A spark was lit in Ecuador last December when the IESS Ambato General Hospital was presented with the country’s first Angels Award for excellence in stroke care. Within six months that spark grew into a blazing fire as a campaign was launched to grow no fewer than 30 hospitals across the country into stroke-ready centres by 2023.
This extraordinary story can be told in several ways – including by a spreadsheet adorned with all the colours of the rainbow on which each colour represents a different hospital’s proposed journey to treating every stroke patient with the best care available. This rainbow resides in the laptop computer of Angels Lead Sol Plamenatz whose task it is to roll out an ambitious campaign established through an agreement signed by by the country’s vice-presidency office lead by Alfred Borrero in March. The campaign is called “Actúa Con Velocidad” in reference to the importance of speed in treating acute stroke, but it serves equally well to describe the task at hand. To meet the vice-president’s deadline, Sol and her team will have to act with speed to ensure each hospital reaches its goal within its allocated 45 days.
But all extraordinary stories are about extraordinary people, so let us introduce instead the formidable partnership of Paulina López and Manuel Jaramillo, two emergency physicians at Ambato General Hospital where a seven-year quest to provide world-class care to patients with ischaemic stroke culminated in a WSO Angels Platinum Award in 2021.
Ambato is not the most important city in Ecuador, and Ambato Hospital is a level 2 hospital – in other words, not among those classified to provide specialised, complex care. But to its great advantage it is the clinical home of Dr Paulina López whose own campaign to improve stroke treatment began seven years ago.
Raised in the world of medicine (her mother was a doctor), and drawn to it by its human aspect, Dr López chose her specialty when she realised that the emergency room was where the action was.
In 2015, after losing her grandfather to stroke, she began petitioning the Ecuadorian ministry of health with evidence about the efficacy and safety of thrombolysis for treating hyperacute stroke.
In the several years it took for the treatment to be sanctioned in Ecuador, Dr López took steps to ensure that Ambato Hospital would be ready to meet the moment. By now joined by Dr Jaramillo, the other half of the award-winning partnership, she wanted to be certain that once the light turned to green, Ambato would have a stroke team and a stroke protocol already in place, and that nurses and residents in the emergency department would know exactly what to do.
Dr Jaramillo had chosen medicine because he dreamed of saving lives and in his third year at medical school realised that the emergency unit was where such dreams came true. That dream gained even more poignancy during his first thrombolysis because the patient who was wheeled through the doors of the emergency unit was someone he recognised. He says,
The patient was my wife’s uncle, so the emotion was double when after receiving the medication he regained his ability to speak and the mobility on his right side. For a doctor, the excitement at witnessing the patient’s recovery was spectacular, but seeing my wife’s joy raised mine to an extraordinary level.”
The first thrombolysis at Ambato General Hospital took place on 27 de junio de 2018. By the following year, the Angels Initiative had reached Ecuador and introduced this hospital to the quality improvement registry for stroke care, RES-Q.
It was exactly what they needed, Dr López says. “At the time we felt that there was no-one in the country who could tell us if we were doing it right or whether our protocol was good. But once we started entering our data into RES-Q we could track our performance and discover what to do to improve.”
Covid hit Ecuador hard and fast the following year, but by late 2021 the stroke team at Ambato General Hospital achieved a median door-to-needle time of 42 minutes and qualified for the award that now looks poised to change stroke care throughout the country.
The target of 30 stroke-ready hospitals includes a roughly equal number of public hospitals that offer free medical care, and those managed by the Social Security Institute (IESS) for its members. The participation of both systems in the same campaign is already one of its early successes.
The process at each hospital starts with a kick-off meeting during which Sol introduces the Angels Initiative, the main criteria for stroke-readiness and the timeline to achieve it. A stroke champion is named from whom the Actúa Con Velocidad team will obtain the hospital’s history and existing stroke protocol. Training commences next and includes mandatory completion of certification courses in the Angels Academy, followed by protocol revision and a stroke pathway simulation to determine whether further intervention is needed.
The protocol developed at Ambato Hospital has become the template for all Ecuadorian hospitals and Drs López and Jaramillo take turns to travel to the hospitals identified for stroke-ready status to help them revise their stroke pathway.
“It’s about ‘learning to unlearn’,” says Dr López of the process to get bigger hospitals in more important cities to change the way they do things. It’s an undertaking that requires a good deal of diplomacy and tact, but nevertheless makes her “really happy”. I feel that I am doing a small thing to change the world.”
Dr Jaramillo calls this one of the most important moments of his career. “Not only because it is a national project that will change the lives of many patients, but for the opportunity to share my hospital’s experience with others and be part of history.”
It’s a desire for change that drives these two doctors, and the chance to show that excellence isn’t proportionate to size or state-of-the-art technology. To keep the flame burning you first and only have to find the fire inside – the will to help others and a dream to save lives.
