The “ResISSSTE Cerebro” program includes seven urban healthcare facilities located in Mexico City and one in each of the neighboring states of Morelos and Hidalgo. According to the World Stroke Organization global stroke services guidelines and action plan (9 (link)), seven facilities are cataloged as essential stroke centers (ESC). Thus they offer access to non-contrast computed tomography (NCCT), clinical evaluation, and potentially IVT (according to IVT criteria cited below). At ESC, there is no personnel with expertise in AS treatment. The eighth facility is an advanced stroke center (ASC) capable of providing advanced stroke services on a 24/7 basis, including multidisciplinary stroke expertise, multimodal imaging, and acute reperfusion therapies for ischemic stroke.
Since its approval in 2019, the program has operated as a modified hub-and-spoke model. It receives funding from the Mexican government through the ISSSTE healthcare system and has access to ambulance services available 24/7. It also includes a stroke telemedicine network to facilitate the evaluation and care of potential patients.
As mentioned above, the program's functioning is mainly based on the hub-and-spoke model but with certain adequations to the Mexican Healthcare system. For example, most hub-and-spoke models function by offering daytime AS treatment at local centers, and the patients in need of treatment out-of-hours and on weekends are treated at hub hospitals. But, in the “ResISSSTE Cerebro” program, all centers provide AS treatment regardless of time or day, with the only difference being that advanced modalities of treatment (EVT and IVT guided by perfusion imaging up to 9 h after the onset of symptoms) are available only at the ASC. Similarly, the drip-and-ship model, as initially conceived, assumes that all centers within a network can diagnose LVO, thus allowing emergency medical services (EMS) to move patients to the closest hospital and only transfer to a thrombectomy-ready hospital for those patients with confirmed LVO. The drip-and-ship model was only partially implemented in our program due to constrained access to ambulances and human and technological infrastructure to perform advanced imaging in stroke patients at the ESC. Our model also accommodates that most of the patients in Mexico arrive at a hospital by their means (for example, the family car or public transportation), with few coming by EMS; therefore, prenotification is uncommon. Consequently, by concentrating the human and technological resources in a single center, the “ResISSSTE Cerebro” program can deliver advanced AS treatment 24/7 while preserving the capability of ESC to provide telemedicine supervised IVT also 24/7.
The stroke telemedicine network utilizes an instant messaging app that includes all the emergency room staff of all shifts grouped by each ESC. Each group, in turn, has all the stroke team members located at the ASC. Emergency room physicians are in charge of all initial evaluations and are responsible for alerting the stroke team and carrying out their instructions regarding treatment. At the same time, they order the NCCT and arrange for a possible transfer to the ASC. The ESC prenotifies all transfers to ASC. The protocol is known by all the staff at the emergency rooms of the ESC, and a print or electronic copy is available for consultation at the office of the head of the emergency department.Figure 1 depicts the pathway for patients initially arriving at ESC, and Figure 2 is that of patients coming directly to the ASC. All the ESCs are staffed 24/7 with emergency physicians, residents (emergency medicine is a 3-year residency program in Mexico), and radiologists. At the ASC, the staff comprises emergency physicians and emergency medicine residents, radiologists, neuroradiologists, clinical neurologists and clinical neurology residents, neurosurgeons and neurosurgery residents, and interventional neurologists and interventional neurology residents.
Since its approval in 2019, the program has operated as a modified hub-and-spoke model. It receives funding from the Mexican government through the ISSSTE healthcare system and has access to ambulance services available 24/7. It also includes a stroke telemedicine network to facilitate the evaluation and care of potential patients.
As mentioned above, the program's functioning is mainly based on the hub-and-spoke model but with certain adequations to the Mexican Healthcare system. For example, most hub-and-spoke models function by offering daytime AS treatment at local centers, and the patients in need of treatment out-of-hours and on weekends are treated at hub hospitals. But, in the “ResISSSTE Cerebro” program, all centers provide AS treatment regardless of time or day, with the only difference being that advanced modalities of treatment (EVT and IVT guided by perfusion imaging up to 9 h after the onset of symptoms) are available only at the ASC. Similarly, the drip-and-ship model, as initially conceived, assumes that all centers within a network can diagnose LVO, thus allowing emergency medical services (EMS) to move patients to the closest hospital and only transfer to a thrombectomy-ready hospital for those patients with confirmed LVO. The drip-and-ship model was only partially implemented in our program due to constrained access to ambulances and human and technological infrastructure to perform advanced imaging in stroke patients at the ESC. Our model also accommodates that most of the patients in Mexico arrive at a hospital by their means (for example, the family car or public transportation), with few coming by EMS; therefore, prenotification is uncommon. Consequently, by concentrating the human and technological resources in a single center, the “ResISSSTE Cerebro” program can deliver advanced AS treatment 24/7 while preserving the capability of ESC to provide telemedicine supervised IVT also 24/7.
The stroke telemedicine network utilizes an instant messaging app that includes all the emergency room staff of all shifts grouped by each ESC. Each group, in turn, has all the stroke team members located at the ASC. Emergency room physicians are in charge of all initial evaluations and are responsible for alerting the stroke team and carrying out their instructions regarding treatment. At the same time, they order the NCCT and arrange for a possible transfer to the ASC. The ESC prenotifies all transfers to ASC. The protocol is known by all the staff at the emergency rooms of the ESC, and a print or electronic copy is available for consultation at the office of the head of the emergency department.
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