Over the past few decades, there have been remarkable advancements in acute stroke care and prevention, providing us with the opportunity to improve patient outcomes by reducing incidence, disability, and mortality rates. However, low- and middle-income countries (LMIC) still face significant challenges in implementing these advancements, leading to an increasing burden from stroke.
To address this gap, in alignment with the World Stroke Organization Roadmap to Quality Stroke Care, WSO has established a dedicated Implementation Taskforce. The taskforce's primary mission is to accelerate the worldwide implementation of evidence-based stroke care. It aims to achieve this by providing specialized support for implementation, service qualification, and quality monitoring. Furthermore, the taskforce is developing a comprehensive educational program that combines virtual and face-to-face interactions, covering both theoretical and practical aspects of stroke care at all levels of service. Additionally, the taskforce will focus on implementing rehabilitation programs in resource-constrained settings and collaborate with the World Health Organization (WHO) to strengthen primary care prevention programs through the HEARTS program.
The Taskforce will serve as a supportive framework for facilitating discussions with healthcare managers and assisting in the development of national stroke plans. The core group of experts brings extensive experience in implementing acute stroke care services on a global scale. The Taskforce's reach will be further enhanced by the involvement of specialists from around the world, contributing to the development and implementation of local programs. Notably, the Angels Initiative plays a crucial role in the taskforce's efforts. Additionally, the WSO Future Leaders Program plays a key role in fostering the growth and capabilities of young health professionals from diverse backgrounds, effectively disseminating the program's objectives.
The Implementation Taskforce was launched at the World Stroke Congress in Singapore in October 2022, with over 100 volunteers from all five continents. Our aim is to triple the number of stroke centers worldwide within four years and double the number of countries with implemented stroke units and reperfusion therapy, while also increasing the number of countries with national stroke plans. We are confident that by working together with governments and specialists, we can bridge the gaps and successfully implement effective stroke programs globally.
A. Evaluation of the Structure of Services
Evaluation of the Structure of Stroke Services through the WSO Online Roadmap
a. Using the WSO online Roadmap (https://www.wsoroadmap.com/panel/EN/) , hospitals can assess the current structure and organization of their stroke services, tracking their progress over time. The Roadmap categorizes hospitals into three levels and provides recommendations for features and protocols to be implemented at each level. The ultimate goal is to incorporate as many elements as possible from the checklist to ensure the highest quality of stroke services.
b. Upon completion of the assessment, hospitals will receive a rating indicating their level of implementation and the proportion of recommended elements achieved within their respective category. They will also receive feedback on areas that can be improved, many of which can be addressed through organization and training.
c. At the hospital level, the checklist serves as a guide to improve the overall structure, with the aim of attaining the maximum number of recommended elements.
d. The Roadmap can be used by societies, local or national health managers, and other stakeholders to evaluate the status of existing hospitals and assess the feasibility of establishing new stroke centers.
B. Expert Advice for Implementation
The Implementation Taskforce provides access to WSO experts who are available to discuss the steps of implementation with each stroke center. These experts can conduct virtual visits to evaluate the available resources and the overall structure of the center. They offer valuable guidance in creating hospital plans and assist in developing local network or regional plans. With an international team representing different regions worldwide, the taskforce ensures that diverse needs are addressed across the globe.
C. WSO Certification of Stroke Centers
The WSO certification of stroke centers was launched in March 2021 in Latin America (https://globalstrokealliance.com/en/certification/) as a crucial step to guide evidence-based stroke care in the region. This certification is instrumental in ensuring that hospitals implement and monitor priority evidence-based strategies that significantly impact the natural history of stroke. The program presents an excellent opportunity for continuous improvement of services and the qualification of stroke care. Stroke centers play a pivotal role as organizers and trainers within the entire local network.
