato

r/al

l am

bula

nces

tim

es 1

00)

• %

of n

eed

cove

red

(act

ual n

umbe

r of

avai

labl

e de

vice

s/to

tal d

evic

es n

eede

d to

co

ver t

he p

opul

ation

tim

es 1

00)

Regi

onal

Tele

-ECG

sho

uld

be a

vaila

ble,

esp

ecia

lly in

ru

ral a

reas

whe

re p

rimar

y PC

I rep

erfu

sion

is

not

reac

habl

e 1–

3 ye

ars

• %

of a

mbu

lanc

e no

n-ph

ysic

ian

team

s eq

uipp

ed w

ith te

le-E

CG

• N

umbe

r of t

ele-

ECG

con

sulta

tions

• N

umbe

r of ti

mes

thro

mbo

lysi

s pe

rfor

med

in

preh

ospi

tal s

etting

s

Esta

blis

hmen

t of t

ele-

ECG

in re

gion

sAm

bula

nce

and

emer

genc

y se

rvic

es

trai

ning

Regi

onal

or

hosp

ital

a Th

is in

dica

tor i

s es

peci

ally

use

ful i

n ru

ral a

reas

.b Pr

ehos

pita

l thr

ombo

lysi

s is

esp

ecia

lly im

port

ant i

n ru

ral a

reas

and

has

a w

ell-p

rove

n eff

ect i

n re

duci

ng m

orta

lity

and

disa

bilit

y. It

requ

ires

ECG

and

defi

brill

ator

ava

ilabi

lity

and

wel

l-tra

ined

am

bula

nce

pers

onne

l, up

date

d pr

otoc

ol a

nd c

heck

list.

All

this

may

be

allo

cate

d in

to o

ne s

tand

ard

defin

ed a

s “a

vaila

bilit

y of

str

oke

thro

mbo

lysi

s fo

r sel

ecte

d pa

tient

s” m

easu

red

with

the

abso

lute

num

ber o

f tim

es p

reho

spita

l thr

ombo

lysi

s w

as p

erfo

rmed

pe

r reg

ion

and

the

perc

enta

ge o

f act

ual t

hrom

boly

sis

proc

edur

es/p

atien

ts w

ith A

CS a

dmitt

ed to

hos

pita

l tim

es 1

00.

3.1.

Pre

hosp

ital

car

e: a

cute

cor

onar

y sy

ndro

me

(ACS

) con

tinu

ed

17

3.2.

Pre

hosp

ital

car

e: s

trok

e

Stan

dard

of c

are

Impl

emen

tati

on

phas

eIn

dica

tors

Impl

emen

tati

on to

ols

Leve

l

A pe

rson

with

sus

pect

ed s

trok

e or

TIA

sh

ould

be

imm

edia

tely

ass

esse

d at

firs

t co

ntac

t usi

ng a

val

idat

ed s

trok

e sc

reen

ing

tool

, suc

h as

the

FAST

(fac

e, a

rm, s

peec

h an

d tim

e) te

st (2

)

1–3

year

s

• %

of s

trok

e pa

tient

s re

ceiv

ing

a te

leph

one

asse

ssm

ent f

or s

uspe

cted

str

oke

(num

ber o

f pa

tient

s re

ceiv

ing

a te

leph

one

asse

ssm

ent f

or

susp

ecte

d st

roke

/str

oke

patie

nts

adm

itted

to

hosp

ital ti

mes

100

)

FAST

am

bula

nce

trai

ning

Ambu

lanc

e re

gist

ryRe

gion

al s

trok

e re

gist

rya

Regi

onal

or

na

tiona

l

Tran

spor

t to

hosp

ital w

ith a

cute

spe

cial

ist

stro

ke s

ervi

ces

shou

ld b

e ac

hiev

ed a

s qu

ickl

y as

pos

sibl

e an

d al

way

s w

ithin

a

max

imum

of o

ne h

our f

rom

am

bula

nce

aler

t (3)

1–3

year

s

• %

of p

atien

ts w

ith p

reho

spita

l sus

pect

ed s

trok

e re

achi

ng h

ospi

tal w

ithin

a m

axim

um o

f one

hou

r fr

om a

mbu

lanc

e (p

atien

ts re

achi

ng h

ospi

tal w

ithin

on

e ho

ur fr

om a

mbu

lanc

e al

ert/

all s

trok

e pa

tient

s ad

mitt

ed to

hos

pita

l tim

es 1

00)

Preh

ospi

tal s

trok

e pr

otoc

ol a

nd

chec

klis

tAm

bula

nce

and

emer

genc

y se

rvic

es

trai

ning

Ambu

lanc

e re

gist

ry a

nd s

trok

e an

d ho

spita

l reg

istr

y

Hos

pita

l or

re

gion

al

The

preh

ospi

tal c

are

of p

eopl

e w

ith

susp

ecte

d st

roke

sho

uld

incl

ude

a 15

-min

ute

pre-

aler

t by

ambu

lanc

e cr

ews

to th

e re

ceiv

ing

emer

genc

y de

part

men

t or

str

oke

unit

whe

re th

e pa

tient

is F

AST

posi

tive

or s

trok

e is

sus

pect

ed to

exp

edite

sp

ecia

list a

sses

smen

t and

trea

tmen

t (2)

1–3

year

s

• %

of s

trok

e pa

tient

s ad

mitt

ed to

hos

pita

l with

a

stro

ke p

re-a

lert

(str

oke

patie

nts

adm

itted

to h

ospi

tal

with

a 1

5-m

inut

e st

roke

pre

-ale

rt/a

ll st

roke

pati

ents

ad

mitt

ed to

hos

pita

l tim

es 1

00)

• Ti

min

g to

adm

issi

on to

hos

pita

l of s

trok

e pa

tient

s

–Ti

min

g to

adm

issi

on to

hos

pita

l of s

trok

e pa

tient

s w

ith p

re-a

lert

str

oke

code

–Ti

min

g to

adm

issi

on to

hos

pita

l of s

trok

e pa

tient

s w

ithou

t pre

-ale

rt s

trok

e co

de

Pre-

aler

t str

oke

prot

ocol

Ambu

lanc

e an

d em

erge

ncy

phys

icia

n an

d ne

urol

ogis

t tra

inin

g

Stro

ke a

nd a

mbu

lanc

e re

gist

ry

Pre-

notifi

catio

n pr

otoc

ol

diss

emin

ation

Ambu

lanc

e tr

aini

ng o

n pr

e-no

tifica

tion

prot

ocol

Regi

onal

a This

is a

lread

y in

pla

ce in

Bis

hkek

but

nee

ds to

be

rede

sign

ed in

a u

ser-

frie

ndly

and

mor

e m

eani

ngfu

l way

.

18

3.3.

Hos

pita

l acu

te c

are:

ACS

Stan

dard

of c

are

Impl

emen

tati

on

phas

eIn

dica

tors

Impl

emen

tati

on to

ols

Leve

l

Avai

labi

lity

of P

CI, i

nten

sive

car

e un

it se

rvic

e, m

onito

red

beds

24/

7/36

53–

5 ye

ars

(?)

