Dr Lengyel Gabriella Kincsó is a neurology resident at Saint Pantaleon Hospital in the Hungarian city of Dunaújváros – a “future neurologist” as she calls herself on her Instagram account where she posts a new picture of the same Christmas tree every December. This past December, however, before the Christmas tree went up, Dr Kincsó posted a gallery of images she had taken in Kaunas, Lithuania.
There’s the Church of Saint Michael the Archangel; the snow-covered bastion and round brick tower of Kaunas Castle; the Christmas decorations in Laisvés Avenue, the longest pedestrian street in Eastern Europe, and the entrance to the Hospital of Lithuanian University of Health Sciences (LSMU), the largest and most advanced medical institution in the Baltic countries.
“Kaunas Stroke Simulation event in Christmas mood with the wonder team,” the caption reads. The final picture is of the “wonder team” – a group of doctors from Bulgaria, Hungary and Romania who had just completed two days of stroke training at the Simulation Centre at LSMU.
It was the third simulation event to take place in Kaunas as the temperatures dropped between September and December 2022. A fourth one for doctors from Ukraine had been planned for November but was postponed after a stray missile raised fears that the Russia-Ukraine war was spilling over to its Polish neighbours.
Lithuania shares borders with Poland, Latvia, Russia and Belarus. It’s the largest of the Baltic states, a region disproportionately impacted by stroke. Intravenous thrombolysis (IVT) became available at two hospitals in the capital Vilnius in 2002, and from 2007 updated guidelines of the Lithuanian Stroke Association recommended IVT as the first line of treatment for ischaemic stroke. The first mechanical thrombectomy was performed in 2012.
However, less than one percent of ischaemic stroke patients received recanalisation therapy in the years before 2014 when a national stroke care network was established with the goal to have a stroke-ready hospital within an hour’s reach of every one of Lithaunia’s 2,8 million citizens.
From 2017, the Lithuanian stroke community received support from the Angels Initiative. Quality monitoring was introduced and the hospitals enrolled with RES-Q. By 2020 treatment rates for both thrombolysis and thrombectomy were on par with the Stroke Action Plan for Europe’s targets for 2030, and in-hospital mortality rates had dipped below 10 percent in most stroke centres.
At LSMU in Kaunas, the average door-to-needle time had dropped to 34 minutes. During a visit to the hospital, Angels consultant Rita Rodrigues was given a tour of the campus, including a new building and sophisticated simulation centre that had been established so students and residents could learn how to manage life-threatening situations in a safe environment.
“Why not use it for stroke?” she suggested.
It was an idea that transformed stroke training in Lithuania, and sparked a partnership between Angels and LSMU that will see the simulation centre in Kaunas become a landmark in stroke care quality improvement in Eastern and Central Europe.
INITIAL plans to bring international groups to Kaunas for training were scuppered by the Covid pandemic but resumed at the end of 2021.
In January 2022, a pilot event for doctors from Ukraine, Belarus and more distant neighbours including Georgia and Moldova was a resounding success that would serve as a model for future events.
At the podium on day one were two experts from Kaunas and two from Vilnius – neurologists Prof Antanas Vaitkus and Dr Prof Vaidas Matijosaitis from the Department of Neurology at LSMU, and Dr Prof Aleksandras Vilionskis and Prof Dalius Jatuzis, respectively the head of the stroke centre at Republican Vilnius University Hospital, and of the Clinic of Neurology and Neurosurgery at Vilnius University.
They gave an overview of hyperacute stroke management and the value of simulation in stroke training, and shared the trajectory of stroke in Lithuania over five years with Angels. After a tour of the LSMU stroke unit and emergency and imaging rooms, it was action time as attendees were divided into teams and briefed on a series of clinical scenarios.
Rita explains how it works. Roles are rotated within the teams so everyone has the chance to participate as neurologist, paramedic, patient and nurse. While one team is taking part in a simulation, the others are assigned roles they must observe carefully and comment on during the debriefing.
Ahead of the event a pre-workshop questionnaire is circulated to the participants so that insights about the conditions in each country can inform the choice of clinical scenarios.
The ability of the presenters to adapt the discussion to the level of experience in the room is one of the reasons these events are so successful, Rita says.
Another advantage is that the training can also be offered in Russian, which is spoken as a foreign language by over 60 percent of Lithuanians.
Visiting doctors also have a lot to learn from the stroke team in Kaunas.
LSMU was already a leading stroke centre when Rita first became acquainted with Prof Antanas Vaitkus and his team in 2017. Its emergency, imaging and pathology services were available round the clock, stroke patients were given priority in the laboratory and CT room, and there were enough dedicated beds for patients to receive specialist post- acute care.
The stroke patient pathway was well organised and incorporated key priority actions recommended by Angels – POC testing for blood glucose and INR, and treating the patient at CT.
Rita and the team agreed to set a door-to-needle target of below 45 minutes, although two successive simulations suggested they could do even better than that. They stopped the clock at 15 minutes in the first round, then shaved off another eight minutes in the second.
Five years on, LSMU has a perfect pathway, Rita says. After a quick pitstop in the emergency room the patient proceeds directly to CT room (there are two inside the ER) and once treated is admitted to the stroke unit.
The Kaunas experience sets a high standard for doctors like “future neurologist” Lengyel Gabriella Kincső and her colleagues from Romania and Bulgaria, but that is why they’re here. Besides, the wonder team who posed for a group photo outside the LSMU entrance in the December snow is now also an informal stroke network whose members have promised to continue sharing experiences across borders.