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Proyecto Flecha Hits Targets Around The World

In 2018, three nurses at the Regional University Hospital of Málaga were assigned the task of reviewing protocols in their newly refurbished stroke unit. The solution they came up with has revolutionised post-acute stroke care in their region and will soon be implemented in hospitals around the world. This is their story.
Angels team 15 November 2023
From left, Sergio González-Román, Almudena Fernández and Álvaro López in high spirits at the Spirit of Excellence award dinner in Munich. 

IT is a rare and almost disconcerting pleasure to meet someone who is completely happy with their life. Someone who really, really loves their job and who knows they are exactly where they are meant to be.

“I am a lucky woman,” says Almudena Fernández, a neurology nurse who embodies Málaga’s claim to being the happiest city in the world. Her life has become even more joyous since she became a mother of three – two boys aged four and two and a three-year- old project called Flecha which she describes as “the apple of my eye”.

This third child shows every sign of becoming an over-achiever, starting out as internal assignment to overhaul stroke unit protocols, and now poised to revolutionise stroke nursing care in hospitals around the world.

It is the result of a process that began in 2018 when Almudena and her colleagues Sergio González-Román and Álvaro López were handpicked
by their supervisor Luisa Vergara to review protocols and clinical pathways in the newly refurbished stroke unit at the Regional University Hospital of Málaga. The existing protocols were long and seldom used. In addition, the hospital’s practice of rotating nurses through the stroke unit and neurology ward magnified the need for a simple, accessible set of procedures to identify patient needs and deliver consistent, evidence-based care.

Luisa Vergara knew what she was doing when she picked her team. There was Almudena with her infectious enthusiasm, a passion for spreading knowledge, and a capacity for dreaming big. Álvaro, a somewhat cautious problem-solver and logical thinker with a gift for technology, and Sergio, a natural leader and experienced organiser with the ability to nurse ideas into reality.

These were their super powers, Sergio observes about each team member’s unique ability. “Álvaro is the analytical one, Almudena is the heart.” What they had in common was the sort of motivation that turned a task into a mission and a mission into Proyecto Flecha.

The arrow that started it all. 

An arrow that targets recovery

Proyecto Flecha standardises post- acute stroke care via a system of colour-coded arrows that are placed at the top of each patient’s bed to
help doctors, nurses and even porters easily identify the type of stroke and side affected, and via a QR code access details of the treatment protocols for each day, such as regular checks for dysphagia, glycaemia and fever.

The first visual cue is the colour of the arrow – red for haemorrhagic stroke, yellow for ischaemic stroke, green for subarachnoid haemorrhage and blue for angioplasty procedures after stroke.

The second cue is the direction of the arrow that indicates the affected side so even staff members who have just come on duty will know instantly on which side to place the blood pressure cuff and intravenous line, where to attach the pulse oximeter for measuring blood oxygen levels, how to approach mobilising the patient and which side is optimal for patients whose communication abilities are impaired.

Sergio explains: “This arrow fulfills several essential functions. First, through its colour, it visually identifies the type of stroke being treated. Its direction indicates the affected area, from the point of origin of the stroke in the brain to the physical sequelae that the patient may present. It guides the care to be carried out based on the patient’s deficiencies, covering aspects such as nutrition, mobility and communication. Finally, the project favours early rehabilitation, providing support to both health professionals and the family.”

Luisa Vergara’s superheroes didn’t think of the arrow on day one. They spent a lot of time talking and listening in the pursuit of a simple and practical model to improve and standardise care. Then, one evening after work, Sergio went for a swim in the pool in his apartment building where a red arrow indicating the location of the change room caught his eye. He took a picture and shared it with Almudena and Álvaro in their WhatsApp group. Then the superheroes went to work.


This job is the best job in the world

Sergio grew up with an interest in healthcare and his academic record suggested he was destined to become a doctor. He realised, however, that he wanted to work directly with patients and his first practical session in nursing school removed all doubt: “I understood I was meant to be a nurse.”

He also wanted to explore the world outside Spain and gain an understanding of different realities, so after graduating he worked in Italy as a transplant nurse. Then, joining an international humanitarian organisation introduced him to the developing world – and his future wife. Pilar was about to move to Chad in Central Africa for four years to work on a project for homeless children. Sergio joined her in the mistaken belief that it might persuade her to return sooner.

When they were finally back in Spain, he took a temporary contract as a neurology nurse and found his niche.

Stroke nursing allows him to work closely with the patient and their family, providing specific nursing care that influences outcomes, he says. “These patients are fragile, their life has changed, there is an enormous responsibility to help them regain the best possible life.”

