# Situation: A public health nurse supervises the midwife and barangay health workers (BHWs) of a Barangay Health Station (BHS), which is linked to the Rural Health Unit (RHU), and oversees its records and referrals. A 62-year-old man is brought to the BHS with one-sided weakness and slurred speech that began 1 hour ago. He is alert, his airway, breathing, and circulation are stable, and an ambulance is ready. The RHU physician is his registered primary care provider. The nurse has these data on nearby facilities: RHU: 10 minutes away; primary care, no computed tomography (CT) scan District hospital: 20 minutes away; basic inpatient care, no CT scan Provincial hospital: 45 minutes away; CT scan and 24-hour emergency stroke care, including clot-dissolving treatment Regional medical center: 2 hours away; CT scan, stroke unit, and neurosurgery Under the Universal Health Care (UHC) Act (RA 11223) and the referral system, where should the nurse send him?

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> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: A public health nurse supervises the midwife and barangay health workers (BHWs) of a Barangay Health Station (BHS), which is linked to the Rural Health Unit (RHU), and oversees its records and referrals.

A 62-year-old man is brought to the BHS with one-sided weakness and slurred speech that began 1 hour ago. He is alert, his airway, breathing, and circulation are stable, and an ambulance is ready. The RHU physician is his registered primary care provider. The nurse has these data on nearby facilities:
RHU: 10 minutes away; primary care, no computed tomography (CT) scan
District hospital: 20 minutes away; basic inpatient care, no CT scan
Provincial hospital: 45 minutes away; CT scan and 24-hour emergency stroke care, including clot-dissolving treatment
Regional medical center: 2 hours away; CT scan, stroke unit, and neurosurgery
Under the Universal Health Care (UHC) Act (RA 11223) and the referral system, where should the nurse send him?

## 보기

1. To the RHU
2. To the district hospital
3. To the provincial hospital **✔ 정답**
4. To the regional medical center

**정답: 3**

## 해설

Two rules apply. Under RA 11223, access to higher levels of care is normally coordinated by the primary care provider, but emergency or serious cases are exempt, and sudden one-sided weakness with slurred speech that began an hour ago is a suspected acute stroke. In the referral system, an emergency goes directly to the nearest facility that is capable of managing it. The provincial hospital is the nearest facility with a CT scan and emergency stroke care; the district hospital is nearer but cannot manage him, and the regional center adds 75 minutes for services he does not need first.

## 심화 해설

A 62-year-old man with one-sided weakness and slurred speech that began 1 hour ago has a clinical picture consistent with suspected acute stroke. The time window matters because intravenous thrombolysis is generally recommended within 3 hours of symptom onset for eligible patients [2]. In this scenario, the man is alert and hemodynamically stable, but stability does not rule out an evolving ischemic or hemorrhagic stroke. The nurse must therefore identify the nearest facility that can actually confirm the diagnosis and deliver time-sensitive treatment.

Under the Universal Health Care Act, access to higher levels of care is normally coordinated by the primary care provider, but emergency or serious cases are exempt from that coordination requirement. A suspected acute stroke is an emergency, so the patient should be sent directly to the nearest facility capable of managing it. The RHU is only 10 minutes away, but it has no CT scan and offers only primary care. The district hospital is 20 minutes away and provides basic inpatient care, but it also has no CT scan. The regional medical center has a CT scan, stroke unit, and neurosurgery, but it is 2 hours away. The provincial hospital is 45 minutes away and has both a CT scan and 24-hour emergency stroke care, including clot-dissolving treatment. It is the nearest facility that can actually manage a suspected acute stroke.

The referral principle is not simply “go to the nearest hospital”; it is “go to the nearest hospital that can manage the condition.” For suspected acute stroke, the minimum capability is CT imaging to distinguish ischemic from hemorrhagic stroke, because thrombolysis is contraindicated in hemorrhage. The district hospital is closer but cannot do this. The regional center is more advanced, but adding 75 minutes of transport time delays evaluation and treatment without providing an immediate benefit that the provincial hospital lacks for this patient’s current needs.

