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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., PHSA Assistant Professor, Department of Emergency Medicine, St. Paul’s Hospital
Quality Forum 2013 March 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.
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LS1 Vancouver
LS2 Victoria
LS3 Virtual/
Prince George LS4
Kelowna Closing
Celebration Surrey
Faculty meeting
Pre-work
Call to action
Develop mission
Information calls
Tuesday June 19
2012
Mon/Tues April 16 & 17
2012
Friday Feb. 3 2012
Mon/Tues Nov. 14 & 15
2011
Mon/Tues Sep. 19 & 20
2011
May 19 2011
P
D
S
A
P
D
S
A
P
D
S
A
P
D
S
A Develop
framework & changes
Planning group
May 2 2011
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 clinics Ensure 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
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Results – Participation
Results – Participation
Results – Participation
Improvement Progress: Self-Assessment Scores
1.0 Forming the team 1.5 Planning for the project has begun 2.0 Activity but no changes 2.5 Changes but no improvements 3.0 Modest improvements 3.5 Improvement 4.0 Significant improvement 4.5 Sustainable improvement 5.0 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
0%10%20%30%40%50%60%70%80%90%
100%
1-10 11-2021-3031-4041-5051-6061-7071-80Mob
ilize
d w
ithin
24
hour
s of
adm
issi
on
Mobilized within 24 hrs
Mobilizedwithin 24hrsGoal
Collaborative Measures
0%20%40%60%80%
100%Glucose checked at bedside
GlucoseCheckedGoal
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.
