Table 4.

The obstacles and possible solutions for stroke care in Iran

Obstacles	Possible solution
Public awareness Lack of public awareness about stroke symptoms and its urgency	Campaigns to increase community awareness Public education in health houses and health centers: face-to-face education with considering language and cultural considerations Mass media: television, radio, outdoor banners, newsletters, the Internet Group educations for relatives of stroke victims in the hospital Special programs for the elderly population in parks, senior recreation centers, religious centers, etc. Education for school children and their family, Banners, and flyers in health centers, physician office, etc.
Pre-hospital assessment and care Traffic congestion and delayed EMS arrival Lack of or inefficient screening protocol and early stroke assessment and management by EMS personnel Lack of public awareness to yield the right of way to an emergency vehicle	Increase EMS resources Provide regular education for emergency call attendances to identify possible cases of stroke through the phone conversation and rapidly dispatch the EMS team Prioritize stroke response in EMS system Improve public awareness to yield the right of way when approached by an emergency vehicle More training for EMS staff about early stroke recognition, recognizing possible cases of large vessel occlusion, and their role in early stroke assessment and care Evaluate the feasibility and effectiveness of Stroke Emergency Mobile in largely populated cities like Tehran. Stroke mobile includes a CT scanner and point-of-care laboratory installed in a fully equipped ambulance
In-hospital acute stroke management Incorrect or delayed assessment of stroke patients in triage Long “Door To Needle” time secondary to lack of fast and efficient triage system, lack of single activation call system, delayed imaging Lack of emergency guideline-based algorithms, trained stroke nurses, urgent access to advanced imaging, 24-hour endovascular program Lack of regular educational program for ED personnel Lack of organized data and performance monitoring and feedback system for quality improvement	Install several easy-to-read wall posters in the ED waiting room to draw patients’ attention to the signs of stroke requiring them to alert the triage nurse immediately Establish standard operating procedures and protocols to triage stroke patients rapidly Provide general education for triage nurses Enable triage nurses to activate stroke alert Establish a team-based approach in the ED and train professional stroke registered nurses Provide organized and professional stroke team at the hospital with a focused goal Single Call Activation System: a single call should activate the entire stroke team at the hospital Provide rapid triage protocol for inpatient and early stroke team notification at the hospital Every hospital medical staff should be able to activate stroke alert
	Mobilize the imaging and laboratory facilities by the aid of activated stroke alert or pre-notification system Performing CT scan (or MRI) within 25 minutes of arrival and complete interpretation of the CT scan within 45 minutes of arrival Rapidly recognize patients with large vessel occlusion and alert the interventional team Provide regular educational programs for ED staff Have a protocol in place for the rapid transfer of patients to a tertiary care center, if needed Establish an organized data monitoring and feedback system for quality improvement evaluation
Inpatient stroke management Lack of trained stroke nursing staff, routine training for nursing staff, and timely physical, occupational and speech therapist evaluation and a multidisciplinary team round. Access to advanced neurological and cardiovascular imaging/testing can be a challenge Lack of coordinated palliative care/end of life pathway Lack of organized data and performance monitoring and feedback system for quality improvement	Admit stroke patients directly to a stroke unit or stroke service under the care of a stroke specialist and a multidisciplinary team. Access to a neurological ICU Easy access to advance imaging for further investigation of stroke patients Provide routine training for nursing staff to provide high-quality nursing care Daily monitoring and documentation of NIH stroke scale Perform swallowing screening assessment on admission by appropriately trained and competent staff Nutritional screening assessment performed within 24 hours of admission Protocol for the promotion of bladder and bowel continence including a policy to avoid urinary catheters Provide established protocols for the prevention and treatment of common complications Establish an organized palliative care/end of life pathway
Rehabilitation program Lack of a comprehensive in-patient, out-patient stroke program in all studied centers	Establish a designated stroke rehabilitation inpatient unit All medically stable patients with stroke should be transferred from the stroke service without delay Screen for cognitive deficits, visual neglect, attention deficits and emotional problems and have access to a specialist in clinical psychology Involve families and caregivers in day-to-day care and rehabilitation Encourage patient and family in secondary stroke prevention and change of lifestyle (nutrition, weight loss, medicine compliance, physical activity) Establish a protocol for patients’ follow-up visit Organize stroke support groups for patients and families Organize the rehab protocol based on patient, family, and community
Other challenges Disparity in stroke care in Iran Lack of national guideline for primary and comprehensive stroke center designation Lack of a pathway to improve the quality of stroke care through national data monitoring systems	Develop telehealth capabilities for remote stroke diagnosis and treatment Develop programs for underrepresented minority populations and women Public-private partnerships and shared resources Develop and certify primary stroke center policy through the national legislative system: examples include primary stroke center designation through a national program, EMS protocols, or hospital bypass policies Monitor, and improve the quality of and access to care for stroke patients from the onset of stroke symptoms through the rehabilitation Track the rate of death and disability from acute stroke Monitor and eliminate disparities in stroke care Increase the epidemiological knowledge of stroke in Iran Introduce pathways to improve the quality of stroke care through national data monitoring systems

EMS: Emergency medical service; CT scan: Computed tomography scan; ED: Emergency department; MRI: magnetic resonance imaging; ICU: Intensive care unit; NIH: National Institutes of Health