The Angels 100 Regions strategy is a bold plan to make the world safe for stroke. It is a regional approach that mobilises different actors around a single mission – to deliver better outcomes for stroke patients.
An Angels Region is one in which community awareness, EMS partnerships and acute hospital care are all optimised to deliver better outcomes for stroke patients. But this can only be achieved if everyone acts in unison. That’s the power of 100 Regions – it sets one goal for everyone and transforms collective goodwill into shared purpose.
In the Czech Republic, Angels consultant Martin Liptay is optimistic that South Bohemia will be among the first in Europe to achieve this status. There is no shortage of collective goodwill in this region saturated with history and culture and dotted with ponds and rustic Baroque-style villages. Its population of just over 600,000 is served by three stroke centres namely Hospital České Budějovice (a comprehensive centre located in the regional capital), and primary stroke centres in the towns of Písek and Jindřichův Hradec. This network places every citizen in the region within an hour’s reach of acute stroke care, with under 50 km separating the primary centres from the capital. Emergency transport is provided by the ZZS Jihočeského kraje (the EMS of South Bohemia), under the directorship of Dr Marek Slabý, who is one of three exceptional leaders steering the region towards gold.
Dr Svatopluk Ostrý
Dr Svatopluk Ostrý became head of neurology at Hospital České Budějovice in 2015, having arrived here in 2012 after 11 years at the celebrated Central Military Hospital in Prague. He’d moved to South Bohemia to change his professional and personal life, he says. “Here was a large hospital in quite a big city but not as big as Prague. Prague was too large for me, I needed something smaller.”
Here, too, was an opportunity to start something new, to tackle another big topic that was nevertheless connected with his years as a neurophysiologist in a neurosurgery team.
“So it was in connection with changing my professional life and improving my personal life,” he says. In the pursuit of these goals he turned his hospital into a landmark for stroke care, treating more patients with thrombolysis annually than any other facility in the country, with a median DTN time between 15 and 18 minutes, carrying out the second-highest number of mechanical thrombectomies per year, and winning three ESO Angels diamond awards.
This level of performance is rooted in daily practice, Dr Ostrý explains. “It is about reviewing every case, every day, going over it again and thinking about ways it could have been better.”
When he arrived in South Bohemia 11 years ago, changing mindsets about stroke required some “passionate” discussion, he says. “We had to convince people to think about stroke patients differently – to try to look at each case as an opportunity to help them, to recognise that when a stroke patient comes in, we are here to change their fate. And that if we decide quickly what to do, and then do it together like one man, we can help them more.”
Dr Ostrý grew up in northern Moravia in eastern Czechia and attended a school where the focus was on mathematics and science. Most of his school mates went on to study economics, maths and physics; Svatopluk Ostrý was among the few who chose medicine as their career, attracted by the potential for using knowledge to impact lives.
Neurosurgery offered the possibility for logical argument, quick decision-making and direct action, and he has found similar characteristics in stroke care. His research focuses on implementing neurophysiology into diagnostic process in acute stroke and exploring a third option for treating acute ischaemic stroke, namely removing clots via microsurgery in cases where mechanical thrombectomy has failed. His joint output with his colleague, renowned neurosurgeon Dr Jiří Fiedler, has brought the world’s attention to the trailblazing work being carried out at their hospital.
Dr Robert Rezek
Dr Robert Rezek is lead physician of the stroke unit at Hospital Písek, a primary centre located in the town of Písek about 45 minutes north-west of České Budějovice. Hospital Písek is one of the Czech Republic’s 40 diamond hospitals, a distinction it achieved for the second time last year. Its average DTN time is a first-rate 17 minutes.
When Dr Rezek came here from Prague about 13 years ago, a stroke care system was already in place but it was following Dr Ostrý’s intervention at České Budějovice that cooperation with that centre improved and stroke patients in the region could receive high-level comprehensive care, he says.
