Stroke is the third leading cause of death in South Korea. 1

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1 Original Contribution Establishment of Government-Initiated Comprehensive Stroke Centers for Acute Ischemic Stroke Management in South Korea Jei Kim, MD; Yang-Ha Hwang, MD, PhD; Joon-Tae Kim, MD, PhD; Nack-Cheon Choi, MD, PhD; Sa-Yoon Kang, MD; Jae-Kwan Cha, MD; Yeon Soo Ha, MD; Dong-Ick Shin, MD, PhD; Seongheon Kim, MD; Byeong-Hoon Lim, MD, PhD Downloaded from by guest on April 13, 2017 Background and Purpose In 2008, the Ministry of Health and Welfare of South Korea initiated the Regional Comprehensive Stroke Center (CSC) program to decrease the incidence and mortality of stroke nationwide. We evaluated the performance of acute ischemic stroke management after the Regional CSC program was introduced. Methods The Ministry of Health and Welfare established 9 Regional CSCs in different provinces from 2008 to All Regional CSCs have been able to execute the critical processes independently for stroke management since The Ministry of Health and Welfare was responsible for program development and financial support, the Regional CSC for program execution, and the Korea Centers for Disease Control and Prevention for auditing the execution. We analyzed prospectively collected data on the required indices from 2011 and repeated the analysis the following year for comparison. Results After the Regional CSCs were established, the first brain image was taken within 1 hour from arrival at the emergency room for all patients with stroke; the length of hospital stay decreased from 14 to 12 days; for the rapid execution of thrombolysis, the first brain image was taken within 12 minutes; intravenous and intra-arterial thrombolysis were started within 40 and 110 minutes, respectively, after emergency room arrival; and the hospital stay of thrombolytic patients decreased from 19 to 15 days. Conclusions The Regional CSC program has improved the performance of acute stroke management in South Korea and can be used as a model for rapidly improving stroke management. (Stroke. 2014;45:00-00.) Key Words: comprehensive stroke care South Korea thrombolytic therapy Stroke is the third leading cause of death in South Korea. 1 The total economic burden of stroke including its medical, nonmedical, and indirect costs was estimated to be US$4.2 billion in The proportion of the population >65 years in South Korea was 11.0% in 2010 and is estimated to increase to 24.3% in Furthermore, the number of stroke cases is also estimated to increase from in 2004 to in 2030, 3 which will consequently lead to a rapid increase in the medical economic burden in South Korea. 4 The establishment of organized care centers including stroke units and centers reduce mortality and increase the survival rate. 5 The United States and Europe have been trying to improve nationwide care quality of stroke through the systematic organization of stroke centers. 6,7 In 2008, the Ministry of Health and Welfare (MHW) of South Korea initiated the Regional Comprehensive Stroke Center (CSC) program to decrease the incidence and mortality of stroke. 4 Thus, CSCs were established in 9 local provincial regions nationwide, excluding the Seoul metropolitan area. Here, we describe initiation process of the Regional CSC program in South Korea. We also evaluated the program s effectiveness for acute ischemic stroke management by comparing performance before and after its initiation. Methods Initiation of the Regional CSC Program In 2006, 40 (48%) of 83 cerebrovascular centers that admitted >200 patients with acute ischemia via the emergency room (ER) and were equipped for emergency care for patients with acute stroke were located in the Seoul metropolitan area, which contains 21% of South Korea s total population ( / ) in just 0.6% (605 km 2 ) of its total area. 4 A survey evaluating stroke Received May 14, 2014; final revision received June 9, 2014; accepted June 16, From the Daejeon-Chungnam Regional Cerebrovascular Center, Daejeon, South Korea (J.K.); Daegu-Gyeongbuk Regional Cerebrovascular Center, Daegu, South Korea (Y.-H.H.); Gwangju-Jeonnam Regional Cerebrovascular Center, Gwangju, South Korea (J.-T.K.); Gyeongnam Regional Cerebrovascular Center, Jinju, South Korea (N.-C.C., B.-H.L.); Jeju Regional Cerebrovascular Center, Jeju, South Korea (S.-Y.K.); Busan-Ulsan Regional Cerebrovascular Center, Busan, South Korea (J.-K.C.); Jeonbuk Regional Cerebrovascular Center, Iksan, South Korea (Y.S.H.); Chungbuk Regional Cerebrovascular Center, Cheongju, South Korea (D.-I.S.); and Gangwon Regional Cerebrovascular Center, Chuncheon, South Korea (S.K.). The online-only Data Supplement is available with this article at /-/DC1. Correspondence to Jei Kim, MD, Department of Neurology, Chungnam National University Hospital, 282 Moohwaro, Joongu, Daejeon , South Korea. jeikim@cnu.ac.kr 2014 American Heart Association, Inc. Stroke is available at DOI: /STROKEAHA

