Created five million years ago from volcanic explosions, Madeira is an archipelago and autonomous region of Portugal situated in the North Atlantic Ocean, about 805 km southwest of mainland Portugal and roughly 500 km from the African coast. Annually, more than 2 million tourists descend on the main island Madeira and its smaller neighbour Porto Santo, to enjoy its year-round spring weather, its rich landscape of high cliffs, steep valleys, and natural volcanic swimming pools, whale and dolphin watching, hiking the world’s largest prehistoric laurel forest, and drinking its famous fortified wine.
But no tropical island paradise is exempt from the challenges in health service delivery as a result of geographic isolation, resource limitations, and high demand during peak seasons. These are exacerbated in the case of time-dependent emergencies like stroke.
Defying geography
Madeira’s 250,000 residents and scores of holiday makers are fortunate to have access to Hospital Nélio Mendonça, which also happened to be the birthplace of soccer legend Cristiano Ronaldo on 5 February 1985. Located in the capital Funchal, the hospital got a stroke unit in July 2009. They were among the first hospitals in Europe to register with Angels in November 2016, and introduced a thrombectomy service in March 2019. They won their first ESO Angels Award in Q3 of 2021, and had won six more by the start of 2025 when they and consultant Inês Carvalho began the process of converting Madeira into Europe’s first island Angels Region.
Inês had gotten to know Hospital Nélio Mendonça’s stroke coordinators at national conferences, and shared the view that geography shouldn’t decide outcomes. Even in the middle of the Atlantic Ocean, everyone should have the same opportunity of being treated, Inês says.
The best access to quality stroke care for the people of Madeira and their guests would come from greater public awareness and optimized emergency transport in addition to the stroke services already available at the island’s main hospital. Becoming an Angels Region would tick all these boxes. At the same time it was an opportunity for Hospital Nélio Mendonça to take their performance up another notch.
Connecting with decision makers
Inês’s approach was twofold. One was to consult widely with all the teams involved in stroke care, including the prehospital, stroke unit, emergency department and thrombectomy teams. Small working groups then agreed on opportunities for improvement, and activities to address gaps.
Equally important was connecting with decision makers in the departments of health and civil protection, and education, whose support she solicited via personalised letters. Working with local government is crucial for achieving Angels Region status, and here geography counted in her favour. Because Madeira is an autonomous region of Portugal, local authorities can make decisions fast and independently of the mainland.
Local government support was particularly effective in bringing on board the Regional Emergency Medical Service (SEMER) which had yet to meet the criteria for Angels Region status. Prehospital care on the islands is provided by firefighters and volunteers and made more complex and challenging by the distance between Madeira and Porto Santo. Helicopter transfers from Porto Santo to Funchal take under 15 minutes but only when Madeira is living up to its nickname, ‘Island of Eternal Spring’. Extreme weather events are becoming more intense as a result of climate change.
Inês’s intervention took the form of protocol adjustments backed up by a series of trainings. She also arranged training for health centres, as uneven EMS cover can lead to patients consulting primary care providers in an emergency.
On top of the mountain
As for Hospital Nélio Mendonça, the doctor prescribed a blind simulation with the EMS to trouble-shoot prenotification and communication, as well as training for the emergency department and stroke unit. Inês also addressed priority actions to reduce delays in door-to-groin time in a round table discussion with the stroke code and thrombectomy teams, and recruited HCP support for the schools-based FAST Heroes stroke awareness campaign, which had gotten off to a slow start.
Remote islands tend to be close-knit communities where everyone seems to know everyone and their cousin. By leveraging a network of aunts and neighbours and parents and teachers, FAST Heroes implementation met its target in under six months, removing the last barrier to Madeira becoming an Angels Region.
The numbers spoke for themselves. Over a period of six months, EMS prenotification had increased from 32 percent to 71 percent, and patients treated at CT from 13 percent to 68 percent. In Q2 of 2025 both the hospital and SEREM won their first diamond award. On 17 March 2026, Madeira celebrated becoming Portugal’s second Angels Region, and in April, Hospital Nélio Mendonça met another milestone by become an ESO certified stroke center.
They were indeed, as Inês says, “on the top of the mountain”.
A bright spot
Madeira may be 800 km away from the mainland, but they are nevertheless a good example for the rest of Portugal, Inês says. “They’re a bright spot because they’re always focused on solutions.”
Perhaps it’s that being an island makes you agile and adept at maximising resources.
Solutions that expand treatment access have included implementing a hub and spoke model in the middle of the ocean to offer a thrombectomy service to the Azores more than 250 nautical miles away, and making CT imaging available on Porto Santos. That way patients on the smaller island can be assured of access to thrombolysis for acute stroke, no matter what the weather gods have up their sleeve.