• N

umbe

r of S

TEM

I pati

ents

trea

ted

with

PCI

–Pr

imar

y PC

I

–PC

I aft

er th

rom

boly

sis

• ST

EMI p

atien

ts: %

of S

TEM

I pati

ents

rece

ivin

g re

perf

usio

n in

the

first

12

hour

s fr

om s

ympt

om

onse

ta

• N

on-S

TEM

I pati

ents

: % o

f pati

ents

with

med

ium

, hi

gh a

nd v

ery

high

risk

of N

STEM

I und

ergo

ing

coro

nary

ang

iogr

aphy

dur

ing

hosp

ital s

tay

Inte

nsiv

e ca

re u

nit a

nd c

athe

teriz

ation

la

bora

tory

ava

ilabi

lity

in s

trat

egic

cen

tres

Staff

(car

diol

ogis

t, n

urse

, tec

hnic

ian)

tr

aini

ngQ

ualit

y m

onito

ring,

loca

l ACS

regi

stry

and

ca

se re

view

Hos

pita

l an

d re

gion

al

Avai

labi

lity

of la

bora

tory

dia

gnos

tic fa

ciliti

es

(pre

fera

bly

high

-sen

sitiv

ity tr

opon

in o

ver

quan

tity

stan

dard

trop

onin

or M

B-CK

)

% o

f pati

ents

with

sus

pect

ed A

CS w

ith tr

opon

in te

st

perf

orm

ed a

t adm

issi

onH

ospi

tal A

CS re

gist

ryIn

sura

nce

com

pany

aud

it

All p

atien

ts w

ith A

CS o

f int

erm

edia

te a

nd

high

risk

, esp

ecia

lly w

ith c

ompl

icati

ons,

sh

ould

be

adm

itted

to th

e in

tens

ive

care

un

it an

d tr

eate

d on

a m

onito

red

bed

until

st

abili

zatio

n

1–3

year

s

In-h

ospi

tal m

orta

lity

for a

cute

myo

card

ial i

nfar

ction

Rate

s of

dea

th w

ithin

30

days

follo

win

g ho

spita

l ad

mis

sion

s fo

r acu

te m

yoca

rdia

l inf

arcti

on

Esta

blis

hmen

t of i

nten

sive

car

e un

itD

efini

ng a

nd im

plem

entin

g AC

S cl

inic

al

path

way

sAu

ditin

g re

gion

al in

sura

nce

com

pany

Staff

trai

ning

, sta

ndar

diza

tion

of

prot

ocol

s an

d ch

eckl

ist i

n th

e co

untr

y,

upda

te o

f ava

ilabl

e dr

ugs

(incl

udin

g st

atins

, bet

a-bl

ocke

rs a

nd a

nti-

thro

mbo

tic th

erap

y)

Nati

onal

, re

gion

al

and

hosp

ital

Com

preh

ensi

ve c

ardi

ovas

cula

rsu

rger

y (c

oron

ary

arte

ryby

pass

gra

ft s

urge

ry; s

urgi

cal

man

agem

ent o

f acu

te d

isor

der o

f the

ao

rta,

val

ves

and

any

othe

r car

diov

ascu

lar

stru

ctur

e) s

houl

d be

ava

ilabl

e in

sel

ecte

d ca

sesb

3–5

year

s

Card

iac

surg

ery

cons

ulta

tions

ava

ilabi

lity:

• N

umbe

r of c

onsu

ltatio

ns

• N

umbe

r of c

ardi

ac s

urge

ry o

pera

tions

per

form

ed

durin

g ho

spita

l adm

issi

onc

Tech

nica

l and

edu

catio

nal u

pdat

e of

sta

ff

and

stru

ctur

es

Nati

onal

, re

gion

al

and

hosp

ital

19

Stan

dard

of c

are

Impl

emen

tati

on

phas

eIn

dica

tors

Impl

emen

tati

on to

ols

Leve

l

Avai

labi

lity

of e

choc

ardi

ogra

phy

for

all p

atien

ts d

urin

g ho

spita

lizati

on (i

n co

mpl

icat

ed c

ases

, with

in th

e fir

st 2

4 ho

urs)

3–5

year

s%

of p

atien

ts w

ith a

sses

sed

LVEF

and

oth

er e

cho

para

met

ers

durin

g ho

spita

lizati

onH

ospi

tal A

CS re

gist

ryIn

sura

nce

com

pany

aud

it

All A

CS p

atien

ts w

ithou

t con

trai

ndic

ation

s sh

ould

be

trea

ted

with

dua

l anti

plat

elet

th

erap

y, A

CE in

hibi

tors

, bet

a-bl

ocke

rs a

nd

high

-dos

e st

atin

1 ye

ar%

of e

ligib

le p

atien

ts re

ceiv

ing

requ

ired

med

icati

ons

Hos

pita

l ACS

regi

stry

Insu

ranc

e co

mpa

ny a

udit

a Re

perf

usio

n co

uld

be P

CI o

r thr

ombo

lytic

ther

apy.

b Th

is p

oint

is v

ery

gene

ral b

ut a

n im

port

ant c

onsi

dera

tion

for t

he fu

ture

vis

ion

and

deve

lopm

ent o

f ser

vice

s.c To

be

defin

ed.

3.3.

Hos

pita

l acu

te c

are:

ACS

con

tinu

ed

20

3.4.

Hos

pita

l acu

te c

are:

str

oke

Stan

dard

of c

are

Impl

emen

tati

on

phas

eIn

dica

tors

Impl

emen

tati

on to

ols

Leve

l

All p

atien

ts w

ith s

uspe

cted

str

oke

shou

ld

have

imm

edia

te a

cces

s to

CT

scan

ning

if

requ

ired

to p

lan

urge

nt tr

eatm

ent.

All

othe

r pati

ents

with

sus

pect

ed s

trok

e to

be

scan

ned

with

in 1

2 ho

urs

of p

rese

ntati

ona (1

)

1-3

year

s (?

)

• D

oor-

to-C

T sc

an ti

min

g

• %

of b

rain

imag

ing

by C

T in

eve

ry s

uspe

cted

st

roke

whe

re C

T sc

anni

ng is

ava

ilabl

e

• %

of a

cute

str

oke

patie

nts

reac

hing

hos

pita

l w

ithin

4.5

hou

rs fr

om s

ympt

om o

nset

rece

ivin

g br

ain

CT s

cann

ing

with

in 3

0 m

inut

es fr

om

adm

issi

on (p

atien

ts re

achi

ng h

ospi

tal w

ithin

4.5

ho

urs

from

sym

ptom

ons

et u

nder

goin

g CT

with

in

30 m

inut

es fr

om a

dmis

sion

/pati

ents

reac

hing

ho

spita

l with

in 4

.5 h

ours

from

sym

ptom

ons

et

unde

rgoi

ng C

T aft

er 3

0 m

inut

es fr

om a

dmis

sion

tim

es 1

00)

• %

of a

cute

str

oke

patie

nts

unde

rgoi

ng C

T sc

anni

ng w

ithin

12

hour

s fr

om a

dmis

sion

(acu

te

stro

ke p

atien

ts u

nder

goin

g CT

sca

n w

ithin

12

hour

s fr

om a

dmis

sion

/all

adm

itted

str

oke

patie

nts

times

100

)

CT s

can

esta

blis

hmen

t pro

gram

me

in

publ

ic h

ospi

tal

Emer

genc

y an

d st

roke

regi

stry

Hos

pita

l an

d re

gion

al

Alte

plas

e sh

ould

onl

y be

del

iver

ed b

y sp

ecia

list p

erso

nnel

em

bedd

ed w

ithin

a

hype

racu

te s

trok

e se

rvic

e w

ho a

re tr

aine

d an

d ex

perie

nced

in p

rovi

ding

str

oke

thro

mbo

lysi

s an

d re

cogn

izin

g co

mpl

icati

ons.

