Until three years ago, stroke calls to the ambulance service in Malaysia’s Negeri Sembilan state were not considered time-critical emergencies. They were assigned level four priority, and protocol only required the patient to be taken to the nearest district hospital.
In 2020, however, stroke shot to level one priority. From then onwards a suspected stroke would place the dispatch centre on high alert. The nearest and most experienced ambulance would be activated to attend the scene, and they would bypass the nearest hospital if it wasn’t stroke-ready, to bring the patient directly to Hospital Tuanku Ja’afar in the state capital, Seremban.
The precursor to this significant change occurred on 5 tháng 5 năm 2019, the day Hospital Tuanku Jafa’ar treated an ischaemic stroke patient with thrombolysis for the first time. Its door-to-needle time of under 60 minutes was enough to win the hospital its first WSO Angels Award. Over the next two years it would double its treatment rate and halve its treatment time to become one of a handful hospitals in Malaysia to meet the criteria for a diamond award.
To reach this milestone and achieve a world-class median door-to-needle time of 25 minutes, the hospital streamlined its pathway to eliminate every unnecessary interaction. One key intervention was making its ambulance service unit part of its stroke team, in recognition of the fact that an optimised stroke pathway began the moment the patient or their relative dialed 999. The result of this collaboration was the development of the HASTE protocol, now used at hospitals throughout the state, and the HASTE kit for prehospital teams.
HASTE stands for Hyperacute Stroke Smart Track in Emergency, and is essentially a model for doing the important things right. At Hospital Tuanku Ja’afar this includes ensuring its paramedic teams are properly trained in prehospital stroke care, and have recourse to the HASTE kit with checklists and stroke scales for assessing the patient, as well as remote supervision by an ER physician.
Prenotification and preregistration ensure a dedicated stroke team is ready to receive the patient when they arrive. After a brief pitstop in the emergency department the patient is wheeled to the CT scanner, which is located about 15 steps beyond the red zone.
Hospital Tuanku Ja’afar has one of the only two CT scans in the state, but stroke patients skip the inevitable queue. In another time-saving tactic, the patient remains on the EMS stretcher until after the treatment decision is made and they are transferred to a dedicated bed in the emergency department.
One result of this integrated strategy has been that Hospital Tuanku Ja’afar keeps adding to its slew of awards – each one a feather in the cap of emergency physicians Dr Emi Noorina Binti Mohd Nor, Dr Syed Hussein Barakbah and Dr Mohamad Azzlee Mustafa who drive the stroke programme with the assistance of Acute Internal Medicine (AIM) Physician, Dr Ng Yin Jie.
The other is that the Tuanku Ja’afar ambulance service unit is also attracting international recognition as the first EMS team outside Europe to receive an EMS Angels Award.
Like the WSO Angels Awards, EMS Awards not only serve to recognise performance but also to raise the standard of care by identifying areas where improvement is needed. Performance is measured against criteria that include on-scene time, prenotification, delivery to stroke-ready hospitals, and reporting of patient medication and time last known normal.
A single percentage point in the prenotification rate kept the Tuanku Ja’afar team from achieving diamond status in Q1 of 2023. But though they’ve had to be satisfied with a second platinum for now, all eyes are on their median on-scene time of 10 minutes, which according to awards coordinator Katarzyna Putyło is the best they have seen so far.
There is growing recognition in the stroke community that a close working relationship between hospital and EMS saves lives, and Tuanku Ja’afar’s single protocol for prehospital and inhospital stroke care is a case in point. A 2020 US study of the role of EMS in stroke systems of care found that integration of EMS was critical to improve rates of thrombolysis among acute ischaemic stroke patients.
An earlier study of hospital-EMS collaboration in cases of acute myocardial infarction (AMI) found that active collaboration was associated with lower AMI mortality rates. The measures recommended by the authors of that study apply equally to stroke pathway collaborations such as the one at Tuanku Ja’afar: strong communication and coordination, engagement of EMS in quality improvement activities, and respect for EMS providers as professionals.
At Tuanku Ja’afar respect is expressed in several ways. Ambulance teams not only receive regular feedback on patient outcomes; they are also invited to provide feedback on how the protocol might be improved, and are included as presenters at joint workshops where they can share their knowledge with doctors and paramedics.
“It is important to acknowledge them,” Dr Mohamad Azzlee Mustafa says. “They are part of our team.”