Implementing Code Stroke and Thrombolysis in the Dominican Republic: A Pilot Study of Barriers, Outcomes, and Public Health Lessons
Cristina Ramos1, Vifranny Espaillat Duran2, Maria Munoz3, Marcos Mota3, Genesis Polanco Jerez1, Raquel Monegro Cordero1, Henry Alvarez1, Dorisbel Grullón1, Carelyn Gonzalez1, Ramón González1, Jamila Paulino1, Yaritza Estrella1, Mariela Madera1, Alvi D. Vargas1, Michelle Hernandez1, Rosa Elba Medina2, Madelein Gomez2, Enoch De los Rios2, Abigail Jean2, Rosa Cheas2, Genesis Mendez2, Marielba Caceres2, Luis Gutierrez Vasquez2, Jirandy Perez2, Karolin Castro2, Nelcidy Moronta Baez2, Minelly Rodriguez Severino2, Luis Tusen2, Ivan Mercader1, Bruno Rosario1, Andelys De la Rosa4, Ryna Then5
1Hospital Regional Universitario José María Cabral y Báez, Dominican Republic, 2Hospital Salvador B. Gautier, Dominican Republic, 3Instituto Tecnológico de Santo Domingo (INTEC), Dominican Republic, 4Ministerio de Salud Pública, Dominican Republic, 5Neurology Division, Jefferson Einstein Philadelphia Hospital, Philadelphia, PA, USA
Objective:
To evaluate outcomes, safety and implementation barriers of thrombolysis in patients with acute ischemic stroke (AIS) at two public hospitals designated as Pilot Stroke Centers.
Background:
Intravenous Thrombolysis (IVT) is the standard of care for patients with AIS when administered within 4.5 hours of stroke onset. The rate of thrombolysis in low-middle-income countries (LMIC) is less than 2%. The benefits of thrombolysis are time dependent, and earlier treatment is associated with better outcomes.
Design/Methods:
Retrospective Review
Results:
Seventeen patients received IVT; 76% were male and 76% were between 51–79 years. Hypertension was the most common risk factor (65%), followed by congestive heart failure (35%) and diabetes mellitus (18%). Most patients arrived by ambulance (59%), and all underwent computed tomography. Thrombolysis metrics such as door to neurology evaluation, door to CT scan and door to needle were assessed, obtaining a median of 40, 31 and 107 minutes respectively. Mean NIHSS decreased from 16 on admission (SD: 6.51; 95% CI: 12.43–19.33) to a median of 8 at discharge (IQR:12; 95% CI: 12.43–13.08), showing significant improvement (p = 0.011). Median mRS on admission increased from 0 (IQR: 0–0.62) to 3 (IQR: 2.11–4.01) at discharge (p < 0.05). Median hospital stay was 6 days (IQR: 3–8). Reported barriers included lack of prenotification, prolong time to neurology consultation, lack of expertise on thrombolytic mixing and materials to complete infusion.
Conclusions:
This pilot program represents the first initiative of its kind in the Caribbean, offering evidence-based, real-life experience of treatment implementation of acute ischemic stroke in the Dominican Republic. There was a statistically significant reduction of NIHSS between admission and discharge. Thrombolysis implementation not only demonstrates feasibility but also highlights the potential for broader adoption and foundation for future implementation in LMIC.
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