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PRENOTIFICATION | A Solution That Sticks

When the EMS service in Poland’s Podkarpackie province needed to reset their approach to stroke, Angels consultant Katarzyna Putyło stayed true to her belief in small things that make a big difference.
Angels team 30 August 2022

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It’s an ordinary sticker, about 21 cm high and 15 cm wide. In the top left-hand corner is the Angels logo; the words “60 minutes = life” appear top right, a list of 16 telephone numbers below. The sticker has a thin adhesive layer that, when you peel off the backing, will stick to almost any surface – like the inside panel of an ambulance, for example.

In fact, you’re likely to find stickers exactly like this one inside every single ambulance in Podkarpackie, a mountainous province in the southeastern corner of Poland where responsibility for stroke management falls to Prof Halina Bartosik-Psujek who is the neurology consultant for the region.

On 23 March this year Prof Bartosik-Psujek was delighted to welcome the heads of neurology from all 16 stroke units in the province to the first face-to-face regional meeting since the start of the pandemic. They had a lot to talk about, including the fact that treatment delays emerging from regional stroke data pointed to shortcomings in the EMS service where the prolonged Covid crisis had disrupted training, increased staff turnover and brought morale low. Ambulance staff throughout the region lacked the ability to diagnose stroke unless symptoms were obvious; no neurological evaluation scale was in use, and prenotification was inconsistent.

Among several interventions that would emerge from the regional meeting (including decision-making workshops, simulation training and FeSS protocol implementation), EMS training took precedence. Late in April, less than four weeks after the regional meeting, 60 EMS members from across the region would gather in the thriving provincial capital Rzeszów for two days of intensive training.

Ahead of the event, Angels consultant Katarzyna Putyło spent a lot of time on the phone calling a specific set of numbers. Feedback she had received from EMS services indicated that calls to the stroke phones at some of the region’s stroke units often went unanswered. Katarzyna had an inkling that the reason for this could be simple, and when an alarming number of times her calls went unanswered, she doubled down on her hunch: Could the numbers themselves be wrong?

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A simple explanation

The idea that simple explanations are generally better than complex ones is a problem-solving principle attributed to William of Ockham, an English mathematician and philosopher born over 700 years ago. “Ockham’s razor”, as the principle is known, holds that one should lean towards simplicity when constructing a theory because over-elaborate explanations often lead one away from the truth.

One by one, Katarzyna called the hospitals in Podkarpackie province to ask, “What is your stroke number – the one where someone always picks up?” The answers varied. At some hospitals the mobile stroke phone had become inoperational after funding ran out. At one top hospital with an impressively organised stroke pathway, the neurology department had moved to a new building and their number changed.

Once she had verified or updated the number for every stroke phone in Podkarpackie, Katarzyna applied another stroke of Ockham’s razor. “It is vain to do with more what can be done with less,” the great logician had believed. So instead of putting the issue of phone numbers on the training agenda or devising a new process for disseminating the updated information, Katarzyna ordered enough stickers for every ambulance in Podkarpackie province, and a good few to spare.

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A tool and a trigger

From stroke symptoms and patient medications to neurological scales, the training provided by Dr Rafal Kaczorowski of the Provincial Clinical Hospital No. 2 in Rzeszów covered every aspect of the prehospital phase, including a video demonstration of the patient pathway with and without prenotification. It was an eye-opener for the teams whose own pathway typically ends at the ER; they were struck by the difference a single phone call could make to a life.

But if the video made the case for prenotification, the sticker did even more. It erased barriers to implementation by installing in every ambulance in the province a tool and a trigger for an action that saves lives. Not only did they have the numbers to call right at their fingertips, but the message about prenotification was impossible to overlook.

After the training ended, Katarzyna was surprised to find herself the target of a queue of participants who were either collecting an extra sticker for an absent colleague or sharing their own suggestions for how the service could be improved.

With the commitment of every EMS team to prenotification, and of every stroke unit to answering the phone, Katarzyna is satisfied that this key priority action is now supported from every perspective – including those of Dr Kaczorowski and Prof Bartosik-Psujek whose formidable reputations should be more than enough to discourage infringement.

Gains made thanks to the sticker have already hit the grapevine as several hospitals report smoother pathways and better treatment times as a result of prenotification. But to really measure what a sticker can accomplish, you should keep an eye on next year’s EMS Awards and look for ambulance teams from Podkarpackie province among the winners.

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