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How did Romania start in ESO EAST?

In Romania, Dr. Cristina Tiu is actively involved in the ESO-EAST project as the coordinator of the Romanian group and under her coordination Romania joined ESO-EAST in 2015.

The first quality assessment of stroke care in Romania was indeed performed as a part of the ESO-EAST project, by analyzing the data collected in the RES-Q Registry.

Romania contributed data to RES-Q since its initial pilot phase in late 2016. How has seeing the actual numbers for the quality of stroke care helped?

Registering data for quality of stroke care helped to identify dysfunctional areas in hospital care for stroke patients and improve them.

Here are some of the improvement registered in Romania over the last three years.

  1. The proportion of patients treated with intravenous thrombolysis changed significantly from 2.24% in 2017 to 5.19% in 2018 and 8.99% in 2019.
  2. Door to needle time decreased from median 67 min in year 2017 to 58 min – 53 min in 2018-2019.
  3. The proportion of patients screened for dysphagia within 24 hours from admission increased from 1.99% in 2017 to 47.87% in 2018 and decreased to 34.7% in year 2019.

Registering data in RES-Q was essential to get a clearer view of the real stroke care situation and motivated the whole country to improve the treatment of stroke patients.

What would you like to see in RES-Q next?

I think that having data from more hospitals would give an even more representative situation of the stroke care within the country.

What do you think the biggest contributor to reducing disparities in stroke care would be?

In my opinion the biggest contributor to reduce disparities in stroke care would be education.

We see disparities in every aspect of stroke care, from lack of awareness for stroke risk factors and symptoms to delayed arrival to the emergency room and increased waiting time. Therefore, it is very important to improve stroke prevention and stroke recognition by educating the public and the healthcare community. For sure, the stroke care can be improved even further.  

What is the current situation with stroke care in Romania?

Romania is a country with about 19 million inhabitants, with about 60,000 patients with acute stroke registered annually, most of which are ischemic accidents. In Romania, stroke represents the second cause of mortality and disability. According to the burden of Stroke report, in 2015 only 1% of Romanian stroke patients had access to treatment in Stroke units.

Having recognized the alarming rise of acute stroke patients per year as something that can and needs to be fixed, the Romanian Ministry of Health and Neurology Society has recently established a national project that involves the establishment of the interventional treatment for acute ischemic stroke in all county emergency hospitals within the country. 

With the implementation of this project started on the 1st of January 2019, Romania benefited the possibility of a fast stroke network expansion in Europe: tripling of the stroke centers, from 14 to over 40, within only a couple of months. At this moment, there are 35 stroke centers in Romania and we are working hard to have the 43 stroke centers by the end of this year. 

Would you say the attitude towards stroke from lay people (non-clinicians) has changed? Are there are any awareness campaigns running right now in Romania?

It is absolutely necessary to educate the population for the early recognition of the signs and symptoms of a stroke.

As mentioned above, in Romania at the beginning of this year for us was a big change to have 33 more treating hospitals.  In this initial stage the focus is on educating the medical personnel involved in the patient's pathway (emergency service operators and ambulance service personnel, as well as the medical staff in the hospitals where the program will be carried out).

The education of the population is for sure something that needs to be considered and that can be achieved through media campaigns (television, print media) or educational campaigns involving the family doctors, with wide addressability, both for the high-risk age groups but also among the young and adolescents who will be able to react promptly if a parent or grandparent suffers a stroke.

In this moment there are some awareness campaigns in our country that are running different from region to region. Nevertheless, there is the need to increase them.

What is Angels Initiative?

Angels Initiative  is a non-profit project aimed at optimizing stroke treatment in Europe and around the world by increasing the number of stroke ready hospitals and implementing best practices in stroke treatment. It is supported by the WSO, ESO and National Stroke Societies. For example, in the Czech Republic we cooperate a lot with the Cerebrovascular Society of Czech Neurological Society.

Why are the education and support of stroke nurses so important?

There are three main phases of stroke treatment: pre-hospital, acute (which is divided to hyper acute and acute phases) and post-acute. Nurses partner with doctors during patient admission. In my country (Czech Republic), as well as in many other countries, nurses usually perform measurements and give patients the treatment (i.e. inject intravenous thrombolysis). During the post-acute phase nurses play a crucial role. They measure and regulate the temperature and sugar levels, and perform the swallowing screening protocols to ensure that patient doesn’t have dysphagia.

