The STroke Alert Responders (STARs) at a public hospital in Metropolitan Manila are living up to their acronym – their commitment to improving stroke care has so far earned four gold awards for the Philippines’ Quirino Memorial Medical Centre.
IT’S an experience that stays with you.
A street vendor had collapsed in the aromatic sprawl of Manila’s informal food trade, his misfortune quickly drawing a small crowd. A tricycle was flagged down and directed to convey the man to Quirino Memorial Medical Centre, zigzagging in and out between the cars, trucks and buses snarling up traffic in the world’s most densely populated city.
Quirino Memorial Medical Centre (QMMC) is simultaneously a recognised centre of excellence and a crowded public hospital dedicated to serving the less fortunate residents of Quezon City in northeastern Metro Manila. It was in both these capacities that it welcomed the stricken street vendor in late 2019.
Four years earlier, a Centre for Neurological Sciences (CNS) had been established at QMMC by noted neurologist Dr Amado San Luis with a view to training neurology residents and nurses and providing neurological services to the city’s indigent population. In April 2018 this centre’s endeavour to improve stroke care had led to the establishment of a frontline multi- disciplinary team of stroke alert responders who went by the acronym STARs, as well as a multi-specialty and inter-professional supervisory team. One month later it sealed a partnership with the Angels Initiative that would support its goals and expedite the procurement of the thrombolytic drug rTPA.
Around the time the tricycle carrying the vendor rounded the corner of JP Rizal and P Tuazon Streets, QMMC-CNS was finally ready to treat its first stroke patient with thrombolysis. You might say that the stars had aligned for the humble man who, following recanalisation treatment, would regain enough strength in his weakened right side to return to the sunny street corner where he plied his trade.
For the STARs themselves – a team composed of specialties including neurology, radiology, internal medicine, frontline nursing and laboratory services – it was a day of elation and nervous anticipation. “It was really intense,” recalls Darren Porras, the QMMC stroke nurse champion who participated in this landmark event. The details of the case may have faded from memory, but the feeling of excitement mixed with apprehension is one he can never forget.
Within a year of treating their first patient, QMMC met the criteria for a WSO Angels Gold Award, designed to honour teams committed to stroke practice and continuous quality monitoring. International recognition for their achievement ignited the ambition of the team who in the third quarter of 2021 would collect their fourth award.
The numbers tell the story. In 2019 the STARs received 61 alerts and administered recanalisation treatment to 15 stroke patients. In 2020 the number of stroke alerts rose to 127, and the recanalisation rate from 25% to 30% as 39 patients were treated with thrombolysis.
Multiple parallel processes, collaboration and good communication underpin their strategy for continuous improvement, says QMMC vascular neurologist and stroke champion Doctor Jo Ann Soliven.
With private emergency ambulance services in Manila only accessible by those with deep pockets, most of QMMC’s patients arrive by tricycle or public utility vehicles, excluding the possibility for EMS prenotification. But as soon as the stroke code is activated, the STARs are assembled in the CT imaging room via Viber, a messenger application similar to WhatsApp. Laboratory processing to rule out contra- indications for thrombolysis takes place simultaneously with NIHSS evaluation and the CT scan; close communication between neurology and radiology expedite the treatment decision, and treatment commences at CT or in the emergency department a few metres away.
A few months prior to the pandemic, QMMC was earmarked for elevation to one of the country’s subnational Brain Centres. Just as it was preparing to roll out the developmental plan, the pandemic brought with it new challenges. As successive waves of Covid-19 hit the Philippine archipelago, President Rodrigo Duterte signed laws in November 2020
increasing the bed capacity, health services and medical personnel at seven hospitals including QMMC.
Already designated a Covid-19 referral hospital, QMMC saw its bed capacity double from 500 to 1000. This vote of confidence from the country’s president notwithstanding, the pandemic ramped up the pressure and tested the stroke team’s ability to provide quality stroke care.
Stroke simulation training, assiduous record-keeping and multi-disciplinary meetings to review performance and identify opportunities for improvement had helped sustain progress. Now, with the assistance of the Angels Initiative, the campaign to optimise stroke treatment quality moved online with a series of virtual events appearing on the calendar including a quality monitoring workshop, virtual academy for doctors and simulation webinars.
Continuous improvement remains their goal, Dr Soliven says. These include prioritising shorter door-to-needle times and developing capacity for thrombectomy that could make QMMC the next hospital in the Philippines to earn diamond status in the WSO-ANGELS Awards.
Working hand in hand with the Angels Initiative will help them reach the goal of providing the best quality of care for those afflicted with stroke, says Dr Victoria Manuel, the head of Neurology at QMMC. “And little by little these endeavours will contribute to decreasing the stroke health burden of our society.”
Already a highly motivated team, the STARs have a secret weapon, Dr Soliven reveals. They are able to count on the strong support of the hospital’s administrators including the Medical Centre Chief Dr Evelyn Reside and Dr Lino Pabillo, chief of the Medical Professional Staff.
It’s a winning combination of which the citizens of Quezon City are the main beneficiaries – a public hospital and centre of excellence that has STARs on the frontline and stars behind the scenes.