NIK about stroke treatment in Podlaskie Province

Brain stroke has been one of the key causes of death for many years now. According to the World Health Organisation, only heart diseases have higher ratings in this respect. The Central Statistical Office data shows that over 22 thousand persons died of brain stroke in 2019. Stroke treatment should be provided in specialised facilities, in stroke wards. In Podlaskie Province there are four stroke wards at neurological wards. According to the annual reports of the Podlaskie Province Neurology Consultant, access to stroke treatment in the Province is insufficient and there is a shortage of neurologists. Because of the aging society, the situation becomes worse and worse for patients every year. Persons after 60 years of age are particularly exposed to brain stroke. Delayed treatment may lead to irreversible changes in an organism. Brain stroke is also a cause of long-term incapacity. Therefore, it entails significant consequences – not only clinical but also social and economic. In line with various estimates, nearly half of patients who survive the acute stroke phase are no longer independent and rely on other people’s help.

Time is the key in case of stroke, just like in case of heart attack. Doctors speak of the stroke chain of survival. It covers quick identification of the problem, calling for medical assistance, transport to the previously notified hospital, quick diagnosis and onset of relevant treatment.

The NIK audit covered by Podlaskie  Province, however part of recommendations made by NIK, especially the ones addressed to the Minister of Health and President of the National Health Fund, are related to the stroke treatment system nationwide.

Key audit findings

In terms of the number of stroke beds, as compared with other provinces, Podlaskie Province takes the fifth place from the end in Poland – about 7.5 beds per 100 thousand patients. The number of cities with stroke wards was the smallest in Podlaskie and Opolskie Provinces (3). For comparison, the best situation is in Śląskie Province (21 cities), Podkarpackie Province (14) and Mazowieckie Province (12). In the past decade, the number of stroke and neurological beds declined from 272 to 210. At the same time, the number of people of 60 and more years of age – potentially most exposed to stroke – was going up.

The liquidation of stroke beds was partly caused by organisational changes in hospitals. But the main reason was the 0.6 nurse per bed principle which became effective on 1 January 2019. After unsuccessful attempts to expand the nursing staff, hospital directors resolved to liquidate hospital beds to meet that norm. As a result of the limited number of beds in Podlaskie Province, more than half of patients were treated in other-than-stroke wards. In this case they did not have access to other specialists which would enable them to start rehabilitation already in the stroke ward.

Competent medical staff is needed to increase hospital bed count. According to the Regional Medical Chamber in Białystok, there should be 150 neurologists in Podlaskie Province. On 30 September 2020, there were 110 doctors with that specialty, including 49 at pension age. Besides, the neurologist specialty is not very popular. As a consequence, doctors’ working time is alarmingly long. Doctors working under employment contracts should have guaranteed the minimum of 11-hour rest after shift. This requirement was not always met and it happened that doctors worked even tens of hours. In case of doctors working under a contract the 11-hour rest requirement does not apply. The audit revealed one case of work for 96 hours without rest.

In Białystok, there were stroke wards in two hospitals but the actual treatment was provided in one of them. The Provincial Polyclinical Hospital and the University Clinical Hospital were on the so-called emergency duty interchangeably. As a result, the whole ambulance traffic was directed to one of them, which prolonged patient waiting time. Even patients with the best prognosis may not receive essential assistance when the number of new patients cumulates in one hospital.

Two methods are chiefly used in the first phase of stroke treatment. They are: thrombolysis and mechanical thrombectomy. The first one is about quick intravenuous administration of medicine which dissolves blood clots and restores blood flow in a closed or significantly narrowed blood vessel. Mechanical thrombectomy is a surgical procedure which consists in removing a clot from a blood vessel. It may be carried out within six hours from the stroke. According to the National Health Fund in Podlaskie Province in the fourth quarter 2018, the thrombolytic treatment ratio was about 9.5% - the lowest one of all provinces. In the third quarter 2020, the ratio reached over 16% - it was the highest quarterly ratio in Podlaskie Province, at the same time the second one from the end in Poland. The best results in the analysed period were reported in Zachodniopomorskie Province (from nearly 18% to about 23%) and Podkarpackie Province (from over 15% to nearly 22%). To sum up, the thrombolysis ratio in Podlaskie Province, ranged from about 10-16% of stroke cases, depending on the quarter. It was lower by 4.6 to 10.5 percentage points as compared with the best province. In case of mechanical thrombectomy, in 2020 (until 30 September), this method was applied to nearly 3% of the total number of patients treated for stroke. It was 11 nationwide , in 15 provinces, where this procedure was applied.

Podlaskie Province had one of the highest mortality rates in stroke patients. Limited access to treatment in specialised wards, including access to thrombolysis and thrombectomy, contributed to high mortality in stroke patients. Within a year from disease onset, about 32-40% of stroke patients die in Podlaskie Province. To compare with, in Zachodniopomorskie and Pomorskie Provinces, it is 24-30% of patients.