Considering all of the above, support, education and acknowledgement of nurses is one of our priorities.

What is the current state of the collaboration between doctors, nurses and EMS (examples from your experience)?

The collaboration is very good. In majority of hospitals, nurses are treated as equal partners and a performance and outcomes of patient in these hospitals is often on high level. When the collaboration is not so close, you can expect inconvenient environment for both medical staff and patients as well. It’s hard to say if there is any collaboration between nurses and EMS, as the doctors usually carry a “stroke phone” and have direct communication with EMS. Nurses are mostly only in touch with EMS during patient admission.

How do you plan to improve post-acute care?

There are two major approaches: education and acknowledgement. With nurses the second one is paramount, because their work in many countries is underestimated and underpaid. Also there are not many possibilities for career development and advancement.

Let me go briefly through initiatives I currently implement for post-acute care improvement.

  • First is our ESO Angels stroke nurse certification program, which is translated to all the European languages in countries where the Angels Initiative is active.
  • Secondly, we organize regional workshops for nurses, as well as Stroke Nurses’ Congress, which happened in June 2019 for the first time. This is unique for my country and gives nurses the opportunity to meet and share experiences – previously only doctors could do so.
  • Thirdly, we implement the QASC project, which is focused on measuring and/or treating temperature, glycaemia and dysphagia. This project uniquely principally involves nurses: usually nurses don’t participate in this kind of projects.
  • And the most important thing that is outstanding is the Angels Nurses Steering Committee. We are planning to organize the first one this year. This committee consists of highly motivated and enthusiastic nurses around the country. They plan and prepare agendas for upcoming events in the country and improve our tools for nurses. This is something I think is the cherry on the top of the cake and a way to improve post-acute care by empowering and acknowledging nurses.

What about the Stroke Nurses Congress? For whom it was, what were the main topics, participants? What was the feedback, and any special insight you gained?

The Stroke Nurses Congress took place recently, in June 2019, and the idea came from myself, my previous manager Katarina and one of the head nurses from a stroke unit Tereza. As we didn’t know if the congress will be interesting for nurses, we offered financial support to one nurse from each hospital. There were also places available for paid participants. Surprisingly, during the first week half of the workshop was booked, including paid attendance. At the beginning, the most challenging aspect was providing nurses information about the congress, as I didn’t have direct contact to nurses. Doctors are too busy to be disseminating this information. Finally we successfully spread the information and we reached the maximum capacity of 80 nurses from almost all centres in the country.

The target audience for the congress comprised stroke unit nurses and neurological specialists.

  • The first part of the agenda was about stroke in general: the pathway of the patient starting from EMS, procedures in the hospital, the treatment, mechanical thrombectomy and structure of the stroke unit in the Czech Republic. It was prepared by most prestigious clinicians, and the Head of the Stroke Society also gave a talk during this part.
  • The second part was dedicated to the nurses’ work, and main topics included dysphagia, aphasia, rehabilitation and physiotherapy. We also covered the QASC project, our ESO Angels nurse certification and the Angels Initiative activities in general, because many nurses didn’t know what it is. Also, selected nurses had a chance to introduce their stroke units and patient pathway in their hospitals. This gave everyone the opportunity to see the differences highlighted, ask questions and share experiences. Nurses also exchanged contacts to stay in touch, as not many of them communicate directly, even if the hospitals are within a few kilometres of each other.
  • We have started expanding the nurses’ experiences and horizon to cooperate with Angels Initiative – what I can clearly see already in my country (Czech Republic).

I would also like to add that 100% of the nurses who took the survey after the event want to visit the next congress. We have also open a discussion for feedback what could be potentially improved for next congress. After the congress I’ve also noticed that nurses are very motivated: now, when I’m coming to the hospital, they invite me to meetings – this has never happened before. I can tell that the nurses’ influence is increasing across Czech Republic.

What is the plan for QASC? Why did you become the QASC Champion?

The plan is to implement simple things doing well that can significantly improve the outcomes of the stroke patients. The QASC project originally comes from Australia. It is led by Professor Sandy Middleton and her team, and the results were published in highly impacted journal Lancet. Prof. Middleton decided to “do the simple things well” ©, and that is exactly what they did: measure and treat temperature, glycaemia and dysphagia. The results of the study were astonishing: they found out that treating these simple things regularly every 6 hours in first three days improves outcomes for patients in some cases at the level of intravenous thrombolysis, and carries minimal additional costs for treatment.

