TWO things you must know about Wałbrzych, the city that is the setting for this story.
One is that it became a coal mining town in the 18th century, and ceased to be one in September 1996 when the last truck of coal was brought to the surface. A museum now stands where the coal mine used to be, but above ground the post-mining town carries the scars. Unemployment is high and many former miners live in straitened circumstances.
“Because the mines existed, and because they closed, the society is sick,” says Dr Patrycja Marciniak, a young strokologist at Dr. Alfred Sokołowski Specialist Care Hospital where it’s common to see chronic diseases of the cardiovascular and pulmonary systems, and as many as 50 stroke patients per month.
To spread awareness among those most likely to be affected by stroke, Dr Marciniak together with cardiologist Dr Aleksandra Potocka-Chmielewska regularly gives talks at the local branch of U3A (a global organisation dedicated to knowledge-sharing among seniors) and is delighted that activists in smaller communes nearby are now following her lead. She also encourages Wałbrzych schools and kindergartens to implement the FAST Heroes campaign through which children learn to recognise stroke symptoms in their relatives and carers.
She says, “This is an extremely important and necessary initiative, especially in communities like ours.”
The second thing to know about Wałbrzych is that its ambulance service and the hospital where Dr Marciniak works are first-rate institutions exceptionally able to care for its vulnerable population. And when it comes to stroke management, they’re among the best in Europe.
Both the hospital and the ambulance service have achieved diamond status in Angels award programmes, and both parties will tell you that they couldn’t do it without the other.
THIS story about two teams working together for the benefit of stroke patients began in 2017 when the neurology department of the Sokołowski Hospital invited members of the ambulance service to a multidisciplinary meeting. Here, with the consent of the director of the EMS Mr Ryszard Kułak, head neurologist Dr Katarzyna Krawczyk-Rojek introduced a protocol for managing stroke.
The ambulance personnel immediately started implementing all the items set out in the protocol. These included using the ROSIER scale to detect stroke, noting the patient’s medical history and medications especially anticoagulants, setting up two peripheral intravenous catheters, prenotifying the hospital emergency department, and calling the neurologist on a special telephone number to let them know a suspected stroke patient was on the way. All these actions served a single aim – to ensure that the patient got treatment faster.
Meanwhile at Sokołowski Hospital, Dr Krawczyk-Rojek was systematically introducing new measures to achieve the same goal by eliminating delays along the stroke pathway.
When Angels consultant Katarzyna Putyło visited the hospital a few years later, she would find a streamlined pathway that left no stone unturned. Ambulance prenotification meant there was a neurologist waiting in the emergency department when the patient arrived. Stroke patients were fast-tracked through the ED, and transferred to the CT laboratory as quickly as possible. Because radiology was a privately owned entity within the hospital, it was not yet possible to deliver patients directly to CT, but the practice of commencing thrombolysis in the CT room was gradually being introduced.
To ensure stroke patients received the best possible care during their stay in hospital, the hospital had opted to participate in QASC Europe, a FeSS protocol implementation study in post- acute care. They had also enrolled with the stroke care quality improvement registry RES-Q, and took advantage of data analysis to monitor their performance and identify gaps.
Every single intervention had a positive impact on patient outcomes. The average door-to-needle time dropped to between 15 and 20 minutes, and the treatment rate rose above 20 percent. In the stroke unit where patients were admitted after treatment, engagement was up among the nursing staff as awareness grew of their impact on patient outcomes. Dysphagia screening was responsible for a dramatic drop in the number of patients with aspiration pneumonia.
At the end of 2019, Sokołowski Hospital received international recognition for their efforts to improve stroke care, reaching platinum status in the ESO Angels Awards. They won their first diamond award at the beginning of 2020, and over the next three years added seven more.
But that is only half the story.
DURING a meeting in 2021, paramedic Mateusz Pitiło’s ears pricked up when he heard Drs Patrycja Marciniak and Dagna Faściszewska talk about the EMS Angels Awards that recognise excellence in prehospital stroke care. The Wałbrzych ambulance service had continued to meet the standard of care defined by Dr Krawczyk-Rojek in 2017. He knew this was something his team could win.
Mateusz says, “Studying the awards criteria, I concluded that we had been conducting ourselves in a similar way and meeting many of the standards for almost four years. Receiving the award seemed almost a formality, but it would also be an opportunity for further development, motivation, updating our rules of conduct to become even more efficient, and monitoring quality.”
In October the following year, Mateusz stood on a stage in Berlin to accept Wałbrzych ambulance service’s first EMS Angels platinum award. Then they raised their game and three months later won a diamond award.
“It is impossible not to notice the correlation between both EMS and the hospital receiving a diamond award,” Mateusz says. A synergistic relationship appears to be at work, in which they each enhance the effectiveness of the other so that together they create a greater contribution than they would independently. This, says Mateusz, occurs as the result of “continuous quality monitoring, mutual understanding and motivation that speed up prehospital and hospital proceedings, and feedback from the neurology department that shows rescue teams how important they are in the management of a patient who has suffered a stroke”.
The F-word is important. Feedback was something the paramedics asked for, Karazyna says, because they otherwise had no idea what happened to a patient after they delivered them. Now doctors remember to text Mateusz with information about patient outcomes.
“We regularly contact the emergency services to let them know that, thanks to their own efforts, a patient could undergo thrombolysis and thrombectomy and their condition improved,” Dr Marciniak says. “It is extremely important to have contact with the rescuers and opportunities to exchange experiences and have joint discussions about specific cases.”
Feedback is the glue in the relationship between hospital and EMS. Mateusz says, “Take for example a patient who was brought to hospital with full aphasia and paresis and was discharged with little or no deficits. Passing this information on to the team lets them see the effects of their own work. It gives a sense of joy and awareness of how important a link you are in patient management.
“Receiving feedback allows for development. Thanks to feedback, teams are able to analyse what was done well and what was wrong. This gives the opportunity to draw conclusions for the future. Feedback identifies areas that require improvement, which allows for appropriate adjustments to be made to common protocols and procedures. I believe that this is one of the key elements to improve cooperation with the hospital.”
TEAMING up with the ambulance service in 2017 was the first step towards improving the quality of the entire patient survival chain, Dr Marciniak says.“They say that a chain is only as strong as its weakest link, and in this instance this is the perfect metaphor.
“The initial links in the chain are the patient and the ambulance service – so we cannot overlook the importance of training the community about stroke. And of course we cannot forget about the next links – working closely with radiologists and improving the quality of care in the stroke ward. Everyone in the community of people involved in treating stroke is familiar with the slogan, ‘time is brain’. We think it is even more accurate to say that ‘team is brain’.”
This kind of teamwork can only come about where there is goodwill, Mateusz says. “Joint development of an appropriate stroke protocol cannot take place without the goodwill of both parties. I am very happy that together with the neurology department in Wałbrzych we can be part of a wonderful machine whose goal is faster and faster procedures, diagnostics and treatment, and minimising deficits in patients with stroke.”