In 2013 stroke was chosen by the MoHLTC as a quality based procedure using an evidence and quality based selection framework that identified opportunities for process improvements, clinical redesign, improved patient outcomes, enhanced patient experience and potential cost savings. Health Quality Ontario (HQO) and the MoHLTC released the “Quality-Based Procedures: Clinical Handbook for Stroke” outlining the key best practices for acute stroke care and inpatient stroke rehabilitation. HQO convened a second Expert Advisory Panel on Post-Acute, Community-Based Care for Stroke Patients in November 2013 to extend its initial Episode of Care work to the community setting. The focus of this phase of disease-specific QBPs is on the post-acute, community-based patient care including the community treatment and cross continuum secondary prevention processes. Southwestern Ontario Stroke Network (SWOSN) staff participated on both Expert Panels.

As many of you are aware, in September 2012 the Ontario Stroke Network released the report “The Impact of Moving to Stroke Rehabilitation Best Practices in Ontario,” the purpose of which was to estimate the potential economic impact of adopting stroke rehabilitation best practice recommendations in Ontario.

In 2013-2014 two more significant reports related to the “economics” of our work were released: “Regional Economic Overview - Erie St. Clair LHIN” and “Regional Economic Overview - South West LHIN”. The two LHIN- specific economic reports were designed to replicate portions of the provincial economic evaluation noted

above, from the perspective of the Erie St. Clair and South West LHINS. The Reports were not designed as a comprehensive economic evaluation, but rather to present contextual information in a way that will guide regional discussion about local stroke care. These Reports have helped us assess our stroke system, identify areas where improvements are possible and inform our discussions with local health care providers regarding system reform.

Evidence indicates that stroke survivors have the best outcomes if they are cared for in a system that is organized and coordinated across the continuum of care. Specifically, stroke survivors require timely access to thrombolysis, treatment on an acute

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Introduction

Steering Committee Vice Chair, Sharon Jankowski, Regional Program Director, Paula Gilmore and

Steering Committee Chair, Patricia (Trish) Dwyer.

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

stroke unit, specialized stroke rehabilitation either in hospital and/or in the community and treatment by health care professionals with expertise in stroke care. To optimize outcomes and efficiencies, hospital stroke volumes should be at least 165 ischemic stroke patients per year per organization. In 2013 we presented these key messages to both the South West and Erie St. Clair LHINs who have responded in the following ways:

• The South West LHIN Hospital and CCAC CEO Leadership Forum approved stroke as a priority across the LHIN in September 2013. The South West LHIN asked the SWOSN to lead the SW LHIN Stroke Capacity Assessment and Best Practice Implementation Project over the next year. This exciting and transformational project will examine stroke care services across the 28 hospitals that currently provide stroke care in the South West LHIN and make recommendations on the type and level of services required to meet the needs of the stroke population aligning with QBP and stroke best practices.

• The Erie St. Clair LHIN is also providing leadership in the implementation of stroke QBP with the assistance of SWOSN and the District Stroke Centre Coordinators. The Erie St. Clair LHIN aligned itself with these best practices in 2013 by conducting a systematic review and gap analysis at a system level as well as facilitating the governance of stroke care in the region through the Erie St. Clair LHIN Quality Council. As well, the SWOSN and other partner organizations have developed a stroke business case focusing on early supported discharge teams.

2013-14 was an exciting year for stroke care in the region and there are many opportunities on the horizon for us to work together to help transform stroke care across the region. The answers are within the health care professionals that work with stroke survivors as well as stroke survivors and their families. We look forward to continued collaboration as we get closer to our vision of “Fewer Strokes, Better Outcomes.”

Paula Gilmore Regional Program Director

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Overall

• The Ontario Stroke Network and the Institute for Clinical Evaluative Sciences released the report, “Ontario Stroke Evaluation Report 2013: Spotlight on Secondary Stroke Prevention and Care” in June, 2013.

• Paula Gilmore co-chaired the Canadian Best Practice Recommendations for Stroke Care Transitions Working Group that updated and released the revised Chapter 6: Managing Stroke Transitions of Care.

• Paula Gilmore (SWOSN), David Ure (CSRT) and Karen Sutherland (CSRT) are participating on the Health Quality Ontario’s Episodes of Care Expert Panel for Post-Acute Community Based Care for Stroke.

• Gina Tomaszewski participated on Registered Nurses Association of Ontario Expert Panel for the development of the Care Transitions Best Practice Guideline. The guideline was published in spring of 2014.

Acute

• Southwestern Ontario Stroke Network Acute Care Advisory Committee was launched in June. The mandate of the committee is to advise the Southwestern Ontario Stroke Network regarding development, coordination, implementation and evaluation of regional stroke acute best practice initiatives and activities.

• An Ontario Stroke Network Working Group lead by Gina Tomaszewski convened to develop an online resource intended to assist health care providers with taking action, recognizing the importance of screening for cognitive impairment

in patients with stroke and those who are at risk for stroke. The resource was presented at the Heart and Stroke Foundation Stroke Collaborative in Toronto in October.

• Under Linda Dykes’ (Sarnia-Lambton District Stroke Centre) leadership, Bluewater Health in Sarnia received approval to become a Telestroke Site in the Fall 2013. The Southwestern Ontario Stroke Network is supporting the education sessions for physicians and staff in preparation for the hospital to go live.

• Gina Tomaszewski provided a provincial videoconference presentation on the newly released 2013 Hyperacute Canadian Best Practice Recommendations which aired on Sept 12