Th

e ea

rlier

the

thro

mbo

lytic

trea

tmen

t is

del

iver

ed, t

he b

etter

the

outc

ome,

pa

rticu

larly

if d

eliv

ered

with

in 9

0 m

inut

es

of s

ympt

om o

nset

. The

lice

nce

supp

orts

th

e us

e of

alte

plas

e up

to 4

.5 h

ours

. O

nce

IV th

rom

boly

sis

is a

vaila

ble

in th

e ce

ntre

, do

or-t

o-ne

edle

tim

e fo

r tho

se a

ppro

pria

te

for i

n-lic

ence

use

of I

V th

rom

boly

sis

as s

oon

as p

ossi

ble

<60

min

utes

(3,4

)

3–5

year

s

• Ab

solu

te n

umbe

r of t

hrom

boly

sis

proc

edur

es

perf

orm

ed

• D

oor-

to-n

eedl

e tim

e

• %

of e

ligib

le p

atien

ts re

ceiv

ing

intr

aven

ous

thro

mbo

lytic

ther

apy

• %

of e

ligib

le p

atien

ts re

ceiv

ing

intr

aven

ous

thro

mbo

lytic

ther

apy

with

in 6

0 m

inut

es fr

om

hosp

ital a

dmis

sion

Acut

e st

roke

pro

toco

lAl

tepl

ase

avai

labi

lity

Emer

genc

y, a

mbu

lanc

e an

d ne

urol

ogy

staff

trai

ning

Hos

pita

l an

d re

gion

al

21

Stan

dard

of c

are

Impl

emen

tati

on

phas

eIn

dica

tors

Impl

emen

tati

on to

ols

Leve

l

Stro

ke p

atien

ts s

houl

d be

man

aged

in a

st

roke

uni

t unl

ess

othe

r con

ditio

ns re

quiri

ng

imm

edia

te s

peci

alis

t car

e do

min

ate.

Str

oke

patie

nts

are

man

aged

by

a m

ultip

rofe

ssio

nal

team

and

rece

ive

a m

ultip

rofe

ssio

nal

eval

uatio

n w

ithin

24

hour

s fr

om s

trok

e un

it ad

mis

sion

(3)

1–3

year

s

• Ra

tes

of d

eath

with

in 3

0 da

ys fo

llow

ing

hosp

ital

adm

issi

ons

for i

scha

emic

str

oke

• Ra

tes

of d

eath

with

in 3

0 da

ys fo

llow

ing

hosp

ital

adm

issi

ons

for h

aem

orrh

agic

str

oke

• %

of a

ll pa

tient

s w

ith a

cute

str

oke

as th

e pr

edom

inan

t pat

holo

gy a

dmitt

ed to

the

hosp

ital

trea

ted

in th

e st

roke

uni

t (or

the

inte

nsiv

e ca

re

unit,

if a

ppro

pria

te)

• %

of p

atien

ts w

ith a

fina

l dia

gnos

is o

f str

oke

with

a

docu

men

ted

phys

ioth

erap

y as

sess

men

t with

in

24–4

8 ho

urs

of a

dmis

sion

to h

ospi

tal

• %

of p

atien

ts w

ith a

doc

umen

ted

swal

low

ing

eval

uatio

n w

ithin

24–

48 h

ours

of a

dmis

sion

to

hosp

ital

Stro

ke c

entr

es a

lread

y ex

ist;

impr

ovin

g st

roke

car

e in

exi

sting

str

oke

units

re

quire

s fo

ur ty

pes

of in

terv

entio

n:

• Q

ualit

y m

onito

ring

and

case

revi

ew

with

str

oke

team

(RES

-Q re

gist

ry

alre

ady

in p

lace

offe

rs a

mon

thly

re

port

)

• St

aff tr

aini

ng (s

peec

h th

erap

ist,

reha

bilit

ation

etc

.)

• Eq

uipm

ent (

sono

grap

hy,

mul

tipar

amet

ric m

onito

ring)

• Es

senti

al d

rugs

Nati

onal

, re

gion

al

and

hosp

ital

a This

sta

ndar

d de

pend

s on

the

avai

labi

lity

of C

T sc

anni

ng e

quip

men

t in

publ

ic h

ospi

tals

, whi

ch is

now

lack

ing.

The

impl

emen

tatio

n ph

ase

ther

efor

e al

so d

epen

ds o

n th

e te

chno

logi

cal i

nves

tmen

t pla

n an

d st

rate

gy. C

T sc

anni

ng is

re

quire

d to

pla

n th

e tr

eatm

ent o

f peo

ple

with

str

oke

and

to e

stab

lish

prog

nosi

s.

3.4.

Hos

pita

l acu

te c

are:

str

oke conti

nued

22

3.5.

Pos

t-ho

spit

al c

are:

ACS

and

str

oke

Stan

dard

of c

are

Impl

emen

tati

on

phas

eIn

dica

tors

Impl

emen

tati

on to

ols

Leve

l

Stro

ke: a

ll pa

tient

s w

ith s

trok

e sh

ould

hav

e ac

cess

to s

peci

aliz

ed n

euro

reha

bilit

ation

se

rvic

es a

nd to

a d

esig

nate

d st

roke

re

habi

litati

on p

rogr

amm

e in

a d

edic

ated

ap

prop

riate

setti

ng (r

ehab

ilita

tion

inpa

tient

uni

t,

nurs

ing

faci

lity,

day

ser

vice

, out

patie

nt c

linic

, ho

me

reha

bilit

ation

) acc

ordi

ng to

the

patie

nts’

ne

eds

and

reha

bilit

ation

pro

gnos

is (e

stab

lishe

d an

d st

anda

rdiz

ed b

y us

ing

stro

ke s

cale

s su

ch

as N

IHSS

, Ran

kin,

AD

L, IA

DL,

Bar

thel

Inde

x an

d M

obili

ty In

dex)

(3,4

)

1–3

year

sN

umbe

r of p

atien

ts re

ferr

ed to

spe

cial

ized

ne

uror

ehab

ilita

tion

serv

ices

at h

ospi

tal

disc

harg

ea

Stro

ke re

gist

rySt

roke

sca

les

Staff

trai

ning

Defi

nitio

n of

str

oke

reha

bilit

ation

in

terv

entio

ns a

void

ing

proc

edur

es

with

no

or p

oor e

vide

nce

Hos

pita

l an

d re

gion

al

Stro

ke: a

ll st

roke

pati

ents

sho

uld

rece

ive

a co

mpr

ehen

sive

revi

ew a

fter

6–1

2 m

onth

s (5

)1–

3 ye

ars

Dis

trib

ution

of d

isab

ility

sco

res

acro

ss th

e st

roke

po

pula

tion

usin

g th

e m

odifi

ed R

anki

n sc

ale

scor

e at

dis

char

ge fr

om a

cute

car

e an

d at

3, 6

and

12

mon

ths

after

str

okeb

ACS:

all

ACS

patie

nts

shou

ld b

e as

sess

ed fo

r el

igib

ility

, ref

erra

l, cl

inic

al a

sses

smen

t and

co

re d

eliv

ery

of c

ardi

ac re

habi

litati

on b

efor

e pr

ogre

ssin

g to

long

-ter

m m

anag

emen

t3–

5 ye

ars

• %

of p

atien

ts w

ith m

yoca

rdia

l inf

arcti

on

refe

rred

to c

ardi

ac re

habi

litati

on

• ca

rdio

vasc

ular

mor

talit

y at

12

mon

ths

after

m

yoca

rdia

l inf

arcti

on

Adop

tion

of s

tand

ardi

zed

prot

ocol

s fo

r car

diac

reha

bilit

ation

Adop

tion

of a

ccre

dita

tion

crite

ria fo

r ca

rdia

c re

habi

litati

on c

entr

es

Hos

pita

l an

d re

gion

al

a Indi

vidu

al in

dica

tors

may

be

used

dep

endi

ng o

n th

e re

habi

litati

on s

etting

.b Th

is in

dica

tor c

an a

lso

be a

dded

to th

e ac

ute

care

tabl

e, to

str

ess

the

impo

rtan

ce o

f usi

ng c

linic

al s

cale

s in

eve

ryda

y pr

actic

e. C

linic

al s

cale

s th

at a

re e

ssen

tial f

or s

trok

e ar

e N

IHSS

, mod

ified

Ran

kin

scal

e an

d, fo

r reh

abili

tatio

n pu

rpos

es, B

arth

el In

dex

and

ADL

and

IAD

L.

23

3.6.