They’ve decided to implement this project in Europe as well, and that’s how the Angels Initiative joined it. We help to introduce the project to the hospitals and motivate medical staff to join the project, which is especially important in Eastern Europe. Here, hospitals are under the limit with resources, and it’s challenging to find a person to do the additional job for free. Participation in QASC requires initial data entry to the RES-Q registry, implementation of the protocols, and then one more round of data collection to compare results.

 Why did I become the QASC champion? The role was offered to me, probably I was one of consultants who have the most enrolled hospitals in the QASC project and I had very straightforward line of communication with Australian QASC team. It’s a big honour to be a QASC champion and help bridge the communication between the QASC team and the Angels Initiative, as well as to support other consultants by sharing best practice and experience. This can be very useful – especially for new ones, who are not so experienced with QASC project yet.

Who can participate in QASC and how?

Basically, every hospital and every stroke unit can participate. It’s easy: hospital has to enrol for  the QASC at our web page, do some administrative work, register to RES-Q, select the internal QASC champion, collect the data, train the team for implementation of protocols and collect data once more time to see the difference.

How do you see the future of post-acute care in the Czech Republic?

I am always very optimistic and I see very promising future from the perspective of post-acute care in stroke because of the all feedback I have already mentioned. the biggest issue which we are unable to manage as Angels Initiative is to make more attractive conditions for nurses as well as to attract young people to become professional nurses. We are struggling a lot in this and we are facing an insufficient number of nurses in the country in general for couple of years. Unfortunately, situation is getting worse. Nurses are underpaid, have limited prospects for career development and thus less people are interested in this job. In the past nurses were well-respected in our country, but it changed. There are not enough highly-educated young nurses, and for smaller hospitals it is getting harder to hire at least some. I think it definitely requires structural and systematic changes from the Ministry of Health – they need to make this job more attractive.

Any success stories of nurses being empowered to contribute to change?

I can share one story of a nurse Tereza Loučná, head nurse of stroke unit of Faculty Hospital Motol in Prague, one of the biggest hospitals in the country. Ales Tomek, The Chief of the Neurology Department is also the head of the Czech Stroke Society and Tereza receives a lot of support from Dr. Tomek. He enables her to advance and improve, and she is cooperating with Angels Initiative a lot: she helped me with organizing the National Nurses’ Congress and couple of regional QASC workshops. We introduced the project from both points of view, mine as a QASC champion and hers as a stroke nurse. I think she is the first one in whole Europe who finished implementing QASC. We also organized a few dysphagia screening training sessions for nurses.

All these are reasons why I nominated her for the Spirit of Excellence award (an award from the Angels Initiative conferred for outstanding contribution to improving stroke care in Europe). I explained that she’s a leader among stroke nurses in the country. She’s doing everything without seeking acknowledgement or benefit, but I was sure she should be acknowledged. My nomination was successful and Tereza was awarded at ESOC 2019. This year, Valeria Caso, the previous president of the European Stroke Organization, was also awarded, and Tereza was standing next to her with the same award – that was an amazing achievement not only for Tereza, and for the Czech Republic, but I would say also for all the nurses in Europe and maybe even around the world. It was a very emotional moment for me. I announced this achievement at the Czech national stroke congress. Achievement of Tereza received the biggest applause from the audience. This surprised me, and I had tears in my eyes. I am very proud she received the Spirit of Excellence Award. This is one of the most wonderful moments during my Angels Initiative consultant journey.

We are glad to announce that the 100 000th patient was registered in June 2019. Since RES-Q started in 2016, its database grew tremendously:

  • Number of patients: from 1300 to more than 100 000 (80 times more). 
  • Number of hospitals: from 116 to 869 (7 times).
  • Participating countries: from 23 to 61 (2.6 times).

It would not be possible without support of national societies in each of the member countries and stroke community network that now can be fairly named the international community.

We are glad to see that more and more stroke specialists become aware of the benefits and necessity of the quality monitoring, and we can share our experience and knowledge in this area by providing cutting-age tools for our members and constantly improving RES-Q.