Reflections on the stroke care plan for the Region of Madrid

Dear Editor:

It was with great interest that we read the recently published consensus document on intravascular treatment of acute ischaemic stroke within the framework of the Madrid stroke care plan. This plan introduces a new action protocol for cases of code stroke (CS) in hospital and non-hospital emergency services by including a new alternative, endovascular treatment, which will probably be implemented in daily clinical practice.¹

The main innovation associated with this treatment is the possibility of administering it to patients at more than 4.5 hours after stroke onset. Under the new protocol, CS will be activated for all patients with acute stroke who have not reached 8 hours of progression time.¹ The principal limitation of this novel treatment is its therapeutic window, as is also true of systemic intravenous thrombolysis. Another crucial determinant, however, is the need for a vascular operating theatre. Availability of this urgent care specialty unit is limited to just a few hospitals, making it necessary to reorganise hospital care in the Region of Madrid so as to be able to offer vascular treatments to the entire population. If the procedure were not available in one centre, the patient would then need to be transferred to another hospital. Our records from an emergency care department in the Region of Madrid show that 739 patients with acute stroke, and for whom CS was activated, were attended between January and October 2013. Of that number, 198 (26.8%) were transferred between hospitals. The median treatment delay in transferred patients was approximately 40 minutes (IQR 27-48). On the other hand, prior experience with implementing CS in hospital and non-hospital emergency services has also led to situations in which this new protocol has not improved results due to several factors. One of these is the transfer time to the reference hospital performing the definitive treatment.²

For the above reasons, making the effort to define potential candidates for endovascular treatment, at the beginning of the care process and with a full understanding of the part played by non-hospital emergency services, is a crucial undertaking. In light of the explanations given here, and since smooth coordination is not guaranteed between care levels, individual care providers, and institutions,^3,4 we must also raise awareness in society and among professionals working as first responders while improving coordination between different care levels.^5,6 These steps are aimed at preventing subsequent transfers to on-call reference hospitals, since eliminating unnecessary transfers will reduce time to definitive treatment and therefore prevent the exclusion of patients who might otherwise have been evaluated within the treatment window.

Conflicts of interest

None.