Álvaro was going to be a motor mechanic, but changed his mind at the last minute. “I made the decision to try to ‘fix’ people instead of cars. Since 2007 I have worked in many different services but from 2016 onwards, when I started in neurology, I have been in what I consider my work family. I have fantastic colleagues and am infinitely grateful to my supervisor Luisa who, contract after contract, has kept me alongside her because she saw potential in me. Because of the opportunities she has given me, I have been able to develop a good level of stroke care.”

His stroke knowledge, deepened by research while developing Proyecto Flecha, made the difference when his father recently suffered a complex and extensive cerebellar stroke. This type of stroke typically has vague symptoms but, from a phone call away, Álvaro was able to detect the likelihood of stroke and alert the neurologist on duty.

Like her two colleagues, Almudena “found her patient” when, after years of working in critical care, she was assigned to the neurology ward and stroke unit.

“This job is the best job in the world,” she says. “It is human, it is scientific, you learn a lot every day. Every person is different. It may be the same pathology but a different patient. It teaches you about life.”

Thanks to revascularisation therapies, the stroke unit has become a place where miracles take place, she says. Rotating between wards means a patient who was critically ill when they were admitted, may be up and about when you return to your shift in the stroke unit two days later. “It’s magical to me,” Almudena says. “It’s the reason I love it.”


The arrow takes flight

About one year after Sergio’s serendipitous swim, the Proyecto Flecha team presented their concept to the multidisciplinary team at the Regional University Hospital of Málaga. “People were happy, they liked it, they thought it was a good idea,” Sergio says. Comments and suggestions from neurologists, physiotherapists and speech therapists added value and was the reason, Sergio says, why Proyecto Flecha was “so complete” when it was officially launched in 2020.

A lot has happened in the three years since then.

Sergio became a founding member of the Andalusian Nurses Steering Committee, which Angels consultant Alicia Arjona established with the goal to standardise stroke nursing care in the region. He was also given a strategic role in the Spanish Society of Neurological Nursing, SEDENE.

The arrow earned the reputation of a fertility symbol when every member of the Proyecto Flecha team had a second child. Despite having more childcare duties at home, the Proyecto Flecha team collaborated with the University of Málaga and the Málaga Biomedical Research Insitute (IBIMA) to obtain validation of their project through the FLECHA-IMPACT study.

In May 2023 the trio was celebrated in Munich, where an ESO Spirit of Excellence award nomination recognised their outstanding contribution to raising the standard of stroke care.

But most importantly, Proyecto Flecha began to spread to hospitals outside Málaga. It traveled well. As Sergio describes it, the project was “alive and in constant movement, being enriched by the contributions of other professionals in different hospitals after its implementation”. By October 2023, there were arrows pointing to improved care in the stroke units of five more hospitals in Andalusia and Madrid, with implementation commencing at 13 more.

The Proyecto Flecha team with Angels consultant Alicia Arjona and Spanish colleagues in Munich.

You feel absolutely proud

But the arrow’s trajectory is not yet complete, as the Angels Initiative is in the process of adapting the model to be rolled out in hospitals around the world.

He loves interventions that make it impossible to do the wrong thing, says Angels global project leader, Jan van der Merwe. “The arrow project falls in the same category as the Angels stroke bag and point-of-care testing. If you use it the way you’re supposed to, you simply cannot make a mistake.”

Proyecto Flecha is especially valuable in situations where patients aren’t treated in dedicated stroke units, Jan says. “A patient in a stroke unit has a good chance of being treated according to guidelines. But for the stroke patient in a neurology ward or the ICU, or wherever there are many different people involved in their care, the arrow becomes a ‘small’ thing that makes a big difference. It saves lives.”

The thought of their small nursing team having this much impact gives her goosebumps, Almudena says. “Everything around Proyecto Flecha is incredible. Everybody is happy about it, and you feel absolutely proud.”

He never imagined so many fantastic things would happen, Álvaro says. The project had started simply enough. “We had a common goal, which was to improve the care of the stroke patient, facilitate access to information and avoid complications by getting ahead of problems. I think I still haven’t grasped the magnitude of it all and the change it can make in the lives of so many people around the world.”

For someone who likes to “work in the shadows”, the attention and recognition have required some adjustment. “Ever since we started working with Alicia and the Angels Initiative, I have felt overwhelmed in a good way,” he says.

The only criticism the project has so far received came from a neurologist citing the Stroke Action Plan for Europe (SAPE), whose objectives include treating 90 percent of stroke patients in dedicated stroke units by 2030. By introducing standardised stroke care in internal medicine and general wards, the arrow project risked undermining this goal by making more stroke units appear obsolete, the neurologist suggested.

But this objection only serves to underline the importance of standardisation, Sergio believes. More stroke units will ultimately expand standardised care across Europe, but the patient who has a stroke today or tomorrow cannot afford to wait seven more years. These patients may owe their lives to an arrow that targets their recovery.


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