WSO October 2023 – Issue 1 - 899

Caso et al.
899
needed to achieve the target of the Angels Initiative of >10,000 stroke-ready hospitals by 2030, and >7500 of these
in LMICs.
Keywords
Acute stroke therapy, antithrombotic, countries, developing countries, stroke, stroke facilities, stroke teams, stroke units
Received: 23 January 2023; accepted: 1 May 2023
Introduction
In 2021, a global survey conducted by the World Stroke
Organization (WSO)1 and World Health Organization
(WHO) found that only one in three hospitals have the
infrastructure and resources required to qualify as a stroke
center that can deliver guideline-recommended, life-saving
stroke care.1 About 70% of stroke patients in Europe lack
access to a stroke center, and globally, less than 5% of
patients who are eligible for intravenous thrombolysis
receive it within the therapeutic time window.2,3 In lowand
middle-income countries (LMICs), patients experience
more than four times the rate of stroke-related death and
disability compared with those living in high-income countries,
yet dedicated stroke units exist in only 18% of LMICs
(vs 91% in high-income countries).4,5
A stroke-ready hospital is defined by a network of trained,
multidisciplinary, coordinated healthcare staff and facilities
(imaging, interventional care, etc.) that ensure timely, guideline-recommended
care based on written procedures and
protocols. These protocols are constantly evaluated based on
time and quality indicators, and care procedures are then
revised and optimized to maximize patient benefit. The evidence
for improved patient outcomes resulting from organized
inpatient (stroke unit) care compared with alternative
services (e.g. care on a general ward) is well established. In a
Cochrane meta-analysis of 29 trials including 5902 participants,
patients treated in a stroke unit were more likely to be
alive, independent, and living at home 1 year after their
stroke.6 Improving access to stroke units and services globally,
especially in LMICs, where the stroke burden is highest,
is therefore an urgent global health priority.
Since its inception in 2016, the Acute Networks Striving
for Excellence in Stroke (Angels) Initiative has supported
over 1700 hospitals that did not previously treat stroke
patients according to evidence-based guidelines to become
" stroke ready. " This initiative has positively impacted the
health outcomes of an estimated 7.46 million stroke patients
(based on an assumption of ~500 patients treated per hospital).7
In LMICs, >1000 new hospitals are now stroke ready,
having benefited an estimated 4.68 million people. Despite
this progress, a continued and coordinated global effort is
needed to achieve the target of the Angels Initiative:
>10,000 stroke-ready hospitals by 2030, and >7500 of
these in LMICs.8
In this article, we describe the foundational pillars of the
Angels Initiative, outline its achievements to date, and
issue a call to action to the global stroke community to help
the Angels Initiative achieve its ambitious goal by 2030.
Reducing the burden of stroke: the
role of the Angels Initiative
What is the Angels Initiative?
The Angels Initiative is a non-profit, non-promotional,
global healthcare program supported by Boehringer
Ingelheim. The initiative has two aims: first, to increase
the number of stroke-ready hospitals, and second, to optimize
the quality of existing stroke units.9 Specifically, the
Angels Initiative targets barriers to optimal stroke care at
different stages of the patient pathway, namely, pre-hospital/early
identification of stroke, including awareness-raising
among carers and emergency services; in-hospital
management, including patient admission, triage, and
treatment with thrombolysis/thrombectomy; and implementation
of acute care protocols to help manage common
complications of stroke, such as fever, hyperglycemia, and
dysphagia (Table 1).
Launched in Europe in 2016, the Angels Initiative is
now global in its reach and is endorsed by and run in partnership
with the WSO, European Stroke Organisation
(ESO), Stroke Alliance for Europe (SAFE), Ibero-American
Stroke Society (SIECV), and many other organizations and
healthcare professionals (HCPs) focused on improving
stroke outcomes across the world (Table 2).33 The Angels
Initiative has received endorsement from national stroke
societies, neurology societies, and stroke nurse organizations
in more than 50 countries. The Angels Initiative has
also collaborated with the World Bank and the WHO on the
topics of implementing organized stroke care and raising
awareness of stroke in specific regions.
What are the pillars of the Angels Initiative?
The Angels Initiative is built upon five pillars, which form
the basis of a behavioral change model. These pillars-consultancy,
standardization, education, quality monitoring,
and community-form the basis of all Angels activities, at
national, regional, and hospital levels (Figure 1).
International Journal of Stroke, 18(8)
WSO October 2023 – Issue 1

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