2 2 Stroke August 2014 unit services in South Korea showed that only 5 of 57 hospitals had stroke units in 2006, although intravenous thrombolysis was provided 24/7 in all hospitals. 8 Furthermore, most patients with acute ischemic stroke were managed in general wards at admission. To improve the quality of care for patients with cerebrovascular and cardiovascular diseases nationwide, the MHW initiated the Regional Cardiovascular and Cerebrovascular Center project to establish regional CSCs in The budget for this project was included in the 2007 state budget. Organization of the Regional CSC Program After finalizing the budget for the Regional CSC project in 2008, the MHW selected locations nationwide (Figure) and decided on the following domains: (1) development and execution of critical processes for management of hyperacute ischemic stroke; (2) establishment of a stroke unit for patients with acute ischemic stroke; and (3) initiation of an education program for early recognition, management, and prevention of stroke. The MHW announced the program to all hospitals located outside the Seoul metropolitan area. To be designated as a Regional CSC in a local provincial region, hospitals submitted a plan to fulfill the 3 required domains. The MHW reviewed the submitted plans of each local hospital to determine their inclusion. From 2008 to 2010, 9 local hospitals outside the Seoul metropolitan area (Gangwon, Daegu-Gyeongbuk, and Jeju in 2008; Gyeongnam, Gwangju-Jeonnam, and Chungbuk in 2009; Busan-Ulsan, Jeonbuk, and Daejeon-Chungnam in 2010) were designated as Regional CSCs. The MHW financially supported the centers to purchase the medical devices required for rapid and accurate evaluation of stroke, such as magnetic resonance imaging, computed tomography, and sonographic machines; provide devices to establish stroke units; and provide human resources to execute the critical processes for stroke management. Each Regional CSC individually established critical processes for stroke management for 1 year after their establishment. Key practices of critical processes to initiate thrombolysis rapidly, establish a stroke unit, and provide education were included in the critical processes for each center (Table 1). Device and facility management were financially supported for the first year. Human resources were financially supported every year after reviewing the performance of each Regional CSC. The Regional CSCs ultimately fulfilled the following comprehensive roles as recommended by the Brain Attack Coalition of the United States: (1) availability of advanced imaging techniques including magnetic resonance imaging, computed tomography, digital subtraction angiography, and transcranial Doppler; (2) availability of personnel trained in vascular neurology, neurosurgery, Figure. Locations of the 9 established Regional Comprehensive Stroke Centers (CSCs) in South Korea and endovascular procedures; (3) 24/7 availability of personnel, imaging, operating room, and endovascular facilities; (4) intensive care unit facilities capable of stroke management; and (5) experience and expertise in treating patients with large ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. 