MAKATI is one of 16 metropolitan cities that together make up the national capital region and heart and central nerve of the Philippines. It is also the country’s financial centre – a thrilling maze of skyscrapers, upscale malls, luxury hotels, and urban parks located at the heart of the Metro Manila.
At its centre, and easily accessible through major roads and expressways, is Makati Medical Centre, a private tertiary hospital with a reputation as glittering as the Makati skyline at night.
Founded in the late sixties by a group of renowned Filipino doctors and businessmen just as Makati was beginning its ascent to becoming the country’s foremost business district, this is a world-class medical facility and one of the premier hospitals in the Philippines.
Over the past 50 years, MakatiMed has garnered numerous laurels ranging from two international awards in recognition of its COVID-19 response to the Daisy Award For Extraordinary Nurses. But recently this bright spot in Philippine healthcare acquired some extra sparkle after receiving a WSO Angels diamond award for excellence in stroke care. MakatiMed is the first and only private hospital in the country to achieve this status and one of just five diamond hospitals throughout the Philippines.
On the already crowded awards wall in the neurology department, this latest accolade joins 10 others, namely the eight gold and two platinum awards the hospital has earned since 2019.
Meet the stroke champions
Like MakatiMed, which now has the second-largest number of WSO Angels Awards in the country, stroke care in the Philippines is enjoying a landmark moment, with much of the momentum brought by the certification programme the Stroke Society of the Philippines (SSP) rolled out at the start of 2023.
The Acute Stroke Ready Hospital (ASRH) Certification Programme recognises hospitals that can provide immediate and time-critical care to stroke patients. These ASRH-certified hospitals receive priority in training and guidance from the SSP committee, and recognition as institutions that deliver quality healthcare to stroke patients. They in turn commit to a programme of continuous improvement which includes implementing quality monitoring as a tool to optimise care.
At a recent quality monitoring workshop in Manila, ASRH-certified hospitals received a crash course about data reporting in RES-Q, the international stroke care quality improvement registry that is endorsed by the SSP. As well as helping hospitals analyse and troubleshoot underperformance and receive recognition via the WSO Angels Awards, this comprehensive push towards quality monitoring will enable the SSP to track stroke care progress throughout a country.
The fact that MakatiMed was among the country’s first stroke-ready hospitals to share data on the RES-Q platform has some roots in Philippine medical history. The hospital’s 2019 decision to adopt RES-Q was driven by Dr Cymbeline Perez-Santiago, a second-generation neurologist who is continuing the legacy of her father, Dr Martesio Perez. Recognised as a neuroscience pioneer in the Philippines, Dr Perez’s use of thrombolytics to treat stroke predates the 1995 study published in the New England Journal of Medicine that lead to thrombolysis becoming the gold standard treatment for ischaemic stroke.
At MakatiMed, Dr Santiago is chief of the neurology section and responsible for quality monitoring in the Acute Stroke Unit. The goal of turning Makati Medical Centre into a centre of excellence for stroke care is one she shares with two passionate stroke champions – Dr Raquel M. Alvarez, who is head of the Neuro ICU and Acute Stroke Unit, and neurologist and neurosonologist Dr Anna Marie S. Nolido.
Dr Nolido’s interest in stroke was sparked during an ultrasound rotation at Columbia in 1999 where she was exposed to the use of ultrasound as a diagnostic tool in patients with ischaemic stroke. In 2002 she joined MakatiMed where she founded and heads up the Neurovascular Unit.
Due to its location and reputation MakatiMed does tend to draw patients from the upper and upper-middle classes of Manila society, Dr Nolido says, but the majority work in the central business district and are covered by private health insurance or HMOs that cover services from in-network providers. This is significant given the high cost of acute treatment in the private healthcare sector. Dr Nilodo says, “Given the nature of our centre many patients can afford the medication as long as it is explained well.”
A promising beginning
If Dr Alvarez’s name sounds familiar, it may be because she was, in 2021, a nominee along with current SSP president Dr Maria Socorro Sarfati in the inaugural WSO Spirit of Excellence Awards. This prestigious, peer-nominated award honours individuals for outstanding contributions to stroke care transformation.
Dr Alvarez has been a neurology consultant at the hospital for almost three decades, two of which have been dedicated to providing better outcomes for stroke patients. It was a preceptorial on stroke at NYC’s Columbia Presbyterian Hospital 22 years ago that marked a turning point for her and for stroke care at MakatiMed.
“Columbia Hospital had started treating acute stroke with thrombolysis just recently and they were very generous with sharing their experience,” Dr Alvarez says.
After three months she returned to Makati intent on establish a stroke service and an organised stroke pathway.
Putting together a neuro response team took time. Dr Alvarez recalls that they were still getting organised when a patient was admitted to the ER with right-side weakness and eye deviation.
Like most of the patients admitted to MakatiMed, this patient worked in the central business district and had reached the hospital via ambulance from a short distance away. Unimpeded by Manila’s notorious traffic jams, he’d arrived at the hospital within the therapy window and became MakatiMed’s first thrombolysed patient. When he was eventually discharged he was fit to return to work.
Ready or not, MakatiMed’s Acute Stroke Unit was off to an encouraging start.
A pathway built for speed
Partnering with the Angels Initiative in 2018 anticipated another turning point for stroke care at MakatiMed. The neuro response team team took advantage of all the support Angels offered, attending stroke conferences, completing online courses in the Angels Academy, and taking part in simulation training to identify quality gaps. Their first gold award in 2019 confirmed they were on the right track. When Covid struck the following year, they were able to adapt to the crisis by swiftly revising their stroke pathway. They continued on their winning streak throughout the pandemic.
Maybe next time it will be a diamond, the hospital directors quipped as the stroke team reeled in one gold after another. Their first platinum award at the end of 2022 was a tipping point, a signal that the elusive diamond might finally be within their reach.
The stroke pathway that finally brought them diamond status is built for speed. Even the security guards who meet patients at the entrance have been trained to recognise the signs of stroke and direct them along the fastest route to the emergency room.
When a suspected stroke patient arrives at emergency, the neuro response team is alerted via the hospital’s public address system, setting in motion a well-rehearsed series of events that includes point-of-care testing in the ER and brisk transfer to the CT room close by. If large vessel occlusion is suspected, a MRI is done to rule out mistakes in diagnosis, and the thrombectomy team put on alert.
“MRI is the imaging modality we primarily use in the hospital,” Dr Nolido says, adding that treatment in some cases commence in the CT scan or MRI area despite the proximity to the ER.
Dr Christine Anne C. Chacon, stroke consultant and the hospital’s first stroke fellow, explains that stroke patients have priority access to the MRI lab and they use an accelerated MRI protocol that “elevates the level of care but doesn’t compromise the time”.
Polish your diamond
Having reached the top, the only way is up for MakatiMed’s stroke champions. Their strategy to ensure their patients continue to receive the highest level of care translates into treating more patients, faster, by reducing the door-to-needle time and raising the thrombectomy rate.
Gap analysis and simulation training will remain key, Dr Nolido says. “You have to continually look where the gaps are to find out what you need to improve.”
That is also the purpose of biweekly multidisciplinary meetings to evaluate every case and every patient’s pathway – a tried-and-tested quality monitoring practice that forms the backbone of their continuous improvement approach.
To broaden access to acute stroke care, they will undertake awareness education both in and outside the hospital, and Dr Alvarez envisages an optimised medical transport service to enable a drip-and-ship model for receiving patients from frontline hospitals.
“A diamond award is an incentive,” she says. “It doesn’t mean you can stop trying to be better. It should energise you to keep doing your best.”
