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NO HAY EXCUSAS | 4 Strategies For Treating At CT

If you are still not treating your stroke patients at CT, take inspiration from four hospitals in Andalusia, Spain, where the question of WHERE to treat patients is answered by WHO.
Angels team 20 June 2022

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#1 SEVILLE | The neurologist

Hospital Universitario Virgen del Rocío in Seville (HUVR) is the biggest and arguably the best hospital in southern Spain and known both inside and outside Spain for the quality of its research. It is the country’s number one provider of mechnical thrombectomy, and a catalyst for stroke care excellence in the region where it has helped many other hospitals improve their pathway.

The engine driving the excellence resides in the lean frame of neurologist Dr Francisco “Pachi” Moniche, who talks about his work with all the intensity you’d expect of someone who has time and again observed the difference between life and death. He still feels it deeply – the moment when the right decision at the right moment changes someone’s life. In fact, he has told his residents that if he ever ceased to become emotional when seeing a stroke patient regain their ability to talk and move, they should tell him to quit.

There is no danger of Dr Pachi Moniche quitting any time soon. A neurologist for the past 16 years, he knew right from the start of his residency that stroke was what he calls “the best part”. With degenerative diseases such as multiple sclerosis or Parkinson’s, a doctor could try preserve and improve a patient’s quality of life. But by treating a stroke you could give someone back their life – and that is something this doctor cannot get enough of.

Like in many hospitals of its generation, there are considerable distances separates radiology, emergency and the stroke unit at HUVR. But prenotification by the ambulance service means the stroke team can meet the patient at the entrance and collect relevant information from the ambulance team and conduct an NIHSS evaluation of the patient as they are wheeled directly to the CT room.

In the past they moved the patient to the emergency department for treatment, Dr Moniche says. “But we realised we were losing time.”

Identifying the right person to treat the patient at CT was a matter of staff logistics and DNA. The stroke unit was too far away and with only one stroke nurse on duty the ward would be left unattended. Radiology was averse to the risk. Then Dr Pachi looked in the mirror and found exactly the person he was looking for.

Injecting the thrombolytic drug themselves is not in every neurologist’s playbook. Some insist on a more conventional environment with nurses and monitors present even if it means incurring some delay. But postponing a miracle is not in Dr Moniche’s DNA. Nor can he agree with the neurologist who at a recent webinar expressed the view that by performing a task usually assigned to nurses Dr Moniche was undermining teamwork.

Not his understanding of teamwork, anyway. On the contrary. “When you are all pushing a stretcher together, that is working as a team,” he says. “What is most important is the patient and no-one is too important to help.”

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#2 MÁLAGA | The stroke nurse

The stroke unit at Virgen de la Victoria University Hospital in Málaga is on the fourth floor, an elevator ride and a brisk walk away from the CT room located on the ground floor close to the emergency department. It’s a route Paloma Caro knows very well.

When a stroke patient is brought to the hospital, it is she who will make her way downstairs, her pace quickened by a familiar rush of anticipation and concern.

Paloma doesn’t remember exactly why she chose nursing 20 years ago but she remembers very clearly when neurology chose her. Early in her career she had struggled to find her way, bouncing between cities and specialities.

“Then suddenly, my big experience – a year working as a volunteer in the Dominican Republic and Haiti, in the middle of the catastrophic earthquake of 2010.”

Returning to Spain and having recently graduated with a Master’s in International Health, it took several more years for neurology to find her. But when it finally did, she felt a sense of recognition – and now it’s personal, she says. “Not only as a nurse but as a woman – I feel that everything to do with stroke is worth my time”.

She joined the stroke unit at Virgen de la Victoria when it opened in 2018 and their first thrombolysis remains fresh in her memory:

“Everyone in the team was nervous, it was the first time for several of us. On my way down I was thinking about doses, side effects, emergency signals, limits for blood pressure ... Next I heard the doctor asking me to prepare the thrombolysis. I remember the patient’s eyes. He couldn’t talk when he arrived but after a few minutes he started shouting, ‘Hey, listen, it’s my voice again!’ I felt like a magician and remember thanking science for making it possible.”

"The stroke nurse going to CT is probably one of the best examples of what ‘teamwork’ means,” Paloma says. “We’re involved in the whole process and we understand our responsibility. At the same time the neurologists are now closer, the communication is better, and we feel more respected, so the relationship is stronger.

