The first Angels Region in Portugal was built out of many disparate pieces – a major hospital that had temporarily lost its award status after becoming a comprehensive centre, a smaller hospital that had lost its stroke unit, and a fractured EMS service partly staffed wth firefighters and volunteers. Angels consultant Inês Carvalho took a tactical approach to turn the glorious Algarve into a safe region for stroke – but the result, she says, is due to people who were willing to lead and who responded to opportunity with courage.
Algarve Central Hospital in the regional capital Faro has been an Angels success story since at least 2019 when it became the third hospital in Portugal to meet the criteria for an ESO Angels Award. Consultancy at this hospital had begun in 2016, immediately after Angels was launched in Europe. Supported by then consultant Claudia Queiroga, the hospital implemented the key priority actions in their stroke pathway and in 2020 won their first diamond award.
In 2022 the hospital sought ESO certification as a route to becoming a comprehensive centre. A mechanical thrombectomy service was introduced in 2023, but in Q2 of 2024 the hospital came up empty-handed when the new service failed to meet awards criteria. A multidisciplinary meeting analysed the data and set new targets for door-to-groin times. By Q3, Faro was back in contention and in the journey to Angels Region status, an important box had been ticked.
Under the leadership of Dr Ana Paula Fidalgo, who is now the hospital’s clinical director, and Dr Ana Varela who has succeeded her as stroke coordinator, this hospital has long been a bright spot in the Portuguese stroke community. Dr Fidalgo is also a strong ally of FAST Heroes whose example has encouraged other doctors and nurses to get involved in the schools-based stoke awareness campaign. As a result, the FAST Heroes implementation targets for Angels Region status were easily met, with almost 900 children educated about stroke in 2024.
Inês notes that in areas where the campaign has already been implemented, the average symptom-to-door time for stroke patients is 165 minutes, compared with the national average of 208 minutes. It’s not an exact science yet, but a hunch will tell you that a correlation between public awareness and stroke patients arriving in the emergency room sooner, is no coincidence.
Inês opened her Angels Regions strategy with a formal invitation to stakeholders that explained what was a stake. After setting out the goals, she wrote, “This challenge will not only enhance the quality of stroke care in our region but also set a benchmark for others to follow.” It was a call to action that was impossible to refuse.
The invitation was important for several reasons, Inês says. “It had to feel meaningful and clarify strategy. It also had to make clear that this was a special project and that the time spent on it was justified.”
Her abilities as a tactician would face its toughest test when it came to the EMS service which in this region is composed of many small units not all of whom were enthusiastic about working together. This made it difficult to standardize care, Inês says, and mandatory training was out of the question. Low awareness among some of the technicians, firefighters and volunteers who staffed the ambulances meant strokes were missed; not everyone was familiar with the Cincinnati scale, and not everyone was keen to adopt the iTeams system of digital reporting to replace the unreliable paper system.
Workshops and simulations were held in Faro and Portimão, where participants were also able to raise concerns in small groups. Some of these concerns were related to hierarchy, making it difficult, for example, for firefighters to be heard regarding issues with hospitals, Inês explains. As for the outcome, “success story” doesn’t begin to describe it. The EMS service in Algarve now holds two diamond awards and during an important stroke conference in February, doctors in the audience spontaneously gave a standing ovation to the firefighters collecting their award. It was a gesture of deep significance and an indicator of how the Angels Regions approach of working towards a common goal can impact communities.
There’s a success story unfolding, too, in the port city of Portimão, where last year a hospital that had no stroke unit until 2023, won two diamond awards. It’s another case of courage meeting opportunity in the person of Dr Isabel Taveira, whom Inês describes as a “very tenacious, very motivated” young doctor who in her drive for stroke care excellence at her hospital puts in extra effort and hours. Being tenacious and motivated had served Dr Taveira well in her campaign to have a stroke unit established at her hospital, but by early 2023 she was close to giving up. Inês realized that recognition of Dr Taveira’s efforts by the wider stroke community could give her a bigger platform in her own hospital, and nominated her for an ESO Spirit of Excellence Award. Being honoured at ESOC 2023 in Munich, alongside stroke heroes such as Prof Aleš Tomek of the Czech Republic and Prof Giorgios Tsivgoulis of Greece, led to the breakthrough Portimão had been waiting for.
Yes, she is a strategist, Inês confirms. “I try to make a map of influencers and the good relationships they have. Understanding who the key people are and the influence they have, can help you reach others who may be reluctant to work with Angels.”
It is just as important to give recognition to people, she says, recalling the goosebumps moment at the stroke conference. “If you do this, people are more open to change.”
And nothing is quite as important as showing up. “I don’t email, I call,” Inês says. She also spends more time at hospitals than she can strictly afford to, but not a minute of it is wasted. “It is very important to be seen,” she says, “to be there in person.”
Ensuring the Algarve maintains its Angels Region status is now in the hands of a regional steering committee whose members have each been given a folder with relevant materials and responsibility for a specific area such as quality monitoring, awareness and so on. It is here that Inês played a strategic masterstroke by involving the stroke patients society in the committee. No one understands the importance of integrated stroke care more viscerally than someone who has survived a stroke, giving them a unique role in the regional body.
As Inês says, “They may not know medicine, but they know their rights.”