Pos

thos

pita

l car

e: s

econ

dary

pre

venti

on fo

r A

CS a

nd s

trok

e

Stan

dard

of c

are

Impl

emen

tati

on

phas

eIn

dica

tors

Impl

emen

tati

on to

ols

Leve

l

Stan

dard

sec

onda

ry p

reve

ntion

pre

scrip

tion

at d

isch

arge

acc

ordi

ng to

car

diov

ascu

lar a

cute

ev

ent:

ACS

, TIA

, isc

hem

ic s

trok

e (3

,4)

1–3

year

s

• %

of p

atien

ts w

ith A

CS w

ithou

t con

trai

ndic

ation

s di

scha

rged

on

high

-dos

e st

atins

• %

of p

atien

ts w

ith A

CS (w

ith L

VEF

40%

) di

scha

rged

on

beta

-blo

cker

s an

d AC

E in

hibi

tors

• %

with

ACS

, TIA

or s

trok

e on

anti

thro

mbo

tic

trea

tmen

t (ac

etyl

salic

ylic

aci

d, c

lopi

dogr

el o

r ac

etyl

salic

ylic

aci

d pl

us c

lopi

dogr

el if

indi

cate

d)

• %

of p

atien

ts w

ith a

tria

l fibr

illati

on a

nd is

chae

mic

st

roke

or T

IA d

isch

arge

d on

anti

coag

ulan

ts

ACS

regi

stry

with

follo

w-u

p

Free

and

/or a

fford

able

med

icati

on fo

r se

cond

ary

prop

hyla

xis

(at l

east

one

ye

ar a

fter

ACS

and

str

oke

or T

IA)

Regi

onal

Com

orbi

dity

(dia

bete

s, o

verw

eigh

t, s

mok

ing)

• %

of p

atien

ts w

ith A

CS, T

IA o

r str

oke

who

rece

ive

smok

ing-

cess

ation

cou

nsel

ling

• %

of p

atien

ts w

ith A

CS, T

IA o

r str

oke

who

rece

ive

lifes

tyle

(suc

h as

die

tary

mod

ifica

tion)

cou

nsel

ling

Regi

onal

an

d na

tiona

l

Hea

lth b

ehav

iour

con

sulta

tion,

pati

ent

educ

ation

and

med

icati

on a

dher

ence

pr

ogra

mm

es3–

5 ye

ars

• %

of p

atien

ts o

n di

spen

sary

obs

erva

tion

• %

of e

ligib

le p

atien

ts p

artic

ipati

ng in

free

-of-

char

ge m

edic

ation

sup

plem

enta

tion

or c

o-pa

ymen

t pro

gram

mes

Polic

y of

dis

pens

ary

obse

rvati

onPo

licy

of fr

ee-o

f-ch

arge

med

icati

on

supp

ly

Refe

renc

es

1.

Beyg

ui F

, Cas

tren

M, B

rune

tti N

D, R

osel

l-Orti

z F,

Chr

ist M

, Zey

mer

U e

t al.

Eur H

eart

J Ac

ute

Card

iova

sc C

are.

201

5 D

OI:

10.1

177/

2048

8726

1560

4119

2.

Om

orov

NK,

Tur

gunb

aev

DD

. [Cl

inic

al re

com

men

datio

ns o

n pa

tient

s’ m

anag

emen

t with

isch

aem

ic s

trok

e an

d tr

ansi

ent i

scha

emic

att

acks

at t

he h

ospi

tal s

tage

.] Bi

shke

k: M

inis

try

of H

ealth

, Kyr

gyzs

tan;

201

7.3.

St

roke

ser

vice

sta

ndar

ds. L

ondo

n: B

ritish

Ass

ocia

tion

of S

trok

e Ph

ysic

ians

; 201

4 (h

ttps

://b

asp.

ac.u

k, a

cces

sed

14 N

ovem

ber 2

018)

.4.

G

uide

lines

200

8. B

asle

: Eur

opea

n St

roke

Org

anis

ation

; 200

8 (h

ttps

://e

so-s

trok

e.or

g/es

o-gu

idel

ine-

dire

ctor

y, a

cces

sed

14 N

ovem

ber 2

018)

.5.

Ki

ng’s

Colle

ge L

ondo

n. T

he b

urde

n of

str

oke

in E

urop

e. B

russ

els:

Str

oke

Allia

nce

for E

urop

e; 2

017.

24

Ann

ex 4

. Prio

rities

for i

nter

venti

ons

4.1.

Pri

oriti

es fo

r 20

18 o

r th

e fir

st 1

2 m

onth

s w

ith

exis

ting

or

limit

ed re

sour

ces

Stro

keA

CS

Syst

em is

sues

• Em

erge

ncy

depa

rtm

ent n

etw

ork

and

mas

ter p

lan

• Cr

eate

team

s (M

inis

try

of H

ealth

, Man

dato

ry H

ealth

Insu

ranc

e Fu

nd, e

Hea

lth, l

ead

card

iolo

gist

s an

d st

roke

clin

icia

ns, p

rovi

ders

) at t

he n

ation

al a

nd

subn

ation

al le

vels

resp

onsi

ble

for i

mpl

emen

ting

the

road

map

, mon

itorin

g st

anda

rds

of c

are

and

achi

evin

g in

dica

tors

• D

isse

min

ate

the

new

nati

onal

clin

ical

gui

delin

es fo

r ACS

and

str

oke

and

trai

n an

d su

ppor

t clin

icia

ns to

use

them

with

the

supp

ort o

f tel

emed

icin

e fa

ciliti

es

• Ag

ree

on in

dica

tors

to b

e us

ed fo

r mon

itorin

g th

e qu

ality

of A

CS a

nd s

trok

e ca

re a

nd th

e pe

rfor

man

ce o

f pro

vide

rs

Preh

ospi

tal c

are

• Ra

ise

awar

enes

s am

ong

the

gene

ral p

ublic

of t

he s

igns

and

sym

ptom

s of

str

oke

and

ACS

and

an a

ppro

pria

te a

nd ti

mel

y re

spon

se

• Tr

ain

prim

ary

heal

th c

are

doct

ors,

nur

ses

and

feld

sher

s on

the

sign

s an

d sy

mpt

oms

of s

trok

e an

d AC

S an

d th

e ap

prop

riate

an

d tim

ely

resp

onse

• Ro

ll ou

t tel

e-EC

G, e

quip

ping

prim

ary

heal

th c

are

wor

kers

and

sup

porti

ng th

roug

h te

lem

edic

ine

• Eq

uip

ambu

lanc

es w

ith th

e m

ost e

ssen

tial e

quip

men

t and

dru

gs fo

r ACS

and

str

oke

• Tr

ain

ambu

lanc

e cr

ews

to re

cogn

ize

stro

ke s

igns

usi

ng F

AST

mne

mon

ic a

nd in

imm

edia

te c

are

• Tr

ain

ambu

lanc

e cr

ews

to re

cogn

ize

STEM

I and

N

STEM

I and

in im

med

iate

car

e

Hos

pita

l car

e

• D

eliv

er a

hos

pita

l mas

ter p

lan

that

incl

udes

the

desi

gn o

f ser

vice

s fo

r ACS

and

str

oke

with

a h

ub-a

nd-s

poke

mod

el e

mbe

dded

in th

e em

erge

ncy

netw

ork

• D

evel

op a

cute

car

e ne

twor

ks fo

r str

oke

and

ACS

usin

g ex

istin

g re

sour

ces

and

scal

e up

• Re

view

tele

med

icin

e an

d eH

ealth

opp

ortu

nitie

s –

desi

gn a

sys

tem

to fa

cilit

ate

acce

ss to

phy

sici

ans

with

acu

te s

trok

e an

d AC

S ex

perti

se a

nd to

sup

port

the

inte

rpre

tatio

n of

dia

gnos

tic te

sts

and

imag

ing

• In

crea

se a

cces

s to

ang

iogr

aphy

by

impr

ovin

g th

e us

e of

exi

sting

reso

urce

s an

d/or

com

mis

sion

ing

prov

isio

n

• Re

view

the

list o

f ess

entia

ls d

rugs

for A

CS a

nd s

trok

e an

d ca

rdio

vasc

ular

and

cer

ebro

vasc

ular

pre

venti

on

• St

art i

mpl

emen

tatio

n of

str

oke

(RES

-Q) a

nd A

CS re

gist

ry

• St

art t

o or

gani

ze s

trok

e ne

twor

ks

• O

rgan

ize

mul

tidis

cipl

inar

y st

roke

team

s

• Re

view

neu

rosu

rger

y se

rvic

e an

d pr

otoc

ols

for h

aem

orrh

agic

str

oke

and

suba

rach

noid

ha

emor

rhag

e

• Tr

ain

nurs

es to

use

feve

r, su

gar a

nd s

wal

low

ing

prot

ocol

and

in n

utriti

on a

sses

smen

t, s

cale

-up

impl

emen

tatio

n an

d m

onito

r per

form

ance

• Tr

ain

emer

genc

y an

d ne

urol

ogy

phys

icia

ns a

nd n

urse

s to

use

clin

ical

sca

les

and

scor

es:

NIH

SS, m

odifi

ed R

anki

n sc

ale,

Bar

thel

Inde

x, A

DL,

IAD

L, s

cale

up

impl

emen

tatio

n an

d m

onito

r pe

rfor

man

ce

• In

crea

se a

cces

s to

imm

edia

te C

T sc

ans

by im

prov

ing

the

use

of e

xisti

ng re

sour

ces

and/

or

com

mis

sion

ing

prov

isio

n

• St

art t

o or

gani

ze A

CS n

etw

orks

• Pi

lot a

udit

of A

MI u

sing

indi

cato

rs

• Tr

ain

card

iolo

gist

s an

d nu

rses

to u

se s

cale

s an

d sc

ores

: mod

ified

Ran

kin

scal

e, A

DL,

IAD

L

25

Stro

keA

CS

Post

hosp

ital c

are

• Ed

ucati

on, s

kills

trai

ning

and

invo

lvem

ent i

n ca

re p

lann

ing

for s

trok

e su

rviv

ors

and

thei

r car

egiv

ers

and

fam

ilies

• Tr

ain

stro

ke a

nd A

CS te

ams

in d

isch

arge

pla

nnin

g, in

clud

ing

in c

oord

inati

ng c

are

with

prim

ary

heal

th c

are

prov

ider

s

• Tr

ain

prim

ary

heal

th c

are

prov

ider

s in

iden

tifyi

ng h

igh-

risk

patie

nts

(his

tory

of s

trok

e or

ACS

) and

in s

econ

dary

pre

venti

on

• In

crea

se a

cces

s to

med

icati

on

• Re

view

ava

ilabl

e po

st-s

trok

e re

habi

litati

on s

ervi

ces

and

avai

labl

e gu

idel

ines

, use

exi

sting

reso

urce

s to

del

iver

evi

denc

e-in

form

ed re

habi

litati

on p

roto

cols

• Re

view

ava

ilabl

e ca

rdia

c re

habi

litati

on s

ervi

ces

and

guid

elin

es a

nd d

esig

n ne

w s

ervi

ces

Sour

ces:

Bra

ndle

r et

al.

(1),

Matt

sson

et a

l. (2

), Eu

rope

an S

ocie

ty o

f Car

diol

ogy

Gui

delin

es fo

r the

man

agem

ent o

f acu

te m

yoca

rdia

l inf

arcti

on in

pati

ents

pre

senti

ng w

ith S

T-se

gmen

t ele

vatio

n 20

17 (3

), Eu

rope

an S

trok

e O

rgan

isati

on S

trok

e U

nit C

ertifi

catio

n Co

mm

ittee

(4),

Mid

dlet

on e

t al.

(5),

Qui

nn e

t al.

(6),

Dal

al H

asna

in e

t al.

(7),

Har

twel

l et a

l. (8

), El

gend

y e

t al.

(9),

Pena

loza

-Ram

os e

t al.

(10)

.

4.2.

Pri

oriti

es d

urin

g th

e ne

xt 1

–3 y

ears

Stro

keA

CS

Syst

em is

sues

• Co

ntinu

e to

mon

itor t

he p

erfo

rman

ce o

f ind

icat

ors

and

hold

lead

clin

icia

ns a

nd p

rovi

ders

acc

ount

able

• Co

ntinu

e tr

aini

ng c

linic

ians

with

sup

port

from

tele

med

icin

e fa

ciliti

es

• Im

plem

ent s

trok

e an

d AC

S re

gist

ries

• Su

ppor

t the

dev

elop

men

t of a

ssoc

iatio

ns o

f str

oke

patie

nts

Preh

ospi

tal c

are

• Co

ntinu

e to

rais

e aw

aren

ess

amon

g th

e ge

nera

l pub

lic a

nd tr

ain

clin

icia

ns

• Co

ntinu

e eq

uipp

ing

ambu

lanc

es fo

r ACS

or s

trok

e an

d de

velo

p fu

rthe

r the

spe

cial

ist a

mbu

lanc

es c

apab

le o

f thr

ombo

lysi

s fo

r ACS

• Co

ntinu

e tr

aini

ng a

mbu

lanc

e cr

ews

in s

trok

e an

d AC

S

Hos

pita

l car

e

• Im

plem

ent t

he h

ub-a

nd-s

poke

mod

el fo

r str

oke

and

ACS

• Re

fine

acut

e ca

re n

etw

orks

for s

trok

e an

d AC

S us

ing

exis

ting

reso

urce

s

• In

crea

se a

cces

s to

ang

iogr

aphy

by

impr

ovin

g th

e us

e of

exi

sting

reso

urce

s an

d/or

com

mis

sion

ing

prov

isio

n

• Co

ntinu

e tr

aini

ng n

urse

s an

d fe

ldsh

ers

in b

asic

str

oke

care

• St

reng

then

the

use

of c

linic

al s

cale

s to

tailo

r car

e, ta

rget

effo

rts

and

mon

itor p

rogr

ess

and

outc

omes

• Ex

pand

acc

ess

to b

asic

dia

gnos

tic s

ervi

ces

• D

esig

n an

d pl

an th

e im

plem

enta

tion

of c

ritica

l car

e se

rvic

es fo

r pati

ents

with

sev

ere

stro

ke, A

CS a

nd s

ubar

achn

oid

haem

orrh

age

• Pi

lot a

nd e

valu

ate

syst

emic

thro

mbo

lysi

s in

cen

tres

onc

e im

med

iate

CT

scan

ning

pos

sibl

e

• Im

plem

ent e

arly

reha

bilit

ation

and

mob

iliza

tion

prot

ocol

s•

Expa

nd th

rom

boly

sis

(in h

ubs

and

spok

es) a

nd

PCI (

in h

ubs)

4.1.

Pri

oriti

es fo

r 20

18 o

r th

e fir

st 1

2 m

onth

s w

ith

exis

ting

or

limit

ed re

sour

ces conti

nued

26

Stro

keA

CS

Post

hosp

ital c

are

• Co

ntinu

e th

e su

ppor

t to

stro

ke a

nd m

yoca

rdia

l inf

arcti

on s

urvi

vors

and

thei

r car

egiv

ers

and

fam

ilies

with

ong

oing

edu

catio

n an

d sk

ills

trai

ning

• In

crea

se a

cces

s to

med

icati

on a

nd li

fest

yles

cou

nsel

ling

for s

econ

dary

pre

venti

on

• O

rgan

ize

com

preh

ensi

ve re

-eva

luati

on fo

r all

patie

nts

with

car

diov

ascu

lar a

nd c

ereb

rova

scul

ar d

isor

ders

six

mon

ths

after

the

even

t

• Ex

pand

pos

t-st

roke

reha

bilit

ation

ser

vice

s an

d m

easu

re fu

nctio

nal o

utco

me

(usi

ng b

otul

inum

toxi

n in

jecti

on to

redu

ce s

ever

e hy

pert

onic

ity in

hem

iple

gic

mus

cles

)

• Im

plem

ent c

ardi

ac re

habi

litati

on s

ervi

ces

4.3.

