In May this year, Dr Angela Konze, director of neuroradiology in Central Tuscany and radiologist at Hospital Santa Maria Nuova in Florence, became the second healthcare professional from Tuscany to receive the prestigious ESO Spirit of Excellence Award for outstanding contributions to stroke care.
The Spirit of Excellence Award is a project of the Angels Initiative, a healthcare intervention dedicated to improving stroke patients’ chance of survival and a disability-free life. The award was inaugurated in 2017 to recognise individuals for their extraordinary commitment to raising the standard of stroke treatment in their hospitals and communities. Winners of the inaugural award included Dr Rossana Tassi, neurologist at the University Hospital of Siena.
Dr Tassi and Dr Konze’s awards mark six years of co-operation between the Angels Initiative and the Italian stroke community. Over this period the number of hospitals in Italy registered with Angels has grown from 37 to 184, including 32 new stroke-treating hospitals. Forty-four hospitals, including seven in Tuscany, have received ESO Angels Awards, which recognise teams and institutions that meet criteria based on the European Stroke Organisation’s quality measures, and are committed to quality improvement through continuous monitoring.
Hospitals are eligible for gold, platinum or diamond awards, with diamond representing the highest level of performance. To date, just seven hospitals in Italy have achieved diamond status, but Hospital Santa Maria Nuova has achieved this distinction no fewer than 10 times, cementing its reputation as a bright spot for stroke care standards in the country. Their remarkable achievement has inspired other hospitals in a region where over 3,000 stroke patients are admitted annually to raise their own performance. As a result, award-winning hospitals in Tuscany now include Careggi University Hospital and Santa Maria Annunziata Hospital in Firenze, along with Santo Stefano Hospital in Prato, San Jacopo Hospital in Pistoia, Santi Cosma e Damiano Hospital in Pescia and University Hospital of Siena.
The Angels Initiative was founded in Germany and endorsed by the ESO in 2016 after which Angels consultants were deployed across Europe to help hospitals meet ESO quality standards for stroke care. The three Angels consultants currently working in Italy – Stefania Fiorillo, Elisa Salvati and Alessia Santori – are lead by Lorenza Spagnuolo who was the consultant invited to Hospital Santa Maria Nuova after Dr Konze first learnt of the project.
Dr Konze had become fascinated by the Angels network after a conversation with former ESO President Prof Valeria Caso at a conference in 2017 during which she learnt that the Angels Initiative had helped several hospitals in Europe achieve door-to-treatment times of 30 minutes or less. The consultancy process that followed included stroke pathway analysis, training and simulations that demonstrated the benefits of implementing priority actions such as prenotification, taking the patient directly to CT, and commencing treatment at CT. By 2018, the hospital had halved its door-to-treatment times while doubling the percentage of patients treated with recanalisation. In the following year, the average door-to-treatment time dropped to 32 minutes, and since then the bright spot at Hospital Santa Maria Nuova has continued to spread its light.
The University Hospital of Siena, where Dr Tassi, inspired by her experience at the Karolinska Institute in Stockholm in 2013, had started a journey of change, was the first Tuscan and Italian hospital to join the Angels community in 2016. Along with stroke unit director Professor Giuseppe Martini, Dr Tassi had set out to bring about change not only at their own hospital but throughout the regional referral network, optimising the patient pathway from diagnosis to treatment. Enrolling with Angels provided a much-needed boost when momentum had begun to flag, offering support for updating their treatment processes and further improving their treatment times through multi-disciplinary workshops and simulation training. But what was equally important was that they started to feel part of a movement bigger than themselves – “almost as if we were the ‘Angels’ within our region,” Dr Tassi wrote at the time. “We were reminded of how significant our daily work was and how impactful we had been.”
The partnership between the Angels Initiative and Italy’s stroke community has already produced many such success stories. In Tuscany, hospital stroke protocols and pathway improvements received support from “stroke heroes” such as Dr Tassi and Professor Giuseppe Martini, but also Dr Pasquale Palumbo, the neurology director of Santo Stefano Hospital in Prato, Dr Konze and Rita Marino, an ED nurse from Santa Maria Nuova Hospital in Florence. Other stories include Hospital Umberto I in Nocera Inferiore that in 2018 thrombolysed their first stroke patient and now has a dedicated stroke unit as well as a post-stroke rehabilitation centre; Avezzano Hospital in the Abruzzo region where implementation of the key priority actions drastically reduced treatment times, and University Hospital in Trieste where re-evaluating the internal stroke path and optimising it through simulation training has dramatically improved outcomes for patients. In each of these hospitals and dozens more, improvement has been recognised through Angels Awards.
Data collection is a prerequisite of eligibility for Angels Awards. Better stroke care requires a commitment to continuous quality monitoring, a mindset promoted throughout Italy by the Angels-supported quality improvement programme, MonitorISA, which requires participating hospitals to record and report stroke patient data for a 30-day period twice per year.
Quality improvement measures like MonitorISA not only help identify underperforming hospitals that need help with optimising their pathways; it also creates a platform for recognising the stroke heroes who do whatever it takes to give life a chance.