9 All Regional CSCs began executing the critical processes for management of patients with acute ischemic stroke between 2009 and All 9 Regional CSCs have been able to execute their comprehensive roles for stroke management since The performance of each Regional CSC was evaluated by the Korea Centers for Disease Control and Prevention on behalf of the MHW. The Korea Centers for Disease Control and Prevention developed 47 indices to evaluate the performance of the 3 domains set by the MWH (Table I in the online-only Data Supplement) and reviewed the achievement of the indices by each Regional CSC every month. Financial incentives for the subsequent year were determined on the basis of the performance of each Regional CSC. The annual performance of all Regional CSCs was graded on a relative scale. The bottom and top 3 centers received funding cuts and increase of 15%, respectively. Data Collection and Comparisons Since 2011, data for the indices set by the MHW were collected monthly from all 9 Regional CSCs. To evaluate the performance of stroke management after the establishment of the Regional CSCs, we analyzed prospectively collected data on the required indices from 2011 and repeated the analysis in 2012 for comparison. Overall performance achievement was evaluated on the basis of the time from symptom onset to arrival at the ER (onset-to-door time), from ER arrival to first computed tomography or magnetic resonance image (door-to-image time), total length of hospital stay, and proportion of patients admitted to the stroke units during the initial 3 days. The performance of thrombolysis achievement for patients with hyperacute ischemic stroke was evaluated on the basis of several indices including the time from arrival to intravenous thrombolysis initiation (door-to-needle time) and intra-arterial thrombolysis initiation (door-to-puncture time), as well as onset-to-door time, door-to-image time, and total length of hospital stay. The numbers of patients who received intravenous thrombolysis within 60 minutes of ER arrival and the proportion of hyperacute patients receiving intravenous and intra-arterial thrombolysis were evaluated. The institutional review boards of the respective designated hospitals provided ethical approval for this study. Statistical Analysis To determine whether the performance of stroke management improved after the establishment of Regional CSCs, we compared the data collected in 2011 and 2012 with those collected retrospectively from patients with stroke admitted at the 9 hospitals before the establishment of Regional CSCs in ANOVA was used to compare the mean and median time intervals of onset-to-door, door-to-image, door-to-needle, and door-to-puncture times, as well as length of admission. The χ 2 test was used to compare the proportions of patients with acute ischemia who underwent intravenous or intra-arterial thrombolysis and intravenous thrombolysis within 60 minutes of arrival. All statistical analyses were performed using SPSS 19.0 (SPSS Inc, Chicago, IL). The level of significance was set at P<0.05. Results The data of patients (3842, 4626, and 5170 patients in 2008, 2011, and 2012, respectively) admitted to the 9 Regional CSCs for the treatment of acute ischemic stroke (coded as I63 according to the 10th version of International Statistical Classification of Diseases) were used (Table 2). Although the number of patients differed by location, all Regional CSCs reported an increase in the number of patients with acute ischemia after their establishment.

3 Kim et al Government-Initiated Stroke Center in South Korea 3 Table 1. Key Practices of Required Domains of the Ministry of Health and Welfare Required Domain Practices Explanations Hyperacute management Triage hyperacute ischemic stroke Activation stroke team First imaging (door-to-image time) Intravenous thrombolysis start (door-to-needle time) MRI Activation intervention team for intra-arterial thrombolysis Intra-arterial thrombolysis start (door-to-puncture time) Data feedback Triage as presenting with hyperacute ischemic stroke at the ER within 6 h of symptom onset. A neurologist confirms an NIHSS neurological severity score >3 and patient arrives within 3 h of symptom onset. Activate stroke team by sending the first SMS or telephone call. Perform CT to rule out intracranial hemorrhage within 25 min of arrival. Confirm less than one-third low density on the infarcted hemisphere. Start intravenous thrombolysis within 60 min of ER arrival. MRI including DWI and PWI checked for patients who received intravenous thrombolysis or had an NIHSS score >3 and arrived after 3 h of symptom onset. Confirm DWI PWI mismatch on the infarcted hemisphere. Send second SMS or phone call to activate intervention team for intra-arterial thrombolysis. Start intra-arterial thrombolysis after intravenous injection or directly. Measuring and tracking