Brazil: Majority of hospitals unfit to handle stroke victims

A survey conducted by the Federal Board of Medicine (CFM) with neurologists and neurosurgeons from all over Brazil found that 76% of the public hospitals where they work do not meet the required conditions to handle stroke cases. Only 3% of the facilities were rated by doctors as “very adequate” and 21% as “adequate”.

The survey, which was released this week, heard 501 doctors working at urgent and emergency care in public health centers in Brazil. They were asked about the conditions in which stroke patients are handled, considering the following aspects: quick access to diagnostic imaging (within up to 15 minutes), availability of beds and specific drugs, instant triaging of patients with stroke symptoms, adequacy of staff size and technical qualification of specialized medical staff and high-quality facilities, among other items based on national and international stroke care standards.

A majority of doctors heard in the survey feel that public health centers are not always ready to adequately handle patients with stroke symptoms.

“The reason we decided to hear their perceptions is that stroke is the second most common cause of death in Brazil, an epidemiological fact. It's also the chief cause of disability in the world and in Brazil, leading to a large number of hospitalizations,” said Hideraldo Cabeça, the neurologist leading the survey. He also coordinates the Neurology and Neurosurvery Expert Committee of the CFM.

Facilities

According to the survey, the facilities for providing care to stroke patients are inadequate in 37% of services, and somewhat inadequate in 39%, which means 76% of services do not fully meet stroke care protocols established by the Ministry of Health.

Essential items more than half of the health centers lack include CT scans within 15 minutes and access to thrombolytic drug therapy (also known as clot busters) used for dissolving blood clots in the brain's veins.

“The fact that thrombolytic therapy is not being istered at all health services is a very serious concern. A patient may or may not receive care close to recommended standards depending on which hospital they check into. And even where thrombolytic therapy is available, are the facilities adequate to ister it? Is it going to be istered to a patient lying on the stretcher or more carefully on a proper bed?” Cabeça asks.

The survey went on to point out that 66.4% of health centers lack adequate emergency medical services (SAMU in the Brazilian acronym). And in 87.9% of hospitals, the number of beds fell short of the influx of stroke patients.

“The shortest it takes to provide care, the better the chances of mitigating the sequelae. Handling patients fast can give them greater benefits and better chances of recovery and a return to a normal life,” the neurologist said.

Training

Staff size was also considered inadequate (28%) or somewhat inadequate (44%) in 72% of the hospitals the expert respondents work at. Insufficiency of medical teams to handle patients was reported for 69.6% of the health centers, and at almost 50%, the medical and multidisciplinary teams were not being trained.

“It is critical that neurologists be trained to handle stroke. There are 6 to 8 specialization programs focusing on stroke in Brazil, but this is too little to meet the challenge posed by the disease. Moreover, stroke research is underfunded. We need to test the drugs available in the country, which often differ from those used abroad. And we need more research that's sensitive to Brazil's reality,” says Octávio Marques Pontes Neto, chair of the Brazilian Cerebrovascular Disease Society (SBDCV).

Role model

Among the few services rated as “very adequate” by respondents in the CFM survey was the Hospital das Clínicas (HC), a hospital in Ribeirão Preto, São Paulo state, which is linked to the University of São Paulo's medical school. Professional training and priority status for stroke patients are among the reasons the region served by the hospital has lower death rates from the disease.

“The World Health Organization recommends that [stroke] patient management should take no more than 60 minutes between hospital ission and the start of the thrombolytic therapy. We have successfully lowered this time to 29 minutes at the Hospital das Clínicas. Here we face the same challenges as any other public hospital, like hallway beds and all, but we have organized our care services and trained all our staff,” said Marques, who is also a professor and head of the Vascular Neurology Department at the HC.

The city also has an urgent care network and well-structured medical regulations since 2000, which speeds up care delivery. “A stroke patient mustn't be driven to hospital, they should be advised to call an ambulance, because emergency medical services already know which local hospitals can handle stroke and are able to notify the hospital in advance,” Marques explained.

The hospital also stands out in of thrombolytic therapy rates. Whereas in Brazil it is estimated that between 1.5% and 2% of patients with stroke are istered clot busters, in the region served by Hospital das Clínicas Ribeirão Preto, around 6% to 8% of patients have access to the therapy.

Sharing the findings

The Federal Board of Medicine is going to share the survey findings with regional boards, which will make the data available to state and local health departments. The aim is to raise awareness of local management to improve the existing services in order to reduce the epidemic number of deaths and people with disabilities.

Also known as crebrovascular accident or thrombosis, stroke is one of the most lethal diseases in Brazil, second only to cardiovascular diseases. The latest available data show over 99,000 people died from a stroke in the country in 2014. According to neurologists, between 80 and 90% of hospitalizations, and even deaths, caused by a stroke could be avoided if care services improve and patients adhere to healthy habits.

Translated by Mayra Borges