E4 Devin Harris - Improving Stroke and TIA Care in the Emergency Department in B.C.: The Stroke /...

www.clinicalcaremanagement.ca

Improving Stroke and TIA Care in the Emergency Department in B.C.:

The Stroke / TIA Collaborative

Dr. Devin Harris, Clinical Lead, Stroke and TIA Initiative, BCPSQC and Medical Advisor, Stroke Services B.C., PHSAAssistant Professor, Department of Emergency Medicine, St. Paul’s Hospital

Quality Forum 2013March 1

Vancouver, B.C.

Disclosure

Funding: BCPSQC; PHSA; SPH Emergency; UBC Department of Emergency Medicine

Advisory: Boehringer Ingelheim

ESD Stroke Rehabilitation Inc.

The Problem.

Why do we care? The 4 D’s of stroke.

#1 cause of adult disability

#2 cause of dementia

#3 cause of death

Significant cause of debt

Fate worse than death

Best practices exist for stroke care.

We don’t always provide best care for stroke patients.

The Stroke Continuum

http://www.strokebestpractices.ca/

The Solution.

10

LS1Vancouver

LS2Victoria

LS3Virtual/

Prince GeorgeLS4

Kelowna

ClosingCelebration

Surrey

Faculty meeting

Pre-work

Call to action

Develop mission

Information calls

TuesdayJune 19

2012

Mon/TuesApril 16 & 17

2012

FridayFeb. 3 2012

Mon/TuesNov. 14 & 15

2011

Mon/TuesSep. 19 & 20

2011

May 19 2011

P

D

S

A

P

D

S

A

P

D

S

A

P

D

S

ADevelop

framework & changes

Planning group

May 22011

Pre-work webinars

• Learning Sessions are Face-to Face (except LS3)

• Action Periods (PDSA cycles are trialed)• Bi-weekly webinars held

via WebEx

Our Faculty

•Dr. Todd Collier•Stroke Neurologist (IHA)

•Chris Considine •Stroke Survivor

•Dr. Valorie Cunningham•ED Physician (VIHA)

•Kevin Harrison•Stroke Coordinator (FHA)

•Dr. Kennely Ho•Stroke Neurologist (FHA)

•Melanie Montague•Stroke Rapid Assessment Unit (VIHA)

•Dr. Andrew Penn•Stroke Neurologist (VIHA)

•Sherry Stackhouse•Leader, Accreditation & Patient/Client Satisfaction Coastal HSDA (VCH)

•Dr. Philip Teal•Stroke Neurologist (VCH)

•Brent Woodley•Clinical Nurse Educator (FHA)

11

Reduce stroke

mortality and

morbidity

Increase tPA Utilization

Increase adherence to stroke best practices in the ED

Appropriate pre-hospital care

Increase Physician uptake of tPA

Appropriate triage

AIMS PRIMARY DRIVERS SECONDARY DRIVERS

Appropriate Transitions

Decrease TIA Conversion to Stroke

Shorten door to needle times

Prevention of aspiration pneumonia

Proper and timely neurovascular imaging

Proper acute blood pressure management

Ensure no glucose abnormalities

Prevention of urinary tract infections

Prevention of deep vein thrombosis

Appropriate triage assessment of TIA

Appropriate physician evaluation and risk stratification of TIA

Appropriate referral to secondary prevention

Commencement of treatment in ED

Affective transition with in-patient units

Ensure proper and timely admission

Ensure follow up at secondary prevention clinicsEnsure patients and caregivers have knowledge of their care

Improve communication to primary care providers

Prevention of dehydration and improve nutrition

Face-to-Face Learning Sessions

Learning Session 1 (Richmond) Learning Session 2 (Victoria)

14

Bi-Weekly Webinars

15

The Results

Results

1. Participation

2. Improvement Progress

3. Outcome Indicators

1. Collaborative Measures

Who participated?

• 17 teams representing 29 sites

• Interdisciplinary teams• 17% physicians• 27% Managers• 19% Nurses• 17% Nurse Educators

18

Results – Participation

Results – Participation

Results – Participation

Improvement Progress: Self-Assessment Scores

1.0 Forming the team1.5 Planning for the project has begun2.0 Activity but no changes2.5 Changes but no improvements3.0 Modest improvements3.5 Improvement4.0 Significant improvement4.5 Sustainable improvement5.0 Outstanding sustainable improvement

Outcome – Death

Outcome – tPA Rates

Collaborative Measures

• True ‘improvement’ measures

• Process measures, collected at point of care by clinical teams, to measure improvement

• 11 choices (all best practices); teams can choose what to measure based on focus

Collaborative Measures

25% drop in time (30 minutes); less variability

Collaborative Measures

Collaborative Measures

Collaborative Measures

Other Significant Outcomes

• Collaborative teams made significant changes, that will influence patient care.

• Examples:– Fraser Health - Royal Inland– Shuswap Lake - St. Paul’s– East Kootenay - Mills Memorial– Campbell River - Victoria

Other Outcomes and Achievements

1. Online resources: www.bcpsqc.ca/quality/stroke.html

- All presentations, webinars, videos are recorded.

2. Instructional videos:Triage: http://www.youtube.com/watch?v=GB2U8baZUCE

Swallowing Screen: http://www.youtube.com/watch?v=HWppunNlhJU

Other Outcomes and Achievements

3. Communications:- Health Authority news releases (Health Quality

Network Communications)- Local newspaper coverage- Provincial news release (PHSA)- Canadian Stroke Congress presentation (Oct.

2012)- International Stroke Conference (Feb 2013)- Ethics approval and academic publications

Other Outcomes and Achievements

4. Cross-site Learning:– Teams presented to each other; shared

resources; shared solutions– Calgary / Saskatchewan now engaged with

next collaborative– National recognition

Other Outcomes and Achievements

5. Momentum:- June 19 provincial leadership meeting- Health Authority momentum- Ministry of Health urgency and profile

What did we learn?

Large-scale change takes action at multiple levels.

Understanding culture and context is the key to success.

Stroke care needs to be improved; B.C. is proving to be a leader in stroke quality

improvement.

There are a lot of fantastic health care providers in B.C.

Acknowledgements

• Noreen Kamal, Quality Lead

• BC PSQC: Christina Krause, Marlies van Dijk , Jill Veenendaal, Ajay Puri, Julian Marsden, Kerianne Poulson, Rebecca Brooke, Doug Cochrane.

• Stroke Services BC: Pam Aikman, Justin LoChang.

• James Watson, MoH CCM Leadership, CCM Steering Committee.

• Collaborative Faculty and Participants.

• HA Stroke Leads.

• HA Leadership and Executive Sponsors.

• HA Decision Support.

• Heart and Stroke Foundation of B.C. and Yukon.

• Specialist Services Committee.

• Canadian Stroke Network.

http://www.youtube.com/watch?v=TUFAaqKwtVo&feature=plcp

Thank you.

devinh@shaw.ca