door-to-needle, door-to-image, and door-to-puncture time intervals. Data reviewed monthly in each Regional CSC and reported to the KCDC. Stroke unit Admission criteria Patients with acute ischemic stroke (<72 h after symptom onset) Thrombolytic patients Transient ischemic attack (<24 h after symptom onset) Recurrent transient ischemic attack Impending ischemic stroke After cerebral angiography After intracranial intervention Unstable vital signs After administration of newly developed therapy or intervention Number of beds >4 beds in a discrete hospital in the center. Multiprofessional team Stroke-trained physician, surgeon, rehabilitation doctors, and nurses, as well as stroke coordinator. Vital sign monitoring Automated monitoring of heart rate, blood pressure, oxygen saturation, breathing. Regular body temperature monitoring. Critical process Preparation and execution for stroke unit care. Multiprofessional team care Regular multiprofessional meetings for stroke unit care. Education For patients One-on-one education for secondary stroke prevention during admission by stroke coordinator. For public Group education for primary stroke prevention. For paramedics Group education for primary and secondary stroke prevention for people working for public health and emergency care. CT indicates computed tomography; DWI, diffusion-weighted image; ER, emergency room; KCDC, Korea Centers for Disease Control and Prevention; MRI, magnetic resonance image; NIHSS, National Institutes of Health Stroke Scale; PWI, perfusion-weighted image; Regional CSC, Regional Comprehensive Stroke Center; and SMS, short message service. Changes in the Performance of Acute Ischemic Stroke Management The sex ratio, mean age, and National Institutes of Health Stroke Scale severity scores of patients with acute ischemia did not differ before and after the establishment of the Regional CSCs (Table 3). After the establishment of the Regional CSCs, the mean onset-to-door time increased from 20 to 24 hours, door-to-image time decreased from 2 hours to 1 hour, and length of stay decreased by 2 days. Over 80% of patients with acute ischemic stroke were admitted to the stroke unit for initial monitoring and management of ischemic stroke, whereas the other patients were admitted to general wards. Changes in the Performance of Thrombolytic Therapy Among patients receiving thrombolytic therapy, the sex ratio, mean age, and National Institutes of Health Stroke Scale severity scores were similar before and after the establishment

4 4 Stroke August 2014 Table 2. Regional CSC Location Numbers of Patients by Region Year Total (%) Gangwon (4.6) Daegu-Gyeongbuk (16.8) Jeju (4.1) Gyeongnam (10.6) Gwangju-Jeonnam (18.7) Chungbuk (5.2) Jeonbuk (12.0) Busan-Ulsan (12.1) Daejeon-Chungnam (15.9) Total (%) 3842 (28.2) 4626 (33.9) 5170 (37.9) (100) CSC indicates Comprehensive Stroke Center. of the Regional CSCs (Table 4). Clinical variables for the execution of thrombolytic therapy improved after Regional CSC establishment. The proportion of patients receiving thrombolytic therapy increased from 8.3% to 13.6% of total patients with ischemic stroke (P=0.000). Door-to-image time for thrombolytic patients decreased from 26 to 12 minutes (P=0.000). The door-to-needle time decreased from 60 minutes (median, 51 minutes) to 41 minutes (median, 36 minutes) (P=0.000). The proportion of patients receiving intravenous thrombolysis within 60 minutes of ER arrival increased from 60% to 89%. The door-to-puncture time for intra-arterial thrombolysis decreased from 136 to 110 minutes. The proportion of patients undergoing intra-arterial thrombolysis increased from 28% in 2008 to >44% in The proportion of patients undergoing bridging intra-arterial thrombolysis after intravenous thrombolysis increased from 10% to 20%. Finally, the length of hospital stay of patients receiving thrombolytic therapy decreased from 19 to 15 days. Discussion The present study details the successful establishment of Regional CSCs by the South Korean government; this model can be used by governments worldwide to improve stroke management rapidly. The first significant improvement introduced by the program was decreased door-to-needle time for intravenous thrombolysis. Previous single-center trials showed that the door-to-needle time decreased to 38 and 20 minutes (mean and median, respectively). 