ON Tuesday 2023년 11월 21일, Dr Caterina Kulyk, a neurologist from Linz in Upper Austria, found herself in an unusual position. She was play-acting the part of an Austrian tourist who during a visit to České Budějovice in the Czech Republic’s South Bohemia region had suffered the great misfortune of having a stroke.
It isn’t hard to see why an Austrian tourist might put České Budějovice on their itinerary. Its well-preserved historic centre has many fine examples of Renaissance and Baroque architecture as well as the largest fountain in the Czech Republic, and the city is famous for its beer.
"Being wheeled through the emergency entrance of Hospital České Budějovice during a stroke simulation workshop, Dr Kulyk felt disoriented. “I could not understand what was happening,” she explains, “and I could not see where I was being taken. Even as a healthy person the experience felt confusing and I was very glad when the personnel around me explained what was happening and what the next steps were."
This patient perspective is one of the factors that has influenced stroke care at Kepler University Hospital since the cross-border simulation exercise last November.
Angels consultant Martin Liptay explains how the simulation came about:
“During ESOC 2023, Robert Havalda (Angels team leader) and I were approached by a Czech neurologist, Dr Michaela Schober, who at the time was working in the Barmherzige Brüder Hospital in Linz. Dr Schober asked if we could do a simulation training in her city. Because we don’t have a consultant there, we thought it would be a good idea to run a simulation training in the comprehensive centre in České Budějovice, which is one of the leading stroke centres in the Czech Republic, and invite some stroke centres from the Upper Austria region to join us.”
Dr Schober had left Linz by the time the invitation went out to five Austrian hospitals including Kepler University Hospital, where Dr Kulyk, an Italian neurologist from Padua, had just succeeded the esteemed Dr Milan Vosko as head of the stroke unit and was focused on improving their door-to-needle times.
“Our times had gotten better,” she says, “but there was still room for improvement.”
“At ESOC we had heard about České Budějovice’s excellent door- to-needle time. We looked forward to exchanging points of view and learning from the experience of our colleagues, as we do in fact work in neighbouring regions, sharing hills and valleys. We’d also heard that the chief neurologist Dr Svatopluk Ostrý was very good and very pleasant, so this was a very good opportunity.”
Three colleagues accompanied Dr Kulyk to South Bohemia – a neurologist who was new to stroke and two residents respectively at the beginning and end of their residency. The trip from Linz to České Budějovice took less than two hours.
Better, faster, safer
The very good and very pleasant Dr Svatopluk Ostrý became head of neurology at Hospital České Budějovice in 2015, having arrived here in 2012 after 11 years as neurophysiologist in a neurosurgical team 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 in neurosurgery.
“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.
Dr Michaela Schober, who is now pursuing a Master of Advanced Studies in Stroke Medicine at the University of Bern, shared pictures of the November simulation on LinkedIn, and captioned them with a description of České Budějovice as “the best Czech hospital”.
Which invites the following question to Dr Ostrý: In a country acknowledged for excellence in stroke care, how do you become best?
The answer lies in improving case by case. “It is based on 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. You have to do an audit of every case, from diagnosis to treatment, to find the weaknesses and adjust the rules so you can avoid them.”
When he arrived in South Bohemia 11 years ago, changing mindsets about stroke required some “passionate” discussion, he says. Not everyone was equally willing to hear critical feedback or to accept that there were better, faster and safer ways to do things. “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.
“Now the patients that come to us are the same as 10 years ago, but the process – the sequence of diagnostics and decisions – is a bit different and hopefully better.”
Now our cooperation is perfect
Things are very different and vastly better, if you want the view of Dr Robert Rezek, 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 Cezch 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.
“He’s a great teacher,” Martin Liptay says, and his lessons are popular with the region’s paramedics who gladly receive the insights of a leading stroke physician.
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.
Working outside a big city like Prague comes with a greater burden of responsibility, Dr Rezek says. “In Prague you can rely on others to help, but here in our region we have to take care of the patients ourselves.” For this reason he values the sense of community fostered by Angels, and the opportunities for “sharing struggles and successes with other hospitals and inspiring each other”.
