Stroke care excellence in the Czech Republic has earned Diamond status for no fewer than 22 hospitals. Those wanting to learn from the Czech example will find no better or a more enthusiastic teacher than Dr Aleš Tomek.
At the 93rd Academy Awards held in April 2021, Oscars were handed out in 24 film-making categories. While the winners were recognised for the artistic and technical merits of their work, there is no standard list of criteria for winning an Oscar. And even if there were such a list, it's doubtful that its purpose would be to help actors benchmark their performance or discover which weaknesses they needed to address in order to do better next year.
In early 2021, ESO Angels Awards were presented to hospitals across Europe. These winners were also receiving recognition for excellence, but performance in this instance was measured against a set of 10 standards for excellent stroke care. Not only do these criteria serve as a tool for recognising and rewarding excellence, they also function as a checklist for stroke centres and stroke ready hospitals committed to improving outcomes for their patients.
In the Czech Republic, Angels Awards for the fourth quarter of 2020 were presented to more hospitals than there are categories at the Oscars; and an unprecedented 22 of these hospitals were recognised as centres of excellence by being assigned Diamond status.
This achievement is remarkable for several reasons. One is that, when the Angels Awards were launched in 2017, not a single hospital in the Czech Republic achieved an award. Four years on, almost 50% of its 46 eligible hospitals received the highest honours. Even more remarkably, this came at a time when health services were severely strained by the Covid-19 pandemic that in the Czech Republic has claimed more lives per capita than anywhere else in the world.
Lessons from the Czech Republic
Those wanting to learn from the Czech example will find no better or a more enthusiastic teacher than Dr Aleš Tomek, whose leadership roles include heading up the Czech Stroke Society and the cerebrovascular programme at Charles University in Prague. Dr Tomek is a renowned stroke neurologist and a fellow of the European Stroke Organization (ESO). And , says Angels Initiative consultant Robert Havalda, he has had a catalytic effect on improved standards of stroke care in and beyond the Czech Republic .
When we asked Dr Tomek how so many stroke accredited hospitals in the Czech Republic were able to meet the stringent criteria for achieving Diamond status in the Angels Awards, four lessons emerged form the discussion.
Lesson 1: Implementation is all down to data
When the Angels Awards were launched in 2017, many stroke centres in the Czech Republic were already providing excellent care in most parameters, including the collection of data, Dr Tomek says .
Tracking and reporting on a set of quality indicators was mandatory for accredited stroke centres, and a 2015 policy change that made this data public had had significant impact. Positive results included small hospitals becoming more ambitious after learning that some of their peers were providing quality care to stroke patients, and underperforming hospitals being galvanised to raise their gam e.
Access to data from insurance companies throughout the country is expected to provide even more insights.
Quality monitoring depends on the meticulous recording of data at all hospitals including the smallest ones, Dr Tomek says. Rather than a scattergun approach to improving quality of care, access to good data facilitates laser-sharp implementation and ensures that resources are spent where they are needed most.
Lesson 2: Small things make a big difference
Despite high rates of recanalization and decreasing door-to-needle times, the 2017 awards showed that there was something missing, Dr Tomek says.
Of the 10 award criteria, Czech hospitals had not met the targets for dysphagia screening, and data regarding the number of atrial fibrillation related stroke patients being discharged with anticoagulants had not been captured. “An administrative matter,” Dr Tomek says of the latter. Catching up to the requirements for dysphagia screening was however a longer project.
“Physicians tend to focus on the bigger things, but small things make a big difference,” Dr Tomek says. “One must also look at the smaller pieces of the puzzle.”
Aspiration pneumonia as a result of dysphagia is associated with a significant number of deaths and higher rates of dependency following an acute stroke. Over the next three to four years in the Czech Republic, dysphagia screening would stay on the agenda at meetings of stroke neurologists, and a topic frequently covered in medical journals.
Interventions supported by the Angels Initiative included training for nurses and speech therapists, and the implementation of the QASC project at hospitals in Europe.
The Quality in Acute Stroke Care (QASC) project is an Australian-led intervention based on the principle of “doing the simple things well” and provides protocols for measuring and treating temperature, glycaemia and dysphagia in stroke patients. Dr Tomek’s hospital has the distinction of being the first hospital to complete QASC rollout in the whole of Europe.
There is a reason for that.
Lesson 3: Empower nurses
QASC is a nurse-led intervention that produces optimal results when nurses are appropriately trained, motivated, rewarded and empowered. It is however not only in cases of acute stroke that quality of nursing equals quality of treatment; the collaboration and mutual respect of physicians and nurses is the engine that drives quality care in all areas.
“As an ICU physician working with severe cases, I know that if I do not have a good nurse, I am not providing good care,” Dr Tomek says. “I have always had a soft spot for educating nurses.”
This commitment to the empowerment of nurses has been reciprocated, Robert says. “Nurses love him. He is the face of improvement and empowerment.”
In addition to the QASC project, the Angels Initiative supports interventions that include an ESO Angels stroke nurse certification programme, regional workshops for nurses and a Stroke Nurses’ Congress inaugurated in 2019. There is also an Angels Nurses Steering Committee that helps drive the agenda.
As well as education, there has to be acknowledgement for both physicians and nurses, Dr Tomek believes. “It helps them feel good about caring and about themselves. The Angels Awards programme does help identify problems, which we can then address. But it also provides positive motivation for a job well done.”
Lesson 4: Keep improving
Despite the extraordinary achievement by Czech hospitals at the Angels Awards, they are not satisfied, Dr Tomek says. “We are always looking for new ways to improve. There is still so much to do.”
The list is long. Reducing the time frames for pre-hospital care. Improving post-stroke care and secondary prevention, which means new guidelines for general practitioners. Raising recanalization rates, especially for intravenous thrombolysis, and extending the treatment window beyond four-and-a-half hours in cases where advanced imaging technology indicates this is both safe and viable for individual patients. And no less important – educating the public about stroke prevention and care through awareness campaigns such as the Time is Brain foundation, of which Dr Tomek is the president.
“I do it properly,” Dr Tomek says when asked how Angels Awards are presented in the Czech Republic, although he regrets that in the past year in-person presentations at major stroke conferences have been been ruled out by the pandemic.
The acknowledgement felt the same; the only thing that was missing was a well-deserved round of applause.