“Between the nurses in the stroke unit teamwork is important too, because if your colleague goes to CT you are responsible for ‘her’ patients, so from the start of every shift we work side by side.”

Paloma’s commitment to stroke care has propelled her into an unofficial leadership role at her hospital. “I just want to share my knowledge and enthusiasm with my colleagues with the aim that the patient should always receive the best care possible, no matter who is on duty.”

When she goes home at the end of a busy shift, often to burn the midnight oil as she works on her PhD studies, she relishes knowing that the team has done its best and that everyone feels valued and recognised. “It’s an amazing feeling.”

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#3 ALMERIA | The ED nurse

University Hospital Torrecárdenas in Almería will soon be collecting its second ESO Angels diamond award, a fitting reward for an improvement focus that has seen their door-to-needle time shrink to below 45 minutes for 80% of their patients, and their recanalisation rate reach 34%. Treating their patients at CT is a key priority action they implemented from the start.

The stroke pathway at Hospital Torrecárdenas is a study in logic. When stroke is suspected, the EMS prenotifies both the neurologist and the emergency department (ED) who alert radiology in their turn. The patient is met at the entrance and taken via a short pause in the ED critical area to the CT imaging room on the ground floor. Following treatment with thrombolysis they are admitted to the stroke unit or, if they are also a candidate for thrombectomy, to the neuro-interventional room directly adjacent.

Administering the thrombolytic drug is the responsibility of Mari Paz Fernández, an ED nurse noted for her proactive approach and commitment to her patients. After 17 years as a nurse she has learnt the knack of not allowing her work to play havoc with her emotions, but stroke may be the exception.

“Stroke marks you,” she says. “You are scared that it could happen to someone you love, so you try even harder to make sure patients receive the best care and can look forward to a quality life.”

It’s the younger parents who affect her the most, she says, recalling a 40-year-old aphasic woman with right-sided hemiparesis. “Our ages are similar and I saw myself reflected in her. It overwhelmed me to think that I could have been that woman.”

However, as soon as Mari administered the bolus, she saw tears forming in the patient’s eyes and felt her squeeze her hand. She says, “The feeling when someone thanks you just be looking at you – that stays with you forever.”

Mari grew up knowing she wanted to work in healthcare and chose nursing because it meant more time with patients. Her experience includes working in EMS, which has given her valuable insight into the interface between the pre-hospital and intrahospital phases and the importance of co-ordination between the teams.

She loves her work because no two days are the same and she see humanity at its best and worst. Being part of a team that saves lives feels incredibly good, she says.

Being responsible for thrombolysis as an emergency nurse makes perfect sense, she believes. “After all, stroke is an emergency.”

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#4 GRANADA | The radiology nurse

It is the work of a moment to change a mindset. Estefanía Terrón, radiology supervisor at University Hospital San Cecilio in Granada, remembers such a moment. It happened quite soon after the stroke protocol at her hospital was changed and the task of injecting the thrombolytic drug was assigned to her team. On this occasion the neurologist had taken the trouble to thank and congratulate the radiology nursing team on their excellent work and to share the news that the patient was recovering quickly.

“The nurse who had given the bolus ran to tell her colleagues and the realisation that their role had been important lead to tears.”

They were a different team after that.

Estefanía embodies the two characteristics that draw people to careers in nursing – courage, and the desire to help others. Both these
attributes are the reason she said “yes” two years ago when, as part of a project to develop their stroke protocol and improve their treatment times, the option of treating at CT was presented to all the services involved in the stroke code.

“Yes,” said Estefanía, her team would do it.

Previously treatment had taken place in the ICU, but with the CT room located right in the emergency department, the new protocol was a potential game changer that would eventually reduce their median door-to-needle time to under 35 minutes.

“We knew from studies that this was best for patients,” Estefanía says. She didn’t think twice about putting up her hand.

The opportunity to make decisions for the benefit of patients is one of the things she loves about her work. She has known since she was a child that nursing was her destiny, but it was as a nurse in the emergency department and EMS that she discovered her true calling. Working in an emergency setting nurtured her belief in teamwork; then stroke and the critical importance of time in stroke care lead her to radiology, where she quickly distinguished herself as a leader.

Change is always difficult, Estefanía says, but you can overcome fear by staying focused on providing quality care to patients. “The key is empathy and putting yourself in your patient’s place. I always say to my colleagues, ‘If the patient was my father, how would I like the team to act?’”


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