“Previously we were unable to provide quality care to patients with large vessel occlusion. However, since 2013 the whole stroke team at České Budějovice changed and now our cooperation is perfect and the rate for mechanical trombectomy has increased dramatically.”
Perfect cooperation between primary and comprehensive centres hinges on a well-trained ambulance service not only capable of transferring patients between centres as efficiently as possible, but also able to select the right patient for the right hospital.
Educating paramedics improves the whole system, Dr Rezek points out. To that end he became a student himself in the autumn of 2022 when he joined an Angels-facilitated advanced stroke life support training workshop in Budapest to become a certified ASLS instructor.
The 18-year-old Robert Rezek who decided to become a doctor did so from an impulse to “help people and improve the world”. Becoming a neurologist was just his good fortune, he says – a sequence of lucky coincidences that brought him from Prague to Písek to help this hospital improve its stroke care programme and help develop South Bohemia as a safe place for stroke.
His first priority after he arrived in this historic town was to change the logistics for the patients, Dr Rezek says. “Previously, the team met the patient at the ambulance and a physical examination was completed before the patient was transferred to the CT room. This took time. Now, with better selection by the paramedics, we’re ready for the patient before they arrive and we receive them in the CT room.”
Treating the patient at CT cuts more precious minutes from the door-to-needle time.
Dr Marek Slabý
“Transferring patients directly to CT was a huge step towards reducing treatment times,” says Dr Marek Slabý who, as well as leading the ZZS Jihočeského kraje, is president of the National Association of EMS and represents the district Tábor in the Senate of the Czech Republic. He has mastered the art of switching between his many roles and finds that his experience as a politican increases his understanding of the connections between health and social issues.
Standardised cooperation between hospitals and ambulance services has had a significant impact on treatment times, Dr Slabý says. He was involved in discussions leading to the formation of a stroke network in Czechia, and is satisfied that disabilities as a result of stroke are decreasing as a result. Defining the stroke centre network and putting in place rules for triage was a massive jump forward in stroke medicine, he says.
“After rules for effective communication and triage to the correct hospital were agreed upon with the stroke centre in České Budějovice, all the key parameters improved drastically and patient transport to small non-treating hospitals were almost completely eliminated.”
The EMS awards have also had a positive impact on prehospital stroke care quality thanks to the feedback derived from the collection and analysis of patient data. “It is important for people to see what they do matters,” Dr Slabý says.
The ZZS JčK, which won its second diamond award in Q3 of 2023, must enter the awards again in 2024 if they are to meet the criteria for Angels Region status.
Recruiting heroes
Becoming an Angels Region should be a matter of course in a context where physicians such as Drs Ostrý, Rezek and Slabý are providing leadership in all aspects of stroke care. They are soon to be joined by Dr František Pfeifer, chief neurologist at Hospital Jindřichův Hradec, the newly certified stroke centre in a historical town 42 km north-east of České Budějovice.
This hospital would have gained award status before now but for its failure to standardise and document dysphagia screening. Martin Liptay is working with Dr Pfeifer on implementing a standardised protocol for the basic water swallow test and making sure it is consistently tracked so the data can be transferred to RES-Q with the ultimate goal of implementing the GUSS dysphagia screening protocol.
On Martin’s to-do list on the road to gold besides helping Hospital Jindřichův Hradec win their first award and having the EMS add another to their trophy cupboard, is expanding implementation of the FAST Heroes campaign.
In order to meet the criteria for Angels Region status, the region needs to enrol the target number of children in the schools-based awareness campaign. The campaign tasks each child with educating two grandparents. The implementation target is therefore based on stroke incidence (number of strokes per population) divided by two. The South Bohemian region needs to recruit at least 700 little superheroes to reach this goal.
The FAST Heroes campaign has received a boost from Dr Ostry signing on as ambassador, and Martin is hopeful that more leading citizens will lend their influence to the project.
Collective goodwill will take care of the rest.