Pri

oriti

es d

urin

g th

e ne

xt 3

–5 y

ears

Stro

keA

CS

Syst

em is

sues

• Co

ntinu

e to

mon

itor t

he p

erfo

rman

ce o

f ind

icat

ors

and

hold

lead

clin

icia

ns a

nd p

rovi

ders

acc

ount

able

• Co

ntinu

e tr

aini

ng c

linic

ians

with

sup

port

from

tele

med

icin

e fa

ciliti

es

• Re

view

str

oke

and

ACS

regi

strie

s an

d in

dica

tors

and

pro

duce

an

annu

al re

port

• U

pdat

e th

e im

plem

enta

tion

stra

tegy

in re

spon

se to

the

repo

rt

Preh

ospi

tal c

are

• Co

ntinu

e to

rais

e aw

aren

ess

amon

g th

e ge

nera

l pub

lic a

nd tr

ain

clin

icia

ns a

nd a

mbu

lanc

e cr

ews

• Pu

t am

bula

nce

bypa

ss a

gree

men

ts in

pla

ce

• Co

nsid

er u

sing

mob

ile s

trok

e un

its fo

r rur

al a

reas

Hos

pita

l car

e

• Re

view

the

prog

ress

and

suc

cess

of t

he h

ub-a

nd-s

poke

mod

el fo

r str

oke

and

ACS

• Im

plem

ent c

ritica

l car

e se

rvic

e fo

r str

oke

and

ACS

• Re

fine

acut

e ca

re n

etw

orks

for s

trok

e an

d AC

S us

ing

exis

ting

reso

urce

s

• D

evel

op a

cute

inpa

tient

str

oke

and

ACS

regi

onal

dat

abas

es

• D

evel

op c

oord

inat

ed re

gion

al re

ferr

al s

yste

ms

• Pr

ovid

e te

lest

roke

con

sulta

tions

for s

mal

ler a

nd m

ore

rura

l cen

tres

• Pu

t rep

atria

tion

agre

emen

ts in

pla

ce to

tran

sfer

pati

ents

bac

k to

hom

e co

mm

uniti

es

• Pi

lot a

nd e

valu

ate

adva

nced

str

oke

serv

ices

ratio

naliz

ed to

a s

mal

l num

ber o

f cen

tres

(hub

s)

• Ac

cess

to a

dvan

ced

diag

nosti

cs (h

ubs)

: mag

netic

reso

nanc

e im

agin

g (M

RI),

CT a

ngio

grap

hy

• Ac

cess

to a

dvan

ced

inte

rven

tions

and

criti

cal c

are

serv

ices

(hub

s): e

ndov

ascu

lar t

hrom

bect

omy;

he

mic

rani

ecto

my

for i

scha

emic

str

oke

• In

crea

se b

asic

dia

gnos

tics

(spo

kes)

: CT

scan

s an

d CT

ang

iogr

aphy

; ech

ocar

diog

raph

y; D

oppl

er

ultr

asou

nd; H

olte

r mon

itors

• D

evel

op a

dvan

ced

surg

ical

and

end

ovas

cula

r se

rvic

es

• H

ypot

herm

ia

• Co

mpr

ehen

sive

car

diov

ascu

lar s

urge

ry

• In

terv

entio

nal v

ascu

lar r

adio

logy

• Pe

rcut

aneo

us s

truc

tura

l hea

rt in

terv

enti o

n

4.2

. Pri

ori

ties

du

rin

g th

e n

ext

1–3

yea

rs continued

27

Stro

keA

CS

Post

hosp

ital c

are

• Co

ntinu

e su

ppor

ting

stro

ke s

urvi

vors

and

thei

r car

egiv

ers

and

fam

ilies

with

ong

oing

edu

catio

n an

d sk

ills

trai

ning

• In

crea

se a

cces

s to

med

icati

on a

nd li

fest

yles

cou

nsel

ling

for s

econ

dary

pre

venti

on

• Ex

tend

the

avai

labi

lity

of s

econ

dary

pre

venti

on d

rugs

and

cou

nsel

ling

• O

rgan

ized

pre

venti

on c

linic

s an

d ex

pert

s

• Po

st-s

trok

e ep

ileps

y as

sess

men

t and

man

agem

ent

• Co

gniti

on a

sses

smen

t and

man

agem

ent

• D

epre

ssio

n as

sess

men

t and

man

agem

ent

• Im

plem

ent p

rolo

nged

ECG

mon

itorin

g de

vice

s

• St

reng

then

car

diac

reha

bilit

ation

ser

vice

s

Sour

ces:

Rod

rigue

s et

al.

(11)

, Su

arez

et a

l. (1

2), D

aou

et a

l. (1

3), C

orte

z e

t al.

(14)

, Jeo

n et

al.

(15)

, Ste

rne

et a

l. (1

6), Pa

n Y

et a

l. (1

7), T

an T

anny

et a

l. (1

8).

4.3.

Pri

oriti

es d

urin

g th

e ne

xt 3

–5 y

ears

con

tinu

ed

28

References

1. Brandler ES, Sharma M, Sinert RH, Levine SR. Prehospital stroke scales in urban environments: a systematic review. Neurology. 2014;82:2241–9.

2. Mattsson MS, Mattsson N, Jørsboe HB. Improvement of clinical quality indicators through reorganization of the acute care by establishing an emergency department – a register study based on data from national indicators. Scand J Trauma Resusc Emerg Med. 2014;22:60.

3. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 2017. Eur Heart J. 2018;39:119–77.

4. ESO Stroke Unit Certification Committee. European Stroke Organisation recommendations to establish a stroke unit and stroke center. Stroke. 2013;44:828–40.

5. Middleton S, QASC Trialists Group. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet. 2011;378:1699–706.

6. Quinn TJ, European Stroke Organisation (ESO) Executive Committee, ESO Writing Committee. Evidence-based stroke rehabilitation: an expanded guidance document from the European Stroke Organisation (ESO) guidelines for management of ischaemic stroke and transient ischaemic attack 2008. J Rehabil Med. 2009;41:99–111.

7. Dalal HM, Doherty P, Taylor RS. Cardiac rehabilitation. BMJ. 2015;351:h5000.8. Hartwell D, Hartwell D, Colquitt J, Loveman E, Clegg AJ, Brodin H, Waugh N et al. Clinical effectiveness and cost–

effectiveness of immediate angioplasty for acute myocardial infarction: systematic review and economic evaluation. Health Technol Assess. 2005;9:1–99.

9. Elgendy IY, Kumbhani DJ, Mahmoud A, Bhatt DL, Bavry AA. Mechanical thrombectomy for acute ischemic stroke: a meta-analysis of randomized trials. J Am Coll Cardiol. 2015;66:2498–505.

10. Penaloza-Ramos MC, Sheppard JP, Jowett S, Barton P, Mant J, Quinn T. Cost-effectiveness of optimizing acute stroke care services for thrombolysis. Stroke. 2014;45:553–62.

11. Rodrigues FB, Neves JB, Caldeira D, Ferro JM, Ferreira JJ, Costa J. Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis. BMJ. 2016;353:i1754.

12. Suarez JI. Diagnosis and management of subarachnoid hemorrhage. Continuum (Minneap Minn). 2015;21(5 Neurocritical Care):1263–87.

13. Daou B, Kent AP, Montano M, Chalouhi N, Starke RM, Tjoumakaris S et al. Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke. J Neurosurg. 2016;124:1773–9.

14. Cortez E, Panchal AR, Davis J, Zeeb P, Keseg DP. Clinical outcomes in cardiac arrest patients following prehospital treatment with therapeutic hypothermia. Prehosp Disaster Med. 2015;30:452–6.

