Going the extra mile took on new meaning for an Angels consultant in southwestern Italy where the installation of a dedicated stroke unit had stalled as the result of a missing purchase order.
News that Hospital Umberto I in Nocera Inferiore was about to start treating patients with acute stroke made local headlines in 2017. It would become only the second stroke treating hospital in Italy’s Salerno province, and its proximity to Naples a 20-minute train ride away lent it even more strategic importance. But the road to becoming a stroke-ready hospital would take many turns and lead an Angels consultant on a paper trail to find a document that would open the doors to a dedicated stroke unit to serve the citizens of this densely populated corner of the Italian peninsula.
The city of Nocera Inferiore is located in Campania, a region equally rich in culture and in natural beauty. For visitors interested in history, its biggest drawcard is the medieval castle on top of Santa Andrea’s Hill whose fortified walls have admitted a procession of popes, prisoners and poets, among the latter Dante Alighieri and Giovanni Boccacio, two of the so-called “Three Crowns” of Italian literature.
A 12-minute walk away from this storied edifice lies Hospital Umberto I where Angels consultant Stefania Fiorillo reported in 2017 at the invitation of the hospital’s chief neurologist Dr Teresa Cuomo. During an Angels meeting to mobilise a stroke network in the region, Dr Cuomo had recognised the opportunity to develop capacity for treating acute stroke at her hospital.
“We need your help,” she told Stefania. "We don’t know where to start.”
For both Stefania and the doctors and nurses at Hospital Umberto this signaled the beginning of a year of intense learning. There was hospital management to convince, a team to create, a pathway to build, skills to develop and, finally, one missing purchase order to be found before Hospital Umberto would find itself on a stage to receive its first ESO Angels Award.
Test-driving theory into practice
Training, which began almost as soon as the hospital was enrolled with Angels, covered all the disciplines involved in stroke care, with contributions from the hospital’s director of neuroradiology Dr Andrea Manto, the head of the emergency department Dr Giovanna Esposito, the local ambulance service, neurologists Drs Antonella Menditti and Dario Coppeta and of course Dr Cuomo herself.
Once the pathway had been structured, streamlined and studied from every angle, Dr Paolo Bovi, an expert neurologist from northern Italy, presented masterclasses in clinical decision-making and seasoned nurse Michele Napolitano provided instruction on patient care in the acute and post-acute phase.
Finally, the stroke-team-in-the-making had the chance to test-drive their theoretical knowledge in a series of simulations that introduced them to even more clinical cases, and on 1 June 2018 Stefania received the text message she had been waiting for: Hospital Umberto I had successfully thrombolysed its first stroke patient.
“As part of our training we commit to doing whatever it takes to give life a chance,” says Stefania who was among the first Angels consultants appointed in Europe in 2016. Consultants are also expected to hone their observation skills in order to detect opportunities for improving the stroke pathway at hospitals. But Stefania’s sleuthing skills were about to be tested to the hilt as she embarked on solving the Mystery of the Missing Monitors.
By early 2019 Dr Cuomo had again reached out to Stefania for help. Almost a year after its first thrombolysis, Hospital Umberto still had no dedicated stroke unit where patients could receive the best possible care from qualified stroke nurses, physiotherapists, speech therapists and other post-acute specialists. For the time being stroke patients were assigned to beds in the emergency department, or commenced their recovery in a temporary unit created within the neurology department.
Patient monitors were needed to make the stroke unit operational, but a year after the acquisition was approved, the monitors had still not arrived and no-one knew the reason why.
Arrival of the monitors unlocks the doors
Hospital management in this part of Italy is a complex system with decision-making powers both at the level of individual hospital administrations and of the healthcare bodies under which they fall. Stefania began her enquiries at the top of this management hierarchy where she established that a document authorising the acquisition of stroke unit monitors had been sent to the admin department for processing. From there the search lead her to the procurement office where the trail went cold.
If the missing purchase order could not be found it would be back to square one for Dr Cuomo and her team.
Searching for a single sheet of paper in a busy procurement office is like looking for the proverbial needle in a haystack, but Stefania isn’t easily discouraged. If optimal care for stroke patients in this part of Salerno hinged on finding a missing document, this was a haystack she was prepared to tackle.
Combing through mountains of documents looking for a single sheet of paper took hours, but Stefania’s determination was rewarded when at last she straightened up holding the purchase order in her hand.
The arrival of the monitors now permitted the immediate activation of four monitored beds in the neurology department. The stroke unit with its open plan layout and dedicated team was finally inaugurated in 2020, the same year the hospital collected its first ESO Angels platinum award. In 2021 they collected another in recognition of achievements that include a 30% recanalisation rate and a median door-to-needle time of under 45 minutes.
The team at Hospital Umberto was not however content with caring for stroke patients only up to the point of discharge. The stroke unit was barely a year old when a post-stroke rehabilitation centre opened its doors at the foot of Santa Andrea’s Hill. Here a highly specialised team lead by Drs Monica Gambacorta and Arturo D’Antonio complete the stroke patient’s care path to give them the best possible chance for autonomy, independence and quality of life.
Proud as they are of the awards, for Stefania as for the team at Hospital Umberto the long-awaited stroke unit, and especially its shiny monitors keeping an eye on patients’ vital signs, serve as a constant reminder of the power and rewards of persistence that goes the extra mile.