For comparison with other provinces, the percentage of patients from Podlaskie Province after a stroke who start rehabilitation, was below the national average. Within two weeks from hospital discharge, 13-17% of stroke patients started rehabilitation. To compare with, in Zachodniopomorskie and Opolskie Provinces, it was 25- 37% of patients.

Severe course of disease is often caused by delayed calling for aid to the patient suspected of stroke. The medical documentation shows that over 59% of patients, in case of whom the approximate time of symptom onset was known, were taken to hospital later than within 3.5 hours after stroke symptoms occurred (over 34% after + 12 hours). Delayed access to healthcare was not caused by late arrival of ambulance but the failure to call an ambulance by patients or their close ones. Another cause was the lack of knowledge about stroke symptoms and procedures of handling them. It is equally important for paramedics to be able to identify stroke as soon as possible. The Governor of Podlaskie Province organised two training programmes for ambulance station employees in 2018. Paramedics lack specialist knowledge of neurology or rescue medicine, though. They often find it hard to take precise medical history, especially in case it is difficult to communicate with a patient. Sometimes there are no incident witnesses or information provided by the patient’s family is misleading. The truth is that a patient properly diagnosed on the incident spot will not be taken to an internal ward in a district hospital but straight to a stroke ward. The audit conducted in hospitals with a stroke ward revealed that it took from 24 to 40 minutes to make computed tomography, whereas in hospitals with internal wards the median ranged from about an hour to 16 hours and a half. In one hospital which did not have a tomograph, it was almost 24 hours. The sooner the diagnosis is confirmed by the CT scan, the sooner thrombolytic treatment can be implemented (available only in stroke wards) and the better the patient’s prognosis. In line with the guidelines of the Polish Neurological Society, the time from hospital admission to therapy onset should be shorter than an hour. The hospital in Suwałki was close to that (1:06 h). In the remaining three hospitals this time ranged from 1:38 to 1:48.

In the audited period, only 309 stroke patients initially treated in internal wards were transferred to stroke wards. Depending on hospital, the number of patients discharged and taken to specialist hospitals varied. In one case not a single patient was transported to a stroke ward.

Depending on hospital, the manner and speed of transporting patients to specialist hospitals differed. In some cases patients waited only for 10-30 minutes and in others it was even 7-10 hours. The problem was related to limited availability of the hospital’s own vehicles or too long waiting time for ambulance from external sources. In line with the guidelines of the Polish Neurological Society, cooperation of all medical rescue services with medical teams of the emergency department and the stroke ward is essential to provide specialist treatment to a stroke patient.

Recommendations

To the Minister of Health and the President of the National Health Fund to:

• work out solutions to make the nurse profession more popular. By the time the number of nurses is increased, adding exceptions to the 0.6 nurse per bed principle in the Minister of Health’s ordinance should be considered,
• add an obligation to the Minister of Health’s ordinance to inform provincial branches of the National Health Fund about the healthcare services referral, its date and facility ID number of the organisational unit to which the referral was issued,  
• add an obligation to the Minister of Health’s ordinance to inform all provincial branches of the National Health Fund about referrals issued in ambulatory and hospital care, and complement the data with the facility ID number of the organisational unit to which the referral was issued.

To the Governor of Podlaskie Province to:

• agree upon – in consultation with the Podlaski Branch of the National Health Fund, ambulance stations and healthcare facilities – a standardised, optimal way of transporting a patient suspected of stroke from hospitals with internal wards  to a facility with a stroke ward,
• work out solutions to boost doctors’ interest in neurology specialty,
• make sure hospitals are notified by emergency medical dispatchers about the transport of each patient suspected of stroke,
• provide efficient legal service of patients suspected of stroke at emergency wards in facilities with stroke wards,
• introduce regular training programmes on stroke identification for medical emergency teams.

To the Marshall of Podlaskie Province to:

• make consultations with competent authorities to establish a new stroke ward in the south of Podlaskie Province,
• finance and implement projects to promote healthcare, focused on stroke prevention, identification and first aid in case of stroke suspicion.

 To the National Consultant in Neurology to:

• evaluate work of stroke and neurology wards in Podlaskie Province and participation of stroke patients in rehabilitation.

To heads of hospitals with stroke wards to:

• make a review of procedures for stroke patient handling and make corrections to adapt these procedures to the guidelines of the Polish Neurological Society.

To heads of hospitals without stroke wards to:

• make sure each patient with diagnosed stroke and indications to be transferred to a healthcare facility specialised in stroke treatment is transported to a healthcare facility specialised in stroke treatment, taking account of specialist medical personnel and care in stroke wards.