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Getting Ahead By Getting Started

For Castilla y León in northwestern Spain, the road to becoming an Angels Region begins with nurses.
Angels team 02 May 2024

Castilla y León combines two ancient kingdoms with centuries of history to form the largest of Spain’s 17 autonomous communities. The sum of nine provinces, it is bigger than both Hungary and neighbouring Portugal, but its 2,4 million inhabitants, thinly distributed across an area almost one-fifth the size of Spain, account for less than 6 percent of the population.

Red wine lovers around the world know the region for its famous Toro wines produced in the province of Zamora – such robust reds that when Columbus sailed westwards looking for a passage to India, one of his three ships was half filled with Tinta de Toro with which to wash down the dried cod and hardtack bisuits. 

Despite a climate locals describe as “nine months of winter and three months of hell” the people of Castilla y León are gifted with longevity, easily outliving the median onset age for stroke by a good number of years. But low stroke awareness puts them in peril. Local hospitals, of which there are plenty, will see approximately 4,500 stroke patients per year. Of these, around 44 percent will arrive under their own steam, having failed to recognise either the signs of stroke or the importance of calling an ambulance. 

There are four comprehensive centres in Castilla y León, three of which are also the only hospitals in the region that have so far met the criteria for ESO Angels Awards. For the region to achieve Angels Region status, consultant Esther Redondo has to convert eight more hospitals to gold, help the emergency services reach a minimum of gold in the EMS Angels Awards, and enroll at least 2,000 elementary school children in the FAST Heroes stroke awareness programme. Only then can it be deemed a safe region for stroke. 

“Hopefully by the end of next year,” Esther says, recognising that an elephant of this size will have to be eaten one bite at a time.

But (as Mark Twain said) the secret to getting ahead is getting started. Esther kicked off her regional strategy on 8 March with a large gathering of nurses in Valladolid, the region’s unofficial capital city. The goal was to improve post-acute stroke care, not only through an agenda focused on best practice and data-driven improvement, but by creating a forum for the exchange of experiences and ideas.

If attendance equals commitment, the Stroke Nursing Work Session at the Hotel Recoletos was off to a promising start. Two nurses each had been invited from Hospital de Burgos, Hospital Santos Reyes and Hospital Santiago Apóstol in Burgos, from Hospital de Benavente and Hospital Virgen de la Concha in Zamora, Hospital de León and Hospital del Bierzo in Léon, Hospital Soria in Soria, Hospital Río Carrión in Palencia, and Hospital Hospital de Medina del Campo and Hospital de Salamanca in Valladolid. These were all hospitals equipped with dedicated stroke units, or hospitals that admitted neurological patients despite not having a designated stroke unit, Esther explains. 

Mortality rates are four times lower for stroke patients who receive stroke unit care, Esther says, citing a 2020 study of organised inpatient care for stroke. Getting to gold isn’t only about reducing treatment times in the hyperacute phase of stroke but also about raising the standard of post-acute care. “The role of nurses is really key here,” she says.

For the workshop on 8 March, no-one declined the invitation and everyone showed up, some after a journey of over 250 km. Also present was Laura Fernández Concellón, a former emergency medicine physician who in 2023 became regional health manager for Castilla y León. 

The involvement of political decision-makers is crucial for regional conversion and to drive positive change within healthcare systems, Esther says. Dr Concellón was not only an enthusiastic participant in the workshop but had asked to open the event in order to demonstrate the political commitment to stroke care improvement. 

Esther says: “We have the same goal – to optimise stroke networks as much as possible.” 


A highlight of the event was a presentation on integrating quality monitoring into practice by María Jesús Canal of the University Hospital of Salamanca, which has become renowned for its comprehensive monitoring of stroke patient care. 

Sr Canal’s presentation demonstrated through insightful data analysis the evolution of care practices and how they used numerical data to pinpoint areas for improvement.  

Esther says, “Her presentation resonated deeply with all the attendees as it underlined the critical role of quality monitoring in shaping patient outcomes. It reinforced the need for healthcare professionals to embrace quality monitoring actively, and illuminated how leveraging numerical insights can lead to tangible enhancements in patient care, ultimately improving outcomes and experiences for stroke patients.

What made it even more meaningful was that the story of quality monitoring at the University Hospital of Salamanca had a distinctive beginning.

In June 2023 Sr Canal and her colleague Paula Isabel Galache attended an Angels Day where a nurse from a different region explained why and how measuring performance had a positive impact on stroke care. They were impressed and when Esther encouraged them to implement it at their own hospital, they were keen to try. 

“I knew they had the potential,” Esther says. “They’re an engaged, motivated team and they receive a high number of stroke patients.” 

Quality monitoring has since become part of daily nursing practice at the University Hospital of Salamanca and will be the subject of a paper at the next National Nurse Neurological Congress. It is no coincidence that since last June this hospital has won two consecutive gold awards. 


Quality monitoring is at the heart of the changes Esther hopes to see at hospitals represented at the event. “I expect them to change the way they work,” she says. “I expect them to implement regular data collection and analysis protocols to monitor key metrics that define patient outcomes. 

“I would like them to introduce quality improvement changes based on data and not feelings or opinions – and finally I’d like to see a culture of continuous learning and professional development that will enhance the working relationship with others in the stroke care chain. 

This is too often overlooked, but data collection will help foster the sense of being part of an unstoppable team.” 

Her strategy for sustaining the momentum the event generated is to focus on motivation. “That’s where everything starts,” she says. “Once someone is eager to follow the advice you gave them, you are building trust and it becomes easier to work together.” 

Her next date is with a hospital where she will congratulate them on their results in RES-Q and complete a survey of what and how to improve. The point, she says, is to create a sense of awareness and control of their pathway, in addition to showing them how to use their data. 

An even bigger date is Friday 4 October, when the next Stroke Nursing Work Session will take place. Dr Concellón has already indicated she will attend – her enthusiasm for collaborating with Angels is something Esther hopes will translate into additional resources and high-level support for implementing changes. 

The positive impact of the first event could materialise in several ways, Esther says. These may include introducing new practices and improving existing ones; increased awareness and commitment, and collaboration between institutions thanks to networks established during the event.

She says, “The best outcome would be to witness a real impact on stroke patient care in the region, with significant improvements in care quality and positive outcomes for patients, that can be sustained over time.”




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