ESO East Supplement 2023 - 53

Gdovinova et al.
53
Introduction
Stroke is a major public health issue due to its high incidence
rates, high case fatality rates, residual physical and
neuropsychological disability risks, and direct and indirect
costs.
Therefore, the European Stroke Organisation (ESO)
updated its 2008 recommendations for Stroke Management
to include the establishment of primary (PCS) and comprehensive
(CSC) stroke centers, recommendations for acute
treatment, as well as primary and secondary stroke prevention.
The MR CLEAN, SWIFT, ESCAPE, and EXTEND-1A
trials published in 2015 confirmed mechanical thrombectomy's
superiority on top of thrombolysis for acute stroke
treatment; this is why interventional management of stroke
patients for 24 h, 7 days per week is an essential requirement
for CSCs.
Although stroke patients in Slovakia had been treated
according to European recommendations, no network of
primary and comprehensive stroke centers had been officially
established; the ESO recommended quality parameters
had not been fulfilled. Therefore, the Slovak Stroke
Society decided to change the stroke management concept
and introduced mandatory evaluation of quality parameters.
This article focuses on key success factors of the change in
stroke management in Slovakia and presents the 5-year
results and perspectives for the future.
Material and methods
We processed data from the stroke register at the National
Health Information Center, which is mandatory in Slovakia
for all hospitals designated as primary and secondary stroke
care centers. The change in stroke management in Slovakia
also resulted in a change in the structure of the register; thus,
the parameters obtained were comparable to the quality
parameters set by ESO,1 as well as with other international
registers, especially the SITS (Safe Implementation of
Thrombolysis in Stroke)2 and later the RES-Q (Registry of
Stroke Care Quality) registries.3 At the beginning of the registry
in 2010, the following parameters were collected: recanalization
rate, treatment time <3 and <6 h, risk factors and
treatment at discharge. Since 2015 we have started to add
" time data " (stroke onset, time of arrival at the hospital, time
of CT examination, time of IVT, so that we can calculate
onset-to-treatment time - ONT, door-to-needle time - DNT,
etc.) to be compatible with the SITS register. With the introduction
of the Angels (Acute Networks Striving for
Excellence in Stroke) project in 2016, a healthcare initiative
that supports hospitals worldwide to be " stroke-ready " in
order to treat acute stroke patients based on international
guidelines, we have harmonized the evaluated parameters
also with Angels criteria. As ESO has endorsed this initiative,
the main quality parameters are those of the ESO
Action Plan for stroke 2018-2030 (% of patients treated
with door to needle (DNT) <60 min, <45 min, %
recanalization procedure rate out of total stroke incidence in
the hospital, % of all suspected stroke patients undergoing a
CT or MRI imaging procedure, % of all stroke patients
undergoing dysphagia screen, % of ischemic stroke patients
discharged with antiplatelets, % of atrial fibrillation related
stroke patients discharged with anticoagulants, stroke
patients treated in a dedicated stroke unit or an ICU during
their hospital stay).4 In 2016 was launched also The Registry
of Stroke Care Quality (RES-Q) by ESO-EAST (Enhancing
and Accelerating Stroke Treatment) to provide a tool for
monitoring the quality of stroke care primarily at Central
and Eastern Europe hospitals, but at present, RES-Q is open
for users from across the world. In order to be able to compare
the data from the national register with other countries,
the IT experts of both registers solved the method of sending
data from Slovakia to the RES-Q register. Aggregate data
for the whole year from the Slovak register are sent to
RES-Q once a year in March of the following year.
Results
Organization
Since 2016, we have started to change stroke management.
After many discussions, a new National Guideline for
Stroke Care was prepared in 2017 and published in 2018 as
a Recommendation of the Ministry of Health of the Slovak
Republic, according to § 45 par. 1 letter (b) of Act No.
576/2004 Coll. On Health Care, Health Care-related
Services, and amendments to certain acts.5 The recommendation
included pre-hospital as well as in-hospital stroke
care, a network of primary stroke centers (hospitals administering
only intravenous thrombolysis - 37), and secondary
stroke centers (hospitals treating with intravenous thrombolysis
+ endovascular treatment (ET) - 6) (Figure 1).
Management
We started with systematic education of emergency call
centers and emergency medical services (EMS). A stroke
priority was instituted, having equally high priority as
myocardial infarction. More efficient in-hospital workflow
and pre-hospital patient triage shortened the time to
treatment. This increased the proportion of eligible
patients for specialized treatments limited by the strict
therapeutic window. In the beginning, we prepared a
" stroke-card " with all critical information in collaboration
with EMS. Part of the card was the G-FAST score, a prehospital
scheme for identifying stroke symptoms, and in
all hospitals, we started to use " stroke mobile phones " for
prenotification. Later, a smartphone application was
developed (Figure 2), and prenotification became mandatory
in all hospitals. The application prenotification
includes all important data from the patient's history, so a
patient's data can be entered into the hospital information
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