His first priority after he arrived in this historic town that straddles the river Otava 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. We do the scan first, before the physical examination, and we don’t wait for laboratory results before commencing recanalisation.”
Finally, treating the patient at CT cuts more precious minutes from the door- to-needle time.
A massive jump forward in stroke medicine
“Transferring patients directly to CT was a huge step towards reducing treatment times,” says Dr Marek Slabý who, as well as being president of the National Association of EMS, is director of the EMS in the South Bohemian region and represents the district Tábor in the Senate of the Czech Republic.
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. Knowledge of the proper terminology also helped paramedics to communicate more efficiently with stroke centres.”
The EMS awards have also had a positive impact on prehospital stroke care quality thanks to the feedback derived from the collection and evaluation of patient data. “It is important for people to see what they do matters,” Dr Slabý says.
The EMS of the South Bohemian region, which has won three platinum and one diamond award, was founded in 2005 and after almost two decades in the director’s seat Dr Slabý can count on a strong team to relieve him of day-to-day tasks. Still, he has an agreement with the political chief of the region that he will step down and work as a regular EMS physician should his other responsibilities become too onerous. He has however 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.
He has also been able to influence discussions on cross-border collaboration, which he says is very important for patients. “Because of tourism, cross-border work and cross-border commutes, for example for shopping, it is essential to communicate and collaborate,” Dr Slabý says. Agreements are already in place with Germany and Austria, and there are also agreements between individual regions such as South Bohemia and Upper Austria – whose citizens, as Dr Kulyk pointed out, look out on the same mountains and valleys.
Points of comparison
“Continuous training of our paramedic staff is essential,” Dr Kulyk says. Besides her insight about the mindsets of arriving patients and using stopwatches in the hyperacute phase as a reminder that time is brain, she intends to follow the example of Drs Ostrý and Rezek and prioritise stroke training for paramedics.
“After optimisation of pre-hospital triage, meeting patients directly in the CT scan would be the next step to shorten door-to-needle time,” she says. “At the moment we feel that patients still do need a triage in the emergency room to rule out stroke mimics.
We also use this first in-hospital assessment to decide whether to send patients to CT or MRI. Our acute stroke MRI protocols are short (10 minutes) but still take longer than doing a CT. The challenge is to find a golden midway between very quick and very accurate.”
Conceding that not all processes can be transferred to another facility without adjusting to the conditions, Dr Ostrý nevertheless maintains that the main steps can be copied within the framework of proven improvement.
“We are proud of being an example to others and we were very happy to show them how it is possible to do it,” he says. But cross-border collaboration is a secondary effect, and raising the standard of care in South Bohemia remains the primary goal. To this end he also serves as a member of the Angels steering committee and is the ambassador for the FAST Heroes awareness campaign in the region.
Nourishing empathy
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. He was chiefly drawn by the potential for applying rules to real life, and for using knowledge to impact the lives of others, he says.
Neurosurgery offered the possibility for logical argument, quick decision- making and direct action, and he has found similar characteristics in stroke care. “You have to decide whether to treat or not and which way to treat,” he says. What makes it even more interesting is that even with guidelines a grey area remains so you cannot in every instance be absolutely certain which option is best.
Dr Ostrý’s 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 previous practices in neurosurgery and neurophysiology are in play as he teams up with his Hospital České Budějovice colleague, renowned neurosurgeon Dr Jiří Fiedler, among other things to develop a protocol for clot removal in an intracranial procedure. Their joint output has brought the world’s attention to the trailblazing work being carried out at their hospital.
It stands to reason that Hospital České Budějovice is a magnet for those seeking professional development in a region 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 Hospital Jindřichův Hradec, a newly certified stroke centre in another historical town about 42 km northeast of České Budějovice.
Under Dr Ostrý’s wing future stroke physicians can expect more than professional growth: there is emphasis also on personal development. The idea is to nourish the capacity for empathy and the ability to look at problems from other people’s perspective, Dr Ostrý explains.
“We are not all the same and this raises the potential for misunderstanding. We may all have the same problem but look at it from different points of view. Each person’s hierarchy of what is important is different, and to work together you have to know what others regard as less or more important in order to understand them better.”
That, too, is how you become the best.
