Stroke is a major public health issue, because of high incidence rates, high case fatality rates, risks of residual physical and neuropsychological disability, and direct and indirect costs.
That is why the European Stroke Organisation (ESO) updated in the 2008 recommendations for Stroke Management, including establishment of primary (PCS) and comprehensive (CSC) stroke centers, recommendations for acute treatment, primary and secondary stroke prevention. The results of MR CLEAN, SWIFT, ESCAPE a EXTEND-IA trials published in 2015 confirmed superiority of mechanical thrombectomy in the treatment of acute stroke, that's why interventional management of stroke patient for 24 hours 7 days per week is essential requirement for CSCs. Above mentioned recommendations were our goals in stroke management.
Although stroke patients were treated in Slovakia according to the European Recommendations, a network of primary and comprehensive stroke centers has not been officially established. We started changing the stroke management in 2016 and after a lot of discussions a new national guidelines for stroke care were prepared in 2017 and in 2018 published as recommendation of The Ministry of Health of the Slovak Republic according to § 45 par. 1 letter b) of Act no. 576/2004 of Codex about healthcare, healthcare-related services and amendments of some laws. The recommendation concerned pre-hospital as well as in-hospital stroke care and network of primary centers – hospitals administering intravenous thrombolysis (43) and centers for endovascular treatment (ET) (6, today 10) was established Fig. 1). Seven from 10 centers for ET we can call comprehensive centers with some limitations.
We started with systematical education of the emergency call centers and emergency medical service (EMS). A stroke priority was instituted, with equally high priority as myocardial infarction. At the beginning we prepared in collaboration with EMS „check-card“ with all important informations. Part of the card was G-FAST score, a prehospital scheme for identifying stroke symptoms and in all hospitals we started to use mobile phones. Later application (Fig. 2) for prenotification was developed and prenotification is mandatory in all hospitals. Application is used also in communication between primary and comprehensive centers.
Fig. 2 Application for stroke prenotification
It helped us to shorten onset-to-treatment as well as door-to-needle time, because thanks information from the application patient can be entered into the hospital information system and so upon arrival at the hospital he can go directly or very quickly to the CT department. The only problem with the application is that due to GDPR, patient identification data cannot be entered into the application, but the doctor must call the EMS crew. The application can monitor the distance of the ambulance from the hospital and its expected arrival in the hospital.
Not only brain CT but also CT angiography is mandatory in all hospitals. The only laboratory test performed at the emergency department is blood glucose test, except for patients with history of treatment by anticoagulant medication or coagulation disorder, when coagulation tests are realised. The CT is interpreted by radiologists and neurologists and if the patient meets criteria for thrombolysis the alteplase bolus is administered on the CT table and then IVT continues.
If the proximal large-vessel occlusion (LVO) is confirmed immediately is activated invasive radiologist and thrombectomy starts as soon as possible. In primary stroke centers emergency medical service in most cases is waiting until the end of CT angiography and when LVO is confirmed, the patient is transported by the same EMS which shortens the time to ET. CSCs offer endovascular thrombectomy in system 24/7/365.
Another important step was a nationwide stroke campaign realised in cooperation with the patient organisation about severity of the stroke, symptoms of stroke and the need to come to the hospital as soon as possible.
These changes in stroke management resulted in an increase in the rate of IVT and ET as early as 2018 (Fig. 3) and shortening of door-to-needle time (Fig. 4) and it continues.
Other key elements of care in a stroke unit should incorporate systemic screening and management of swallowing disorders, management of food and fluids. To improve dysphagia screening and consequently reduce the risk of aspiration bronchopneumonia, the leading cause of death in stroke patients, we have repeatedly organized dysphagia courses for nurses in all regions in collaboration with the ESO Angels initiative.
Fig. 5 Dysphagia screening course for nurses in University hospital L. Pasteur in Košice for nurses from East Slovakia
Early assessment of impairments and rehabilitation needs and development of a network of centers for poststroke rehabilitation is our most important goal for the future and we are currently working on it in cooperation with the Ministry of Health. Speech therapy is an integral part of stroke care.
One of the parameters for assessing the quality of stroke care is secondary prevention. In most hospitals, ˃ 85% of patients are discharged with antithrombotic treatment (antiplatelets, in patients with atrial fibrillation anticoagulants - dabigatran, apixaban, rivaroxaban, edoxaban).
Confirmation that we achieved quality stroke care in our hospitals is that each hospital has at least the ESO Angels gold award.
The results of our work are presented in publications. Our publications also confirm the importance of data collection within the registers, as this then allows us to process the data and publish them. Here are articles published in the last 3 years.
Author: Prof. MUDr. Zuzana Gdovinova, CSc., Slovakia