In one of the most famous stories ever told, a noble Spaniard besotted with tales of chivalric romance styles himself as a knight-errant intent on reviving the past glories of chivalry. In one memorable adventure he mistakes a row of windmills for giants and spurs his horse into an encounter that leaves him defeated, his lance shattered, and his pride wounded.
The windmills that inspired this iconic scene in Don Quixote are iconic of Castilla-La Mancha which is the setting for both that story and this one. In both instances these are stories about the belief in a better world and the pursuit of larger-than-life goals.
Castilla-La Mancha is the third largest of Spain’s 17 autonomous communities. It is located in the middle of the Iberian peninsula and made up of five provinces, Albacete, Ciudad Real, Cuenca, Guadalajara and Toledo. Its 2,2 million population is sparsely and unevenly dispersed across its vast surface area, with many living in small, rural and aging communities. This coincidence of demographics and distribution is of concern to Angels consultant Araceli García who was herself born in one of the small villages of Ciudad Real and who has made it her goal to turn the entire Castilla-La Mancha into an Angels Region. For this population, many of whom live a long distance from the nearest hospital, being educated about stroke can literally mean a matter of life and death.
When Araceli first began working in the region less than a year ago, she found reasons for optimism. With two hubs and five spokes, including two with brand-new stroke units, La Mancha didn’t need more stroke centres. And she was struck by how professional the staff at these hospitals were, and by their commitment to doing the best for stroke patients.
Still, for Castilla-La Mancha to become an Angels Region, some issues needed to be addressed.
Communication was poor between nurses and neurologists from different hospitals, and between hospitals and EMS. The FAST Heroes awareness campaign had yet to be implemented in schools, and hospitals and EMS would have to start capturing their stroke patient data in a stroke registry in order to become eligible for ESO and EMS Angels Awards.
Far from tilting at windmills like her fictional compatriot, Araceli went about her task in a doggedly systematic way. To mobilize FAST Heroes implementation, she teamed up with the regional stroke coordinator, Dr Oscar Ayo, and a group of enthusiastic nurses from Ciudad Real Hospital led by Laura Barrios. Among the strategies they employed to get the FAST project into schools, they delivered the campaign directly in their children’s classrooms; sent letters to schools about the importance of awareness-raising; organized meetings with teachers and got provincial education decision-makers to support the roll-out to all classrooms.
Araceli was impressed with the performance times of the EMS service despite the long distances between hubs and spokes. Their stroke protocol included use of a stroke scale capable of detecting large vessel occlusion, and although knowledge of the scale was poor it wasn’t anything training couldn’t fix. By the end of the first quarter of 2024, the emergency service of Castilla-La Mancha collected their first gold EMS Angels Award.
Working with seven hospitals presented a bigger challenge, but Araceli had two aces up her sleeve. One was to establish a regional Stroke Nurses Committee, a tactic that is often the key to creating a community of hospitals. Through this committee she seeded the ideas of standardization, quality monitoring, stroke care improvement and stroke awareness. This coalition of stroke nurses became a forum for knowledge and experience-sharing, and the cross pollination of ideas, such as a nurse-run “school” for families affected by stroke. It brought the goal of standardizing and improving care throughout the community within reach.
With more experienced nurses stepping up to help their colleagues at the two new stroke units implement stroke unit care, Araceli was able to work on her next masterstroke. A regional Angels Day would consolidate all her efforts in the region – improve communication, bring multi-disciplinary teams together at the same event, provide training by local experts, and celebrate progress.
Presenters were drawn from across the region for a packed programme that included parallel workshops on key priority actions and stroke unit care, and a joint EMS-hospital simulation. Araceli says, “With this activity the whole chain worked together, so it was clear to see how important each link was, as well as not wasting time in any of the steps. The idea was built that each service was important but working together was more important.”
The day was also a celebration as they were able to recognize the good work of three hospitals that had won ESO Angels Awards. Two hospitals – Hospital Universitario de Guadalajara and Complejo Hospitalario Universitario de Albecete – had lead the way by winning gold ESO Angels Awards in quarter one of 2024. Albecete went on to win diamond status in quarter two as did Hospital General Universitario de Ciudad Real following an intervention to improve their dysphagia screening rate from a paltry 6,8 percent to 100 percent.
Gold awards for four more hospitals and reaching targets in FAST Hero implementation are now all that stand in the way of Castilla-La Mancha becoming an Angels Region – a goal Araceli hopes to reach in 2025.
It’s a bright outlook for a community located at the crossroads of history and fiction. While the local winds turn the sails that to Don Quixote appeared like the arms of giants (“some of them almost two leagues long”), across La Mancha, Angels are putting wind in the sails of change.
