ESO East Supplement 2023 - 49

Tiu et al.
49
Table 4. Quality indicators for acute stroke care with a good performance.
NIHSS assessment at
admission (%)
54.05
Cerebral imaging
CT/MRI (%)
2017
2018
2019
2020
2021
2022
80.10
73.55
70.40
63.40
86.00
Data from RES-Q registry.
Table 5. Quality indicators for acute stroke care that need to be improved.
Carotid
imaging (%)
2017
2018
2019
2020
2021
2022
58.62
67.23
59.89
50.12
45.44
60.10
Data from RES-Q registry.
increased to 86. Although the results in Table 4 look homogeneous
over the 6 years, we can comment that there was a
significant improvement over time because in 2017 there
were only 10 experienced centers that included patients in
the registry, while in 2021, there were 36 centers registering
patients and more than half of them were initially not habituated
with the standardized management of stroke patients
but improved their activity after analyzing the RES-Q quality
indicators. Brain imaging is performed for all patients
(the missing percentages are due to very severe cases who
decease immediately after admittance).
Evaluation of dysphagia using the GUSS scale has been
implemented in Romania due to RES-Q Registry. Several
training workshops for nurses were organized during the
annual National Congress of Neurology and the National
Stroke Conferences and the local stroke coordinators were
advised to repeat the GUSS training at the hospital level. As
a result, the percentage of standardized dysphagia screening
at admission using the GUSS scale increased from 0.1%
in 2017 to 45.07% in 2021, but further improvement is certainly
needed.
Table 5 lists the most stringent things to be improved. Of
utmost importance is the increasing mortality rate. It is true
that the results for 2021 are influenced by the pandemic and
that mortality is calculated for both ischemic and hemorrhagic
stroke, but in-hospital mortality is unacceptably high
and the situation is probably worse at 90 days. Beside the
low number of patients admitted to stroke units, many other
causes contribute to this reality, but the final link is the
chronic low funding of the entire health system. Romania
Country Health Profile for 20194 mentions that health
spending in Romania is the lowest in the European Union,
both on a per capita basis (EUR 1029, EU average EUR
2884) and as a proportion of GDP (5%, EU 9.8%). Directly
associated with the low funding, we have the highest mortality
rate from treatable causes (208 per 100,000 population,
EU average 100/100,000).
On average, 40% of the patients admitted for acute
ischemic stroke are discharged without any carotid imaging
and less than one-third of the symptomatic carotid stenoses
are revascularized. The percentage of newly diagnosed
atrial fibrillation has increased since 2017, although monitoring
for cardiac arrhythmias for (24-48 h), or longer is not
broadly available. A seriously weak point is the low percentage
of the decompressive craniectomy (<0.3% on
average for all 6 years).
The transfer to neurorehabilitation varies between 5.76%
and 9%. The access is usually limited to one or two intervals
of 14 days and younger people (median age 65 years) with
modified Rankin scores 3-5 are more likely to be eligible.5
The insufficient number of neurorehabilitation facilities and
the absence of palliative care institutions lead to an increased
proportion of disability among stroke survivors, a high inhospital
mortality and a chronic lack of beds for emergencies,
as patients with modified Rankin scores of 5 remain in neurology
departments for weeks and sometimes even months.
>50% carotid
stenosis (%)
6.49
5.21
5.02
7.77
7.33
4.21
Revascularization Newly
of symptomatic
carotid stenosis
(%)
22.95
28.7
31.62
17.14
18.32
22.20
diagnosed
AF (%)
5.96
11.11
8.95
10.95
12.76
10.90
97.94
98.15
98.42
97.30
98.03
97.00
Anticoagulant
treatment (%)
95.27
97.42
98.47
97.07
97.06
88.01
Antiplatelet
treatment (%)
92.64
94.26
95.33
94.96
91.41
94.03
Antihypertensive
treatment (%)
86.34
88.64
89.15
88.13
87.51
81.00
Statin treatment
(%)
79.36
76.5
78.92
78.68
91.63
70.00
Hemicraniectomy
(%)
0.11
0.27
0.16
0.01
0.47
0.37
Mortality
(%) Transfer to
rehabilitation
(%)
14.96
13.31
16.02
15.08
19.30
15.80
5.76
8.42
6.46
6.36
6.96
9.00
Dysphagia
screening
(Guss scale)
(%)
0.1
39.12
34.82
54.04
42.39
45.07
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