Abdul Malik
Consultant Neurologist,
President, Pakistan Stroke Society
E-mail: drmaharmalik1@gmail.com
Pakistan is the sixth most populous country in the world, with an estimated population of 240 million. Non communicable diseases including stroke now account for 41% of the total disease burden of Pakistan. An estimated 4.8% of Pakistan’s population is living with stroke; this translates to almost more than one million individuals. Until recently, stroke was mostly believed to be a disease for which little or nothing could be done. We now know that strokes are among the most preventable and treatable of all diseases. Thousands of people are dying each year due to stroke when their lives could be saved. Hundreds of thousands more are living with permanent disability for the want of vital service improvements. What are the effects of inadequate services?
Dr. Abdul Malik
Facts: Stroke-specific fatality has been reported between 7% and 20% in various studies from Pakistan. Up to 63% of all stroke patients develop complications and up to 89% are dependent, partly or completely for activities of daily living. Fact: Stroke units have proven to decrease mortality and morbidity in acute stroke. Even in major cities of Pakistan, stroke unit care is missing. If all acute care hospitals have a stroke unit, significant number of lives could be saved. Fact: Due to fragmentation of care & risk of allowing other specialties allowing to lead stroke care specifically stroke unit services other than neurologists a large percentage of strokes are misdiagnosed or mistreated.
It is estimated that less than 0.01% of stroke patients receive the life-saving clot buster/thrombolysis treatment in Pakistan. Fact: It is estimated that less than 10 % patients of stroke receive acute rehabilitation services. A vast majority of our patients are not aware of the role of rehabilitation services in stroke care. Unfortunately, a large number of treating physicians do not emphasize on getting rehabilitation services. All the above facts imply that the place, time and day of a particularly stroke largely determine whether the stroke patient recovers, dies, or lives the rest of his/her life with disability. Where patients live also dictate whether they receive the rehabilitation and support they need after leaving hospital. For many who survive with disabilities after being unable to receive prompt treatment, there is a double injustice. The lack of availability of acute rehabilitation means that many people must live with avoidable or unduly severe disabilities. Do stroke services cost too much? The economic burden related to cost of stroke care and loss of life years related to stroke related disability in Pakistan is not known.
However, international data strongly suggests that the death and disability prevented by appropriate and timely stroke intervention not only saves healthcare related costs, but also outweighs the overall economic burden on the society incurred by these facilities. How can change be secured? We are asking people in general – regardless of whether their lives have yet been touched by stroke or not – to join our campaign urging the decisions makers to implement the measures that will eliminate avoidable death and disability from stroke. We are calling on to implement the following recommendations:
POINT 1: Public Education on Stroke and Cardiovascular Diseases. Research from developed nations shows that even the vast majority of their people would not know if they were having a stroke. Less than half would ring an ambulance if they knew they were having a stroke. A high-intensity public education campaign including electronic and social media, advertisements in community newspaper and billboards, and mailed household brochures showed an increase in awareness of stroke warning signs i.e. FAST and need to call for emergency services-1122. WE CALL ON to establish a program to educate the public about signs and symptoms, as well as risk factors of stroke and cardiovascular diseases. The program should aim about the recognition of conditions/illnesses that can result in stroke and heart attack, and how to reduce their risk of having a heart attack, stroke or the warning sign of stroke, a Transient Ischemic Attack (TIA).
POINT 2: Declaring Stroke as a Medical Emergency. Unlike heart attack, stroke unfortunately is not perceived as a medical emergency. Most people don’t know that immediate medical treatment after stroke can make the difference between recovery, death or permanent disability and dependency. Greater awareness would save many lives by getting more people into hospital quicker, provided that our hospitals are equipped with providing appropriate acute stroke care.
WE CALL ON to support a national campaign to increase public awareness of the warning signs of stroke, and early recognition of stroke. The campaign shall aim at ensuring that stroke is not only recognized early but is treated as a medical emergency.
POINT 3: Stroke Unit Care. The provision of stroke units in acute hospitals could reduce death and dependency rates by 20% – saving hundreds of lives and sparing thousands more from disabilities requiring long term care due to disabilities either at home or in institutions like nursing homes and long term health care facilities. WE CALL ON to ensure that every hospital admitting patients with acute stroke patients has a properly staffed and fully resourced stroke unit lead by a neurologist. Stroke care whether conservative, interventional, or post interventional conducted outside a Comprehensive Stroke Center is an ethical failure and a disservice to patients.
POINT 4: Stroke Unit Standards. Any dilution in the definition of what constitutes a stroke unit, or any operational failure to comply with required standards, especially in relation to capacity, staffing and equipment will reduce their effectiveness and cost lives. WE CALL ON to comply with Pakistan Stroke Society Guidelines in the delivery of a national network of stroke units and to continually monitor compliance with these standards. To make sure for the clot busting treatment medication availability in all the public sector institutes where neurologist(s) is available with stroke unit services. Necessary staffing and equipment supply shall be ensured at all levels of care including government and non-government teaching institutions as well as public and private sector hospitals.
POINT 5: Clot-busting Treatment (Thrombolysis). With the availability of thrombolysis there shall be trained staff with acute decision making and tPA administration, neuro-intervention when required. Pre and post interventional care. For this neurologists are uniquely trained for this holistic approach. WE CALL ON to ensure 24/7 availability of thrombolysis to all suitable stroke patients. This shall be made an urgent priority.
POINT 6: Emergency Response Services. In acute stroke approximately two million brain cells die every minute. It is estimated that less than 10% of patients are admitted to hospital within two hours of stroke onset. After two hours a patient’s chance of recovering with little or no disability is greatly reduced. Trained ambulance staff, telemedicine support and properly equipped ambulances and emergency departments are crucial to the prompt treatment of stroke patients. WE CALL ON to guarantee that emergency services are equipped and empowered to deal with acute strokes. Telemedicine which is now established field in acute medicine shall be targeted as the main fortress of delivery of acute stroke care
POINT 7: Consultant Stroke Physicians. There are not appropriate trained stroke specialists in the whole country, it is therefore necessity to have formal stroke fellowship across the country main teaching institute accredited by the universities as well CPSP. This shortage of specialists is exacerbated by the fact that stroke can be difficult to identify. At least 35% of strokes and more than half of TIAs are currently misdiagnosed in Pakistan. The failure to provide the correct diagnosis in a large number of cases carries devastating consequences for patients. Without having trained human resource there is severe risk of malpractice and compromised patient safety. WE CALL ON to ensure at least one year Stroke Fellowship training for most physicians who have PMDC accredited postgraduate neurology degree. Specialized stroke training shall be designed for internal medicine physicians interested in providing stroke care. The government shall on an urgent basis recruit and train more consultant stroke physicians in all public sector hospitals to provide greater expertise in the diagnosis and treatment of stroke. Besides this we shall have trained dedicated stroke nursing and neuro-critical care physicians. Awarding training certifications without ensuring comprehensive education in all aspects of stroke management risk malpractice and compromises patient safety. Training in neuro-intervention should be conducted in designated stroke centers under the leadership of neurologists.
POINT 8: Training of Ambulance Personnel and First Contact Emergency Care Providers. . Appropriately trained ambulance staff is a must for success of any acute stroke care program delivery. In some of the developed nations, the ambulance are equipped with CT scan facilities, and stroke physicians respond to the emergency calls for stroke by travelling in the ambulance and providing acute care at first contact with the patient. WE CALL ON to have formal ambulance drivers training program so they are aware of the basic emergency measures. They shall be trained how and where to take the patient for emergency treatment on the basis of the signs and symptoms of patient. There are several ambulance services in the country, which all need to have a unified structured training program for ambulance drivers and emergency ambulance staff.
POINT 9: Post stroke rehabilitation, discharge and after care. Currently, there is no existing continuing of care and long-term care plans for stroke patients in the country. It is well established that patients with stroke do better in the society if they receive coordinated care with necessary rehabilitation, availability of necessary equipment, and support for continued care after discharge. Only rarely proper discharge and long-term care plan and education are provided to the family of stroke patients. Very limited resources are available for those who need long term nursing care. WE CALL ON to give every patient privilege to appropriate levels of short- and long-term rehabilitation in hospital and in the community. Additionally, there shall be access to long term nursing and home health care. Stroke care needs a multidisciplinary team including neurosurgeons, neuro-rehabilitation specialists, radiologists, physiotherapists, speech therapist, occupational therapists, psychologists and stroke trained nurses. Pakistan must align with these standards for better outcome.
POINT 10: Ban on avoidable stroke risk factors. Stroke does not happen in one day. Several modifiable and non-modifiable risk factors bring changes in the blood vessel over a period of several years before the stroke strikes. It is important that all modifiable risk factors be appropriately treated. However, some of the risk factors are not medical conditions, but are potential addicting substances including smoked (cigarette, huqqa, biri, shisha, etc.) and chewed tobacco (naswar, pan, mishri, ghutka, bajjar, ghundi etc.) and need to be immediately eliminated from the society. WE CALL ON to have formal implementation of existing legislations to ban the import, manufacture, sale and consumption of these potentially lethal substances including smoked and chewed tobacco.
POINT 11: Monitoring and maintenance of stroke care. Anyone can suffer from a stroke including infants and children. Stroke does not differentiate between gender, race, and age. There is high discordance in the provision of care for various segments of the society. There is a wide gap in the services available to different strata of population in the country based on several factors. WE CALL ON to appoint provincial stroke coordinators with responsibility for ensuring that stroke services are meeting the needs of people who have had a stroke in every community in Pakistan and to eliminate age, gender, and other discrimination from stroke services.
POINT 12: National Stroke Registry. Patient registries that collect the demographic, clinical and non-clinical data on patients, not only assist in planning and evaluation of health care systems, but also ensure quality of care. National stroke registries are established in several countries and are contributing significantly to the continued improvement of stroke care. WE CALL ON shall form on urgent basis a National Task Force for Stroke Care with involvement and participation of all stake holders including government, physicians, professional organization, Non- Governmental Organizations (NGO’s), patient support groups and media. This task force shall ensure that all the above recommendations are appropriately evaluated and carried out. This task force shall also be given the task of organizing and maintaining a National Stroke Registry.