The certification program is based on the WSO Roadmap for Quality of Stroke Services. The certification criteria were developed by experienced WSO members in collaboration with the Ibero American Stroke Organization, Society of Vascular and Interventional Neurology/Mission Thrombectomy, as well as country Medical Societies, Health Managers and Ministries of Health. Committees have been established in 13 Latin American and Caribbean countries, supported by an international team of stroke experts, currently consisting of 80 professionals working on the implementation of the certification. The program incurs no costs for participating hospitals, whether public or private. In Latin America, the program is supported by Boehringer Ingelheim, Medtronic, Rapid AI, Siemens, and Penumbra. The certification program has expanded to India in November 2022 and is scheduled to extend to Africa and other Asian countries in 2023.
The certification process involves the following steps:
Self-Assessment Tool: Hospitals can utilize this tool to evaluate their current status and identify areas for improvement before applying for certification.
Application for Certification: The web platform allows hospitals to apply for certification. 100% of mandatory items are considered minimal requirements for classification into each category (Essential and Advanced). In addition to the mandatory requirements, hospitals need to fulfill at least 75% of recommended elements to obtain certification.
Onsite Visit: If the system confirms the criteria for certification, an onsite visit will be scheduled, conducted by qualified stroke physicians and stroke nurses.
Certified Stroke Team: The stroke team must also receive certification for training in stroke care. The certification program recognizes the importance of continuous education and aims to provide additional opportunities for learning and professional development. These initiatives will enhance the knowledge and skills of healthcare professionals involved in stroke care. The Implementation Taskforce will collaborate with various educational platforms and organizations to offer a comprehensive range of educational resources. These may include the utilization of the Angels Initiative educational tools, the Stroke Centers Course from Medtronic Academy, the RAPID AI course and national educational stroke courses and upon successful completion, participants receive a certificate.
Board Review: The board review is the final step in the certification process, where the onsite visit findings are presented and evaluated. This comprehensive review ensures that all necessary criteria and requirements for certification have been met. The board, comprised of qualified stroke physicians and experts, carefully assesses the information and recommendations provided during the onsite visit. Based on their evaluation, the final certification decision is made, confirming the hospital's successful completion of the certification process. This rigorous review process guarantees the credibility and validity of the certification, further validating the hospital's commitment to delivering high-quality stroke care.
Implementation of quality acute stroke care and the certification program relies heavily on enhancing the skills and expertise of healthcare professionals. WSO is actively developing and implementing a comprehensive education program to address immediate and emerging education needs.
D1. World Stroke Academy
The World Stroke Academy (WSA), the WSO virtual educational platform, plays a crucial role in supporting the development and delivery of specific educational courses.
Course 1: A structured teaching course on the step-by-step organization of services and treatment protocols (20 hours) will be available through the World Stroke Academy platform, which will complement the implementation and certification program. This course aims to facilitate the dissemination of the Global Guidelines and provide healthcare professionals with valuable knowledge and practical guidance in stroke care. This initiative promotes continuous learning and the implementation of evidence-based practices.
Course 2: Virtual interactive clinical cases of acute stroke care, featuring a virtual simulation course focused on emergency acute stroke care.
Course 3: Interactive sessions focused on endovascular procedures, including interactive questions to enhance learning and understanding.
D2. Mechanical Thrombectomy Training Pathways in LTMICs
To address the specific training needs in LMICs, WSO has developed the Mechanical Thrombectomy Training Pathways program. This one-week training program focuses on mechanical thrombectomy, a crucial procedure in stroke treatment. A trained neurointerventionalist with significant experience in mechanical thrombectomy will travel to a selected region, such as India, in collaboration with a high-volume mechanical thrombectomy center. The program will include local physicians (trainees) who have been trained in neuroendovascular procedures and have hospital privileges to perform neurointerventions. The training will involve trainees from the main hospital as well as other selected institutions. The proctor will be available 24/7 for a week to assist with all emergent mechanical thrombectomy cases. The training week will include lectures on stroke triage, mechanical thrombectomy indications, procedural techniques, and hands-on sessions with flow models. Local faculty will also be invited to participate in the lectures, fostering collaboration and knowledge sharing. The program will collect data and angiographic outcomes of all treatment cases.