15. Jeon SB, Koh Y, Choi HA, Lee K. Critical care for patients with massive ischemic stroke. J Stroke. 2014;16:146–60.16. Sterne JA, Bodalia PN, Bryden PA, Davies PA, López-López JA, Okoli GN. Oral anticoagulants for primary prevention,

treatment and secondary prevention of venous thromboembolic disease, and for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess. 2017;21:1–386.

17. Pan Y, Chen Q, Zhao X, Liao X, Wang C, Du W et al. Cost–effectiveness of thrombolysis within 4.5 hours of acute ischemic stroke in China. PLoS One. 2014;9:e110525.

18. Tan Tanny SP, Busija L, Liew D, Teo S, Davis SM, Yan B. Cost–effectiveness of thrombolysis within 4.5 hours of acute ischemic stroke: experience from Australian stroke center. Stroke. 2013;44:2269–74.

29

Ann

ex 5

. Sum

mar

y of

the

road

map

1In

fras

truc

ture

Hos

pita

ls w

ith 2

4/7

cath

eter

izati

on la

bora

tory

and

CT

scan

ning

faci

lity,

with

inte

nsiv

e ca

re u

nit a

nd a

vaila

bilit

y of

thro

mbo

lysi

s an

d th

rom

boex

trac

tion

in s

trok

e, P

CI in

ACS

, end

ovas

cula

r tre

atm

ent f

or s

ubar

achn

oid

haem

orrh

age

Avai

labi

lity

of c

ardi

ac s

urge

ry a

nd n

euro

surg

ery

(on-

site

or r

egio

nal p

lan

of tr

ansf

er)

Avai

labi

lity

of p

ost-

acut

e re

habi

litati

on a

nd lo

ng-t

erm

car

e st

ruct

ures

2Po

licie

sCV

D a

nd e

mer

genc

y ca

re g

over

nmen

t pro

gram

me,

loca

l gui

delin

es a

nd c

linic

al p

athw

ays

prot

ocol

, est

ablis

hed

paym

ent m

odel

(DRG

s?),

conti

nuin

g m

edic

al e

duca

tion

3In

sura

nce

and

fu

ndin

gTo

tal v

olum

e of

car

e pl

anni

ng a

nd fu

ndin

g, c

over

age

of a

ll ex

pens

es fo

r who

le c

ase

4Pa

tient

flow

Firs

t con

tact

Ambu

lanc

eEm

erge

ncy/

inte

nsiv

e ca

re u

nit

Inte

rven

tion

Hos

pita

lRe

habi

litati

onSe

cond

ary

prev

entio

n

ACS

Stro

keAC

SSt

roke

ACS

Stro

keAC

SSt

roke

ACS

Stro

keAC

SSt

roke

ACS

Stro

ke

5G

oals

Firs

t

ACS

awar

enes

s an

d as

sess

men

t

Stro

ke

awar

enes

sFA

ST

asse

ssm

ent

ACS

pre-

aler

t by

am

bula

nce

crew

sEK

G

Defi

brill

ation

Basi

c lif

e su

ppor

t am

bula

nce

equi

pmen

tFA

ST v

alid

ation

Stro

ke p

re-a

lert

Trop

onin

Med

icati

onN

o de

lays

in

emer

genc

y or

in

tens

ive

care

un

it ad

mis

sion

CT s

can

24/7

Caro

tid

sono

grap

hy

No

dela

ys in

em

erge

ncy

asse

ssm

ent

Thro

mbo

lysi

sFe

ver,

suga

r an

d sw

allo

win

g pr

otoc

ol

Thro

mbo

lysi

s 24

/7

Neu

rosu

rgic

al

prot

ocol

s

Inte

nsiv

e ca

re

unit

criti

cal c

are

(mon

itore

d be

d)

ACS

clin

ical

pa

thw

ays

acco

rdin

g to

the

vasc

ular

risk

Med

icati

ongu

idel

ines

ad

here

nce

Stro

ke u

nit c

are

(mon

itore

d be

ds)

Mul

tipro

fess

iona

l ev

alua

tion

Clin

ical

pat

hway

s

Nati

onal

str

oke

guid

elin

e ad

here

nce

Revi

ew c

urre

nt

card

iac

reha

bilit

ation

pr

otoc

ol, G

L an

d fa

ciliti

es

Early

in-h

ospi

tal

reha

bilit

ation

(o

ccup

ation

al

ther

apis

t, S

T,

FKT)

Use

EB

reha

bilit

ation

pr

otoc

ols

Revi

ew,

reor

gani

ze

exis

ting

reso

urce

s an

d se

rvic

es

Mea

sure

fu

nctio

nal

outc

ome

Coor

dina

ted

disc

harg

e pl

anni

ng

with

prim

ary

heal

th c

are

prov

ider

s

Med

icati

on

avai

labi

lity

Life

styl

e co

unse

lling

EBM

med

icati

on

avai

labi

lity

Antic

oagu

latio

n in

pos

t-st

roke

at

rial fi

brill

ation

Care

give

r an

d pa

tient

in

volv

emen

t in

life

styl

e co

unse

lling

Seco

nd

Tim

e ch

ecki

ngTi

me

chec

king

Tele

-ECG

to

ass

ist

thro

mbo

lysi

s in

pre

hosp

ital

setti

ng

Stro

ke

ambu

lanc

e ne

twor

k es

tabl

ishm

ent

Echo

and

co

mpr

ehen

sive

ca

rdia

c di

agno

stic

wor

k-up

for a

ll pa

tient

s

Angi

o CT

sca

n 24

/7ad

vanc

ed

neur

oim

agin

g (M

RI,

perf

usio

n CT

) 24

/7

PCI 2

4/7

Endo

vasc

ular

th

rom

bect

omy

24/7

Endo

vasc

ular

pr

oced

ures

(a

neur

ysm

em

boliz

ation

) 24

/7

Neu

rosu

rger

y

Qua

lity

cont

rol

prog

ram

me:

ACS

regi

stry

Audi

t

Qua

lity

cont

rol

prog

ram

me:

Stro

ke re

gist

ryAu

dit

Esta

blis

h ca

rdia

c re

habi

litati

on

serv

ices

, im

plem

ent c

ardi

ac

reha

bilit

ation

na

tiona

l EB

guid

elin

es

Expa

nd

post

-str

oke

reha

bilit

ation

Impl

emen

t co

gniti

ve

reha

bilit

ation

Dis

pens

ary

obse

rvati

on

12 m

onth

s aft

er A

CS

Com

preh

ensi

ve

re-e

valu

ation

si

x m

onth

s aft

er

the

even

t

6Pe

rspe

ctive

Coun

tryw

ide

disp

atch

ing,

co

ordi

nate

d an

d fle

xibl

e AC

S ne

twor

k

Coun

tryw

ide

disp

atch

ing

prot

ocol

s

Coor

dina

ted

stro

ke

netw

ork

and

ambu

lanc

epr

otoc

ol

Preh

ospi

tal

tria

ge,

coun

tryw

ide

avai

labi

lity

of

preh

ospi

tal

basi

c tr

eatm

ent

with

spe

cial

ist

ambu

lanc

es

capa

ble

of

thro

mbo

lysi

s fo

r ACS

Ambu

lanc

e by

pass

ag

reem

ents

in

pla

ce w

ith

dire

ct tr

ansf

er

from

hom

e to

rem

ote

PCI

cent

re, s

kipp

ing

loca

l non

-PCI

ho

spita

l

Stro

ke n

etw

ork

Impl

emen

tatio

n

Preh

ospi

tal

tria

ge,

ambu

lanc

e by

pass

to

tran

sfer

pati

ent

from

hom

e to

ne

ares

t str

oke

cent

re (s

poke

or

hub)