10,11 Furthermore, in 94% of cases, intravenous thrombolysis was started within 60 minutes of arrival at the center. 11 However, such a reduction is more difficult to achieve on a national level. In the United States, the Target: Stroke project was initiated nationwide in 2010 to reduce the door-to-needle time. 12 Accordingly, from 2010 to 2013, the door-to-needle time was reduced to 67 minutes (median) nationwide, and the proportion of patients undergoing intravenous thrombolysis within 60 minutes of arrival increased to 53.3%. 13 In South Korea, after initiation of the Regional CSC program, the door-to-needle time decreased to 41 minutes (mean), and intravenous thrombolysis was started within 60 minutes of ER arrival in 89% of patients in The second significant achievement of the Regional CSC program is the increased proportion of patients undergoing bridging or primary intra-arterial thrombolysis for acute ischemic stroke. On-call intervention teams for intra-arterial thrombolysis were also available 24/7 in the Regional CSCs, and the proportion of patients undergoing intra-arterial thrombolysis increased by 60%. Intravenous thrombolysis is recommended for rapid recanalization in patients with acute stroke. 14 However, the recanalization rate in intravenous thrombolysis is insufficient, especially for large artery occlusion in the proximal middle cerebral artery or terminal internal carotid artery. 15 Bridging and primary intra-arterial thrombolysis performed using mechanical thrombectomy has increased the possibility of recanalization in patients with acute ischemic stroke. 16 Although recent studies failed to verify the relationship between improved recanalization rate and favorable clinical outcomes after intra-arterial thrombolysis, intra-arterial thrombolysis might help achieve good clinical outcomes in patients with acute ischemic stroke. 20 To increase the probability of a good outcome, intra-arterial thrombolysis should be conducted more often for patients with acute ischemic stroke who have undergone unsuccessful intravenous thrombolysis or arrived after the time window for intravenous thrombolysis. The roles played by the participating organizations MHW for program development and financial support, Regional CSCs for program execution, and the Korea Centers for Disease Control and Prevention for auditing the Table 3. Performance in Acute Ischemic Stroke Management Before and After Regional Comprehensive Stroke Center Establishment Year P Value Patient number Male:female, % 2239:1600 (58.3:42.7) 2677:1949 (57.9:42.1) 2010:2160 (58.2:41.8) Age (M:F) y 65.9±12.4:70.8± ±12.1:70.5± ±12.0:71.9±11.6 NIHSS at arrival 6.1± ± ± Onset-to-door time (19.9) (24.0) (22.9) (minutes, hours) Door-to-image time, min Stroke unit admission, % 15.8% 79.4% 81.7% Length of stay, d Values are presented as mean±sd. F indicates female; M, male; and NIHSS, National Institutes of Health Stroke Scale.

5 Kim et al Government-Initiated Stroke Center in South Korea 5 Table 4. Performance of Thrombolytic Therapy Before and After Regional Comprehensive Stroke Center Establishment Year P Value Patient number Proportion from total ischemic 8.3% 13.3% 13.6% patients Male:female (%) 195:123 (61.3:38.7) 357:260 (57.9:42.1) 409:293 (58.3:41.7) Age (M:F) y 66.7±12.7:69.7± ±11.4:70.3± ±11.5:71.7±11.6 NIHSS at arrival 11.7± ± ± Onset-to-door time, min Thrombolysis methods, % Intravenous 233 (73.3) 383 (62.1) 393 (56.0) Intravenous+intra-arterial 29 (9.1) 114 (18.5) 153 (21.8) Intra-arterial 56 (17.6) 120 (19.4) 156 (22.2) Door-to-image time, min Door-to-needle time Mean Median Proportion of intravenous 60.3% 84.9% 88.6% thrombolysis within 60 min of arrival at the ER Door-to-puncture time Length of stay Values are presented as mean±sd. ER indicates emergency room; F, female; M, male; and NIHSS, National Institutes of Health Stroke Scale. execution were the main factors underlying the program s rapid success. Stroke was the second leading cause of death in middle-to-high income countries in the past decade. 21 As such, nations worldwide may soon require national measures to lower the human and economic burdens of stroke by reducing its the incidence and mortality. 22,23 Thus, the Regional CSC program, established by the South Korean government in association with local hospitals, could be an effective model for the rapidly improving comprehensive stroke management. To improve further the stroke care system of Regional CSCs, more efforts are required to shorten the prehospital delay after stroke onset. The education programs of most Regional CSCs for both the public and paramedics initially focused on the early recognition of stroke symptoms and importance of the time window for thrombolytic therapy. In fact, more patients received thrombolytic therapy with no delay in onset-to-door time at the Regional CSCs. However, the onset-to-door time increased in overall patients with stroke, despite the increased number of patients with stroke. Current education programs are more balanced and include management processes for both acute stroke management and thrombolytic therapy. These programs emphasize the importance of rapid arrival at the ER of all patients with acute ischemia. The development execution revision process of stroke education program might be an ongoing duty of the Regional CSCs toward a complete stroke care system. The first part of the Regional Cardiovascular and Cerebrovascular Center project was 2009 to After the successful establishment of Regional CSCs in 5 years, the MHW initiated the second part of the project from 2014 to Two more Regional CSCs were designated in Gyeongi province in The MHW added the following 2 goals to extend quality of care for stroke to people living in rural areas: (1) establishment of primary stroke centers (PSC) in rural areas, and (2) development of a network among Regional CSCs and PSCs. In other countries, despite differences in the directions and ideas for organizing nationwide infrastructure for stroke care system, PSCs are key units of organizations to provide nationwide quality care for stroke. 5 7 PSCs, which aim to provide acute management of patients with stroke, could start intravenous thrombolysis after inclusion criteria evaluation. If a patient requires intra-arterial thrombolysis as bridging or primary therapy after initial therapy in a PSC, the patient will be transferred to a Regional CSC. The MHW is also planning a systematic network between PSCs and Regional CSCs to coordinate stroke management and perform thrombolysis within the time window of intra-arterial thrombolysis. The experience gained in the establishment of the Regional CSC program may play a central role in the establishment of PSCs and communication among centers in South Korea. Conclusions The South Korean government successfully established comprehensive stroke centers throughout the country. The establishment of Regional CSCs improved the overall performance of stroke management, as well as execution of thrombolysis. Through the Regional CSC program, the government provides financial support for device management and personnel to execute critical processes for acute ischemic stroke management and regularly assesses the program s performance. Establishing PSCs in rural areas requires a stronger network among Regional CSCs and local rural hospitals.

6 6 Stroke August 2014 Acknowledgments We thank the following coordinators of the Regional Comprehensive Stroke Centers for data collection: Sangeun Yoo, MS; Jihui Kim, MS; Yeongju Kwon, RN; Mihye Lee, RN; Miyeong Kim, RN; Sujin Kang, RN; Yeongkwon Park, MS; Sujin Lee, RN; and Huijin Kim, RN. Sources of Funding The present study was supported by a Research Grant (2013E ) for public health from the Korea Centers for Disease Control and Prevention. None. Disclosures References 1. Causes of Death in South Korea, Korea National Statistics Office Web site. cd=1012. Accessed April 6, 2014 (Korean). 2. A study on measuring the economic burden of cardio-cerebrovascular disease in Korea. Korea Centers for Disease Control and Prevention Web site. jsp?menuids=home001-mnu1155-mnu1083-mnu1375- MNU0025&fid=28&q_type=&q_value=&cid=1662&pageNum=1. Accessed April 6, 2014 (Korean). 3. Hong KS, Bang OY, Kang DW, Yu KH, Bae HJ, Lee JS, et al. 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7 Establishment of Government-Initiated Comprehensive Stroke Centers for Acute Ischemic Stroke Management in South Korea Jei Kim, Yang-Ha Hwang, Joon-Tae Kim, Nack-Cheon Choi, Sa-Yoon Kang, Jae-Kwan Cha, Yeon Soo Ha, Dong-Ick Shin, Seongheon Kim and Byeong-Hoon Lim Stroke. published online July 3, 2014; Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX Copyright 2014 American Heart Association, Inc. All rights reserved. Print ISSN: Online ISSN: The online version of this article, along with updated information and services, is located on the World Wide Web at: Data Supplement (unedited) at: Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Stroke can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: Subscriptions: Information about subscribing to Stroke is online at:

8 ONLINE SUPPLEMENT Supplemental Tables Supplemental Table I. Indices set by Korean Centers for Disease Control and Prevention for the Regional Comprehensive Stroke Centers Required domain Index Remarks for data input Patient information Patient identification Center code/year/patient serial number Admission date Discharge date Name code English initial letter Sex 1, Male; 2, Female Age Years ICD-10 code Patients coded as I63 or I62 were included Modes of ER arrival 1, using emergency transportation; 2, not using emergency transportation Height cm Weight kg Body mass index weight/height 2 Type of treatment at the ER 0, no data; 1, anticoagulation; 2, antiplatelet; 3, intravenous thrombolysis; 4, intraarterial thrombolysis; 5, carotid stent NIHSS evaluation at the ER Evaluation of stroke severity at the ER using NIHSS NIHSS score NIHSS score at the ER Hyperacute management Last normal time hh:mm First abnormal time hh:mm Arrival at the ER hh:mm Onset-to-door time (minutes) From first abnormal time (or last normal time if first abnormal time is unclear) to ER arrival First imaging tool 1, CT; 2, MRI; 3, transfer after CT and/or MRI imaging from other hospitals Time of first image hh:mm Door-to-image time (minutes) From ER arrival to first image. Recommendation: <25 minutes Execution of IV thrombolysis 0, no; 1, yes for execution of intravenous thrombolysis

9 Cause of non-execution IV thrombolysis Time of start of IV thrombolysis Door-to-needle time (minutes) The reason for no execution of intravenous thrombolysis for patients arriving within time window for treatment hh:mm From ER arrival to start of intravenous thrombolysis. Recommendation: <60 minutes 0, no; 1, yes for execution of intraarterial thrombolysis hh:mm From ER arrival to start of intraarterial thrombolysis Execution of IA thrombolysis Time of start of IA thrombolysis Door-to-puncture (minutes) Acute management SU admission 0, no and 1, yes for admission in stroke unit Date of SU admission Date of SU leave Length of stay in SU From stroke unit admission to neurology ward transfer or discharge Total length of stay (days) From admission to discharge Evaluation of swallowing difficulty 0, no; 1, yes for evaluation of swallowing difficulty within 2 days Consultation for early rehabilitation * 0, no; 1, yes for rehabilitation consultation within 3 days after admission Date of consult for early rehabilitation Consultation for transfer to RM 0, no; 1, yes for consultation for transfer for rehabilitation Transfer to RM 0, no; 1, yes for rehabilitation transfer Date of transfer to RM Antiplatelet agents prescription at discharge 0, no; 1, yes for prescription of antiplatelet agents at discharge Anticoagulant prescription at discharge 0, no; 1, yes for prescription of anticoagulant at discharge Complications 0, no; 1, yes for occurrence of medical complications during admission Death during admission 0, no; 1, yes for death during admission Education Stroke education before discharge 0, no; 1, yes for execution of stroke education before discharge Satisfaction of stroke education given before discharge Grade 1 to 5 for satisfaction with stroke education given before discharge

10 Understanding of stroke education given before discharge Satisfaction of stroke management Grade 1 to 5 for understanding the stroke education given before discharge Grade 1 to 5 for satisfaction with the facilities and execution of stroke management during admission ICD-10, International Classification of Diseases-10, ER, emergency room; NIHSS, National Institutes of Health Stroke Scale; CT, computed tomography; MRI, magnetic resonance imaging; RM, rehabilitation medicine * Early rehabilitation means individual therapy for 30 minutes per day at bedside or active in physiotherapy room during admission in the stroke unit or general ward. The type and duration of physiotherapy are requested by the RM doctors after evaluating each patient.