WSO October 2023 – Issue 1 - 903

Caso et al.
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Figure 2. Number of hospitals involved in Angels Initiative (target vs actual), overall and by LMICs.
2000
4000
6000
8000
10000
12000
2016 2017 2018 2019 2020 2021 2022 20232024 2025 20262027 20282029 2030
LMIC, low- and middle-income country.
Angels Initiative, the median door-to-treatment time for
thrombolysis in stroke patients in Romania and Moldova
has reduced by 35 min (40% reduction vs baseline) and
15 min (19% reduction vs baseline), respectively. In Egypt,
door-to-treatment time decreased by 60 min between 2017
and 2021 (50% reduction vs baseline).43 In terms of recanalization,
the percentage of thrombolysis procedures carried
out in Europe increased from 6.8% to 13.1% between
2015 and 2020. Similar improvements in quality monitoring
have also been observed, with data for 500,000 stroke
patients from more than 2000 hospitals captured within the
RES-Q registry since 2016.44 One notable example of a
country where quality monitoring has increased substantially
is Mexico, where 38 new centers have enrolled in
RES-Q, SITS-QR, or national registries; 430 new HCPs
have been trained in stroke management; 60 in-hospital
stroke simulations have been carried out; and 35 hospitals
have put in place checklists (protocols) since 2016.42
The data collected by registries are used by the Angels
Initiative to assess the performance of each stroke unit.
RES-Q, for example, collects stroke unit performance data
based on 24 variables, which are grouped into seven ESOrecommended
key performance indicators (KPIs).33 These
KPIs provide the basis for the three tiers of ESO Angels
awards, which are categorized as gold, platinum, and diamond
(the highest accreditation) (Table 3).33 The evaluation
is carried out independently of the Angels Initiative by
a steering committee, which includes delegates from participating
registries (RES-Q, SITS-QR) and national coordinators,
usually presidents of national stroke societies.45,46
A similar award system has been established by the Angels
Initiative together with the WSO for all stroke-ready hospitals
across the world,40 thus encouraging even more hospitals
to participate. The number of hospitals that have
received Angels awards is steadily increasing, demonstrating
the success of the initiative.40,47 In the second quarter
(Q2) of 2017, 10 hospitals achieved ESO gold, platinum, or
diamond status, and this increased substantially to 317 ESO
Angels awards in 2021 Q2, 99 of which were diamond
awards. As of Q2 2022, a total of 2707 awards had been
granted, of which 729 were diamond awards.42
In recognition of these achievements, the Angels
Initiative was awarded the WSO Award for Stroke Services
at the World Stroke Congress 2021.41 The initiative has also
been featured as a best practice example in the Access to
Medicine Report 2021, funded by the Bill & Melinda Gates
Foundation.
Strengths, weaknesses, and future
directions
The key strength of the Angels Initiative is its non-commercial
nature and international reach. As a public-private partnership,
Angels works in collaboration with the WSO and
ESO, regional and national stroke societies, governments,
non-governmental organizations, and local hospital networks
to leverage the most relevant expertise from each
partner and maximize its impact. In this sense, Angels represents
a bridge between science and implementation, designing
and delivering practical solutions tailored to local needs.
International Journal of Stroke, 18(8)
Actual/Forecast all
Actual/Forecast LMICs
Target all
Target LMICs
Number of hospitals
WSO October 2023 – Issue 1

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