ESO East Supplement 2023 - 55

Gdovinova et al.
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Figure 3. IVT: intravenous thrombolysis; ET: endovascular
treatment.
Blood samples are drawn from all patients; the only laboratory
tests affecting treatment decisions are blood glucose
and coagulation status in patients on anticoagulants.
In patients with a confirmed proximal large-vessel
occlusion (LVO), interventional radiology is activated
immediately and thrombectomy starts as soon as possible.
The EMS stays at the CT facility in primary stroke centers
until the CT angiography is finished. If LVO is confirmed,
the patient is transported to an EVT secondary stroke center
by the same EMS. This shortens the onset to recanalization
time (door-to-groin puncture time). From 2019 all secondary
stroke centers offer endovascular treatment in a
24/7/365 system.
Quality control
We consider the introduction of quality control one of the
most critical steps in stroke management. Outcomes and
performance of individual centers are presented at various
cerebrovascular seminars and conferences. This regular
benchmarking creates an opportunity for the members of the
stroke team to improve treatment processes internally by
comparing their performances and/or externally with other
teams. These results are also sent once a year to hospital
directors and presented to the public over the last 3 years.
The percentage of patients treated with IVT is commonly
used in the literature to document improved evidence-based
care processes for patients with stroke. The
rising numbers of patients treated with IVT and MT and
DNT shortening (Figures 3 and 4) confirm that the quality
of care has improved significantly since 2018. The recommended
door-to-needle time in literature is below 1 h. In
Slovakia, quality indicators from RES-Q show that in all 43
hospitals, more than 75% of patients had a DNT <60 min,
and in 42 hospitals, more than 50% of patients had a DNT
<45 min; some hospitals even achieved a DNT <20 min
and median DNT in 2021 was 30 min. After achieving a
higher proportion of patients treated with endovascular
treatment, we focused on reducing the time to the start of
endovascular treatment (door-to-groin puncture time). In
Figure 4. Door-to-needle time (DNT) and *DNT was not
calculated before 2015.
2020 the percentage of patients treated with a door-to-groin
time <120 min was more than 75% in 38 primary hospitals
(door here means the door of the primary care center).
The advantage of the mandatory stroke register is that
every year we have quality data from all 43 hospitals with
stroke for the entire previous year.
Other quality parameters are evaluated in the structure
required by the ESO only in recent years in collaboration
with the ESO Angels Initiative. Based on the agreement, we
then send them to the RES-Q register in March for international
comparison. While in 2019, the proportion of all
stroke patients undergoing dysphagia screening was 26.4%,
in 2020, after educational training of nurses organized by
the Angels, this was 85.9%. In 36 out of 43 hospitals, the
proportion of ischemic stroke patients discharged with antiplatelets
was >85%. In 40 hospitals, the proportion of atrial
fibrillation-related stroke patients discharged with anticoagulants
was >85%, and in 29 of them >90%. In total,
58% of stroke patients are treated in a dedicated stroke unit.
Most of the remaining stroke patients with acute stroke are
treated in multidisciplinary intensive care units, where not
only stroke patients are hospitalized. The most important
procedures for improving stroke care in Slovakia are shown
in Figure 5.
Education and collaboration with the Angels
Initiative
To expand knowledge to the nurses and raise motivation,
the Angels Initiative supported educational training courses
for nurses, with the topics of early rehabilitation, positioning,
and the psychological aspect of working with stroke
patients and their relatives.
The international Angels Initiative improved the education
of emergency services in Slovakia, providing training
courses in pre-hospital management on the national and
regional levels and implementing quality monitoring in
pre-hospital stroke care by involving the EMS providers in
the EMS Angels Awards program, which is based on data
ESO East Supplement 2023

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