D3. Neuro-interventionalist Fellowship Program
WSO recognizes the critical need to develop the clinical, research, and leadership skills of the next generation of stroke professionals. To address this need, WSO is fully committed to establishing a Neuro-interventionalist Fellowship Program specifically designed to enhance the capacity for endovascular treatment in LMICs. The program aims to provide three to five physicians with backgrounds in neurology, neurosurgery, and/or radiology with a unique opportunity to participate in a comprehensive two-year clinical development program at a high-volume institution located outside their country.
The selection of participants for the fellowship program will be based on the highest recommendations from their mentors, colleagues, training institution(s), and/or their Health Ministry. Fellows will be supported either by their own societies/governments or by receiving WSO sponsorship, along with a stipend that reflects the current salary of trainees and the cost of living in the training city.
During the fellowship, neuro-interventionalists will have the invaluable chance to collaborate and share learning opportunities with the WSO Future Stroke Leaders cohorts. This interaction will facilitate the exchange of knowledge and experiences, ultimately contributing to the improvement of stroke care on a global scale.
By establishing the Neuro-interventionalist Fellowship Program, WSO aims to empower talented physicians with the necessary skills and expertise to perform endovascular treatments and make a significant impact on stroke care in LMICs. This initiative will not only strengthen the capabilities of individual clinicians but also foster the development of sustainable stroke care systems in their respective regions.
Institutions already selected to train include:
-Western University, London, Canada
-Vel d’Hebron, Barcelona, Spain
-Hospital Geral de Fortaleza, Brazil
- Hospital Estadual Central, Vitória, Brazil
Leadership Committee Faculty to prepare the content and monitor the neuroinvernaltionist program:
•Violiza Inoa – Neurologist, USA
•Marc Ribo – Neurologist, Spain
•Raul Nogueira – Neurologist, USA
•Demetrius Lopes – Neurosurgeon, USA
E. Global Policy – Global Stroke Alliance Meeting
GSA (Global Stroke Alliance) is an impactful implementation meeting organized by WSO (World Stroke Organization). Its primary objective is to foster a global alliance dedicated to enhancing stroke care worldwide by discussing and implementing evidence-based interventions across all levels of care, including prevention, treatment, and rehabilitation. This prestigious congress serves as a platform that brings together leaders from various countries, renowned researchers, health professionals, health managers, scientific societies, industry representatives, and patient associations.
The key focus of the GSA is to disseminate knowledge, exchange valuable experiences, and formulate region-specific action plans tailored to the unique challenges and opportunities present in each part of the world. The congress encompasses four fundamental pillars: Education, research, organization of services, and political engagement. By addressing these pillars, the GSA aims to contribute significantly to the implementation of effective stroke care globally.
One notable highlight of the GSA is the Ministerial Meeting, where representatives from Ministries of Health across different countries come together with stroke experts to deliberate on the existing gaps, explore the best models of stroke care, and propose potential solutions. Concrete plans for improvement are formulated during these discussions, ensuring a tangible and impactful outcome. The inaugural Ministerial Meeting took place in 2020 in Brazil and witnessed the participation of representatives from 11 Latin American countries, leading to a substantial drive for stroke care improvement in the region.
Moving forward, the GSA will rotate annually in different regions of the world to promote inclusivity and address the specific needs of each region. In 2023, the GSA is scheduled to be held in India, followed by Abu Dhabi in 2024. This rotation ensures that the congress reaches a diverse range of stakeholders and facilitates a global dialogue that accelerates progress in stroke care implementation on a global scale.
Achieving our vision of a life free from stroke is a task that WSO cannot achieve alone. We are committed to building our partnerships at the global, regional and national level to scale up and deliver improvements in prevention, treatment and support to reduce the burden of stroke.