“News spreads fast in a town like mine,” says Dr Christian Emmanuel Lim of Governor Celestino Gallares Memorial Medical Centre in Bohol, an island province in the Central Visayas region of the Philippines.
The “town” he is speaking of is Tagbilaran City, the provincial capital and gateway to the island. It is a self-styled “city of peace and friendship” in reference to a famous treaty between a local native chieftain and a Spanish colonizer four-and-a-half centuries ago. Today, it is among the Philippines’ most progressive cities, and in the days that followed 1 Juli 2019, Governor Celestino Gallares Memorial Medical Centre (GCGMMC) was the talk of the town.
Tagbilaran City is every inch Dr Lim’s home town. After completing medical studies at Siliman University, and his specialization in neurology in the Philippine capital Manila in 2018, he headed straight here – one of only two neurologists on the island and the only one serving full-time in the public healthcare system.
GCGMMC is a tertiary hospital but when Dr Lim arrived at the start of 2019 it had no specialist care for stroke, which accounts for roughly 70 percent of all neurological cases. He reached out to the Angels Initiative for help with a programme of transformation that prioritized training for stroke nurses and data-driven improvement.
Six months after he arrived, the event that set tongues wagging was that GCGMMC had just treated its first stroke patient with thrombolysis, exactly as they’d said they would. “We showed that after a half year of seminars what we’d been saying was true, that we could do what we’d said we could,” Dr Lim says.
For the precise reason that news spread fast in a town like theirs, Dr Lim and his team had been patiently waiting for the patient who would be first. “I had to succeed, or all our effort would be wasted,” he explains.
Then on Monday 1 July an off-duty nurse called the hospital to say that his father had had a stroke. He was on his way to fetch him and bring him to the hospital.
The stroke team at GCGMMC had been trained but not yet tested. Now all their training kicked in as they rushed to meet their colleague and his father in the emergency room. Even before the patient was discharged, word got out that Bohol island had a stroke-ready hospital.
This auspicious beginning galvanized the nursing staff, says Vanessa Alonso, nurse manager in the acute stroke unit at GCGMMC.
“Witnessing the remarkable effectiveness of thrombolysis fuelled our determination and made us strive even harder for knowledge and improvement. In our pursuit of competence, we organized extensive stroke management training sessions. Unfortunately, the emergence of the pandemic halted these plans, marking the first significant challenge. But being prevented from conducting face-to-face meetings did not impede our commitment to learning. With invaluable support from Angels, we attended online courses and simulations, virtual lectures, and coaching and mentoring sessions.
“Angels also guided the team in optimizing our stroke pathway. In this regard the stroke care quality improvement registry (RES-Q) contributed greatly to our progress. The tool helps us monitor our stroke care performance, identify gaps and implement the necessary adjustments.”
Success came early. GCGMMC won its first WSO Angels gold award at the end of 2020, and its first diamond mid-way through 2022. Now with eight diamond awards to their credit, they were one of three Philippine hospitals honoured as a centre of excellence after reaching diamond status in all four quarters of 2023.
“It’s a team effort,” Dr Lim says emphatically. “Once we have everyone on board, from security manning our doors to the emergency department, radiology, pathology, pharmacy, nurses and doctors from all specialties, we continuously evaluate each other’s response to maintain our standard.”
In March 2024, GCGMMC hosted the second Stroke Nurse Masterclass 2024, an initiative of the Stroke Society of the Philippines and Angels Initiative that will develop 200 nurses to be certified within three years. The 60 nurses that completed their first module in Tagbilaran in March came from 15 hospitals in the Visayas region.
Training nurses is also the starting point for Dr Lim’s strategy to expand stroke care in Bohol province. Tagbilaran City is located in the south west of the island. In the opposite corner lies Ubay where Don Emilio Del Valle Memorial Hospital is destined to become Bohol’s second stroke-ready hospital. So far four nurses from Ubay have undergone three months’ training at GCGMMC prepared by the stroke team lead by Mr Arthur Mendez, and attended the Stroke Nurse Masterclass in March. This brings Dr Lim a step closer to his goal for all Boholanos to have equal access to evidence-based stroke care.
To understand the goal you have to consider the topography of the island. Bohol is rolling and hilly and world-famous for its Chocolate Hills, a constellation of more than 1,200 cone-shaped limestone hills that turn brown in the summer. “We have mountains,” Dr Lim says. So, while Ubay may only be 100 km away from Tagbilaran, the trip by road takes at least two hours – “with the ambulance driver racing like a Ferrari racer”, he adds.
Once Don Emilio Del Valle is stroke-ready, everyone on the island will be within 90 minutes of acute stroke care.
“We have identified some doctors who will be able to help us with stroke management but we need trained nurses in the ER and the stroke unit,” Dr Lim says. “We can always do telestroke but we need nurses on the ground.”
What they also need is an informed public that can recognize the signs of stroke and know how important it is to seek help within the window for thrombolysis. This is a challenge the GCGMMC team has embraced with creativity and resilience, Nurse Alonso says.
“We organized stroke awareness campaigns in schools, barangays, and other hospitals. We connected with other municipalities so they’re aware of the services offered by our hospital and we have strengthened ties with the emergency management system to ensure a fast and coordinated response in times of crisis.”
The message of prevention and early detection is spread via online platforms, radio broadcasts and townhall meetings, and less formally to patients and their caregivers in other hospital wards including surgery, obstetrics, orthopedics and so on. There are also plans to reach school children via school principals and teachers.
Although they haven’t formally measured the effect of their awareness activities, the impact is being felt at the hospital door. Dr Lim says it’s an opportunity to look into the future.
He says, “At the start we had one patient arriving on time per month, and now we are thrombolysing seven, 15, as many as 20 patients every month.”
What Dr Lim won’t do if a patient is a candidate for thrombolysis, is ask for consent. On the contrary: “If they refuse to be treated, we ask them to sign a waiver.”
As far as his hospital is concerned, thrombolysis is the standard of care, and he will no more ask for your consent than he’d ask your permission to give you oxygen if you were gasping for air.
Although the Philippines doesn’t yet have reliable stroke incidence data, Dr Lim believes it’s higher than generally believed. He says, “We see on average eight stroke per day and no day goes by without at least one stroke patient.”
Like many public hospitals outside of major cities in developing countries, GCGMMC routinely runs at 150 to 200 percent occupation, which imposes a heavy burden on healthcare workers and hospital resources. Responding to this burden, five years ago the hospital adopted the mantra, “So Gallares, So Kind” to encourage overworked staff to do more than go through the motions.
Dr Lim explains: “We try to provide the best quality care. One of the attributes of quality care is the value of kindness. The mantra is a reminder that despite our busy load, we still need to be kind.”