, ski

ppin

g lo

cal n

on-s

trok

e re

ady

hosp

ital

Cons

ider

mob

ile

stro

ke u

nits

for

rura

l are

as

ECM

OH

ypot

herm

iaSh

ock

trea

tmen

t pr

otoc

ol

Impr

ove

timel

ines

s of

st

roke

car

e em

erge

ncy

asse

ssm

ent

and

inte

rven

tion

at a

ll le

vels

PCI +

CAB

G

on s

iteEx

pand

acc

ess

to a

dvan

ced

inte

rven

tions

and

ne

uroc

ritica

l car

e se

rvic

es:

Thro

mbo

lysi

sEn

dova

scul

ar

proc

edur

esH

emic

rani

ecto

my

Hea

rt te

amTo

tal A

CS

regi

stry

Qua

lity

accr

edita

tion

and

benc

hmar

king

of

stro

ke c

entr

es

Stre

ngth

en c

ardi

ac

reha

bilit

ation

cu

lture

and

se

rvic

es s

uch

as in

prim

ary

heal

th c

are,

an

d in

inpa

tient

an

d ou

tpati

ent

depa

rtm

ents

co

untr

ywid

e

Pref

eren

tial

med

icati

on

supp

ly /

ad

here

nce

cont

rol

prog

ram

mes

Man

agem

ent o

f po

st-s

trok

ede

pres

sion

, ep

ileps

y,

cogn

itive

di

sord

ers

Incr

ease

acc

ess

to p

atien

t ca

regi

ver

educ

ation

and

ev

iden

ce-

info

rmed

dru

gs

7M

onito

ring

and

qual

ity c

ontr

olM

onito

ring,

nati

onal

regi

strie

s, in

dica

tors

30

Ann

ex 6

. Sum

mar

y di

agra

ms o

f the

road

map

Fig.

A6-

1. P

ossi

ble

mod

el o

f ACS

car

e fo

r Ky

rgyz

stan

: pha

se 1

– n

ext 1

–3 y

ears

Urban areas Rural areas

Ambu

lanc

eca

ll

Ambu

lanc

eca

ll

PCI 2

4/7

PCI 9

–16

Preh

ospi

tal t

hrom

boly

sis

Tran

sfer

< 1

20 m

in o

r NST

EMI

Tran

sfer

> 1

20 m

in

Prim

ary

PCI

Phar

mac

oinv

asiv

ePC

I for

NST

EMI

CABG

?

In-h

ospi

tal t

hrom

boly

sis

(if n

eede

d)D

elay

ed P

CI

Reha

bilit

ation

Seco

ndar

y pr

ophy

laxi

s

Loca

l non

-PCI

hosp

ital

In-h

ospi

tal t

hrom

boly

sis

(if n

eede

d)

Reha

bilit

ation

Seco

ndar

y pr

ophy

laxi

s

Tran

sfer

for P

CI o

r CAB

G

Tele

-ECG

31

Fig.

A6-

2. P

ossi

ble

mod

el o

f ACS

car

e fo

r Ky

rgyz

stan

: pha

se 2

– n

ext 3

–5 y

ears

Urban areas Rural areas

Ambu

lanc

eca

ll

Ambu

lanc

eca

ll

PCI 2

4/7

Tran

sfer

< 1

20 m

inor

NST

EMI

Prim

ary

PCI

Phar

mac

oinv

asiv

ePC

I for

NST

EMI

Emer

genc

y CA

BG

Reha

bilit

ation

Seco

ndar

y pr

ophy

laxi

s

Loca

l non

-PCI

hosp

ital

Reha

bilit

ation

Seco

ndar

y pr

ophy

laxi

s

Tran

sfer

for

PCI o

r CAB

G

Preh

ospi

tal t

hrom

boly

sis

PCI 2

4/7

Tran

sfer

> 1

20 m

in

Tele

-ECG

OR

Prim

ary

PCI

Phar

mac

oinv

asiv

ePC

I for

NST

EMI

Emer

genc

y CA

BG

Preh

ospi

tal t

hrom

boly

sis

Tran

sfer

> 1

20 m

in

Tele

-ECG

32

Fig.

A6-

3. P

ossi

ble

mod

el o

f str

oke

care

for

Kyrg

yzst

an: p

hase

1 –

nex

t 1–3

yea

rs

Urban areas Rural areas

Ambu

lanc

eca

ll

Ambu

lanc

eca

ll

Stro

ke u

nit

Tran

sfer

with

in 6

0 m

infr

om a

mbu

lanc

e ca

ll

CT s

can

– fir

st 1

2 h

if st

able

or

imm

edia

tely

in

emer

genc

y ro

om

NIH

SSM

ultid

isci

plin

ary

eval

uatio

nIC

U s

tay

24 h

min

imum

Reha

bilit

ation

Seco

ndar

y pr

ophy

laxi

s

Loca

l hos

pita

lW

ithou

t str

oke

unit

FAST

pro

toco

l

Pre

-ale

rtm

in 1

5 m

in

Stro

ke U

nit

Tran

sfer

with

in 6

0 m

infr

om a

mbu

lanc

e ca

ll

CT s

can

–fir

st 1

2 h

if st

able

or

imm

edia

tely

in e

mer

genc

y ro

om

NIH

SSM

ultid

isci

plin

ary

eval

uatio

nIC

U s

tay

24 h

min

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34

Annex 7. Possible model of stroke care rehabilitationThe following table presents a possible organization model for settings of care (1). The guiding principle is that rehabilitation starts in the acute phase (early rehabilitation) and continues in the post-acute phase in a proper environment. The current trend is to separate the two things (acute care and rehabilitation), even for financial reasons: the hospitals are reimbursed with a DRG-based system, whereas rehabilitation is reimbursed through a daily rate calculated based on the level of intensity of care provided. The level of intensity of care provided is decided based on patient condition, level of stroke severity (here the Barthel index, NIH stroke scale and other measures are very useful). For example, to be admitted to inpatient rehabilitation, a patient’s Barthel index score must be below 49 and able to do three hours of rehabilitation per day. The number of rehabilitation beds for each region should be calculated based on demographic and epidemiological data.

Setting AdmissionLength of stay

Specialist involvement Features

Inpatient rehabilitation facilitya

5–7 days after stroke

8–45 days

MD: physical medicine and rehabilitation (physiatry) or trained neurologists; allied health personnel: specialized stroke nurse, speech therapist, physiotherapist, occupational therapist, social worker, psychologist

General rehabilitation in patient facility with rehabilitation programme suitable for stroke patients and access to neurorehabilitation services. Able to deliver services seven days a week.

Stroke inpatient rehabilitation facilityb

5–7 days after stroke

8–45 days

MD: physical medicine and rehabilitation (physiatry) or trained neurologists; allied health personnel: specialized stroke nurse, speech therapist, physiotherapist, occupational therapist, social worker, psychologist

Defined geographical area with suitable facilities, with clinical practice showing evidence of multidisciplinary teamwork: structured team meetings at least weekly, regular programmes of stroke education tailored to the needs of staff and patients, multidisciplinary notes, involvement of family and caregivers in treatment programmes and regular goal planning meetings. Able to deliver services seven days a week.

Nursing home Variable Prolonged and highly variable

MD: geriatrician, internal medicine; nurse, physiotherapist, occupational therapist

Defined geographical area to admit patients objectively assessed as failing to respond to a tailored programme of stroke rehabilitation or in case the prognosis of other comorbidities does not allow time for a trial of rehabilitation

Outpatient rehabilitation facility

Variable (typically 5–30 days)

Variable

MD: physical medicine and rehabilitation (physiatry) or trained neurologists, specialized stroke nurse, speech therapist, physiotherapist, occupational therapist, social worker, psychologist

Outpatient neurorehabilitation services offering different level of rehabilitation intensity, with rehabilitation programme suitable for stroke patients. Able to deliver services seven days a week

aThis is a post-acute level of care. A rehabilitation facility could be part of a hospital or placed outside in a dedicated rehabilitation facility.bStroke inpatient rehabilitation is an inpatient residential rehabilitation facility that is dedicated to stroke care.

35

Reference

1. Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47:e98–e169.

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