This aligns with the evidence that early recognition and referral are critical to minimizing morbidity and mortality in acute stroke [1]. The systematic review emphasizes that referral patterns and efficiency in primary and emergency care settings directly affect outcomes. In rural or resource-limited settings, transfer delays remain a major barrier to timely reperfusion therapy and are associated with worse functional outcomes [4]. Choosing the regional center over the provincial hospital would create an unnecessary delay. Choosing the RHU or district hospital would require a second transfer after the patient fails to receive definitive stroke care, which compounds the delay.

Watch out! Some examinees select the regional medical center because it has the most comprehensive stroke services, including neurosurgery. However, the referral system prioritizes the nearest appropriate facility, not the most advanced one. The provincial hospital can perform CT and administer clot-dissolving treatment, which addresses the immediate time-sensitive need. Neurosurgery is not required first for a patient who is alert and stable.

Key point! Suspected acute stroke is an emergency that bypasses the usual primary care provider coordination requirement under RA 11223. The correct destination is the nearest facility with CT and emergency stroke care capability.

The time factor is reinforced by the recommendation that patients with acute ischemic stroke should be immediately transported to the nearest hospital for rapid evaluation and treatment, with intravenous t-PA considered within 3 hours of symptom onset [2]. In this case, symptom onset was 1 hour ago, so the patient is still within the potential thrombolysis window. Every minute of unnecessary transport reduces the chance of receiving treatment within that window. The provincial hospital at 45 minutes is the best balance of capability and proximity.

The 2026 AHA/ASA stroke guidelines perspective also highlights that time-critical workflows differ across health systems, and referral decisions must account for local infrastructure . In a setting where CT is not available at the RHU or district hospital, the provincial hospital functions as the appropriate receiving facility for acute stroke. The nurse’s role is to recognize the stroke signs, activate the referral pathway, and ensure transport to the facility that can act on the diagnosis without delay.References (research sources)

- [1]Early Recognition and Referral of Acute Stroke in Primary and Emergency Care: A Systematic Review.Meta-analysis/systematic reviewAlmunif TM, Alkaabba AF, Alomran KW, Alanazi AM, Alharbi FN, Alshahrani SS (2026) · DOI: 10.5811/westjem.50827

- [2]Acute Ischemic Stroke.Research articleChan BP, Albers GW (1999) · DOI: 10.1007/s11940-999-0009-5

- [4]The Role of Videoconferencing Teleconsultation in Improving Transfer Efficiency and Functional Outcomes in Rural Stroke Care: Retrospective Cohort Study.Research articleWang CS, Chen YJ, Lin TC, Huang HM, Tu PR, Chen PL, Huang JA. (2026) · DOI: 10.2196/86436

## 임상 시나리오

Suspected Acute Stroke ReferralEmergency bypasses primary care coordination
Sudden one-sided weakness with slurred speech within 1 hour of onset is a suspected acute stroke. Under RA 11223, emergency cases are exempt from primary care provider coordination.

Send the patient directly to the nearest facility capable of managing stroke. The provincial hospital is 45 minutes away and has CT scan and 24-hour emergency stroke care including thrombolysis.

CautionDo not send to the RHU or district hospital despite shorter travel times; they lack CT and cannot provide time-sensitive stroke treatment. The regional medical center adds 75 minutes for services not needed first.

## 핵심 개념

- **Universal Health Care Act (RA 11223)** — Philippine law that coordinates access to higher levels of care through the primary care provider, with exemptions for emergency or serious cases.
- **Referral system** — Process of directing patients to appropriate facilities; emergencies go directly to the nearest facility capable of managing the condition.
- **Suspected acute stroke** — Clinical presentation of sudden one-sided weakness and slurred speech, requiring urgent CT imaging and possible thrombolysis within a narrow time window.
- **Intravenous thrombolysis** — Clot-dissolving treatment for ischemic stroke, generally recommended within 3 hours of symptom onset for eligible patients.
- **Nearest capable facility** — Referral principle that prioritizes the closest facility with the required diagnostic and treatment capability, not simply the closest facility.

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