STROKE AND HEART ATTACK PROJECT 2010-2013 WORLD HEALTH ORGANIZATION/ MILLENIUM CHALLENGE ACCOUNT- MONGOLIA
THE PROJECT GOAL To improve care delivery framework for comprehensive medical care to the patients with stroke and acute myocardial infarction (AMI) such as early detection, treatment, adequate rehabilitation and prevention of recurrence stroke and myocardial infarction (MI). Main activities to implement: New ASU, CICU and step down units The trainings of the core team of integrated stroke and AMI specialists Registration of stroke and myocardial infarction Secondary prevention: Salt intake study and intervention activities The under and post graduate training curriculum and module National clinical guidelines and protocols of stroke, AMI and rehabilitation Cost-effective rehabilitation program
Development of the national clinical guidelines including protocols The members of sub-twgs were approved by the Minister for Health s order 211 on 27 June 2011. Following four national clinical guidelines were approved by the order 27 of the Minister for Health on 18 January 2013. 1. Clinical guideline of acute stroke 2. Clinical guideline of AMI 3. Stroke rehabilitation guideline 4. MI rehabilitation guideline As the request of the Mongolian government, the clinical guidelines have been developed based on the European modern clinical guidelines.
Essential equipment technical specification of Acute Stroke Unit (ASU), Cardiac Intensive Care Unit (CICU) and Rehabilitation Unit According to the specifications (for 106 kinds of equipment) of equipment developed by the project, the equipment for the following newly establishing and re-organized units have been provided by MCA; Catheter laboratory (angiography) Computer tomography Acute stroke unit Cardiac intensive care unit Step-down units Cardiac rehabilitation Rehabilitation
Human resource development Study tour In order to improve the myocardial infarction medical care services at Shastin Central Hospital (SCH), a study tour at the Severance Cardiovascular Hospital of Yonsei University Health System (YUHS) of Seoul, Korea was organized from 19 to 24 November 2012. A working group from SCH consisted of cardiologists, cardio surgeon, doctors, specialists and nurses was appointed to study the international modern experience of AMI management at the YUHS, Korea on how to run the diagnoses and treatment basing on the clinical guidelines and protocols including nursing care service, the registration system of MI and the rehabilitation care services on how to run and link it to inpatient and outpatient services.
Human resource development WHO fellowship trainings in abroad The project have been training a total of 15 doctors and specialists consists of cardiologist, intervention cardiologist, cardio surgeon, neurologist, rehabilitation doctors, pragmatist, nurses and technician in abroad. Stroke and MI teams (10 fellows) - for 1-6 months from 28 April and 6 May 2013, at the Yonsei University, Korea Rehabilitation team (5 fellows) - for 1-6 months from 1 July 2013, at the Manipal University, India
Human resource development Local trainings Workshops, seminars, trainings and stakeholders meetings were arranged during every visiting of international consultants of the project.
Human resource development Local trainings In order to implement the newly developed clinical guidelines at the project selected hospitals, a total 1,583 doctors, specialists, social workers and nurses were trained in 15 different topics.
Service delivery Stroke, MI and rehabilitation teams were established at the project selected hospitals. The technical working groups of the project developed a patient follow in AMI at the SCH with the consultation of Severance Cardiovascular Hospital of YUHS, Korea. The draft structure of CICU, ASU and rehabilitation departments of SCH including internal operational procedure and job description have been developed in 2012 as well.
Under and post graduate training curriculum and module The under and post graduate training curriculums and modules of stroke, MI and rehabilitation of HSUM based on the national clinical guidelines of stroke, MI and rehabilitation have been updated and were approved by Scientific Committee of HSUM on 6 February 2013. Developed 6 undergraduate and 5 postgraduate training modules; and 7 teacher s, 4 student s and 3 resident doctor s handouts. By comparative analysis of updated curriculums implementation in stroke, MI and rehabilitation, mean level of pre-test was 51,05% and post-test level was improved as 73,03%. Newly developed teacher, doctor and students handouts were more detailed and understandable which could resulted to increase post evaluation result. This complete renewal of undergraduate and postgraduate medical curriculum and training modules would be high importance on providing training unity and continuity and promoting clinical guidelines implementation issue.
Research Salt intake study and reduction activities: The Salt intake of the population survey was conducted involving 1034 persons aged 25 to 64 from 4 provinces of Mongolia and Ulaanbaatar city. - The average sodium excretion level over a 24-hour period in the urine of a Mongolian person was 4354.3 mg. - The average daily salt intake was 11.1g (more than two times higher than the WHO recommendation). 83.2% of the population consumes more than 5g of salt per day. - There were 19.1% who did not know which foods were high in salt content; 12.5% did not have knowledge or an understanding of salty foods adversity to health. - There were one in 2 people (50%) had the habit of consuming salty tea and high salt meals on a regular basis. - There were one in 3 people do not take any action to reduce their consumption of salt, the results show that there is an urgent call to develop and implement a national salt intake reduction strategy program and promote national campaigns educating the population on the proper consumption of salt. - The survey some results were presented during the 24th meeting of International Hypertension Association. The Journal of Hypertension Vol 30 e-supplement 1 September 2012, http://www.jhypertension.com). - Salt intervention activities are being implemented under Pinch salt sub-project at the project selected companies of Talkh chiher, Makh-Impex and Goyo.
Heart attack and stroke rehabilitation activities
Stroke registration Web-based and Microsoft Access program based stroke registration software programs were developed in English and Mongolian Languages. The government is working to become the member of Stroke STEP Surveillance System of WHO. A hospital and community based pilot registration of stroke was started implementing from 1 November 2012 at the project selected hospitals including Bayangol district.
Stroke registration PROPOSED MONGOLIA NATIONAL STROKE REGISTRY DEVELOPMENT PLAN REGISTRY PHASE 1 Hospital registrations 1st, 3rd, and Bayangol hospitals REGISTRY PHASE 2 Hospital and expansion to Bayangol community 200,000 population UNDER CURRENT PROJECT Next Step REGISTRY PHASE 3 expand to all 3 hospitals community registrations REGISTRY PHASE 4 First further expansion beyond 3 hospitals catchment area 1 Current Consultation 2 After 3 months 3 After 5 months 4 Phase 1 Final Report October 06, 2012 Current contract After 3 months Proposal for Phase 2 Phase 2 Final Report and proposal for Phase 3 April, 2013 After 3 months FUTURE PROPOSED PROJECT Phase 3 Final Report and proposal for Phase 4 December, 2013 The project developed a proposed Mongolia stroke registry development plan Registry phase 1 was implemented under the project and concerned about the resources required to fulfil the requirements of phase 2 and 3. However, immediately following successful deployment of the Phase 1 for the three hospitals (State 1st Central Hospital, SCH and Bayangol district hospital) the project is planning to conduct the community based registration pilot survey in Bayangol district area (population approx. 200,000). The longer term plan of stroke registry development for future can be found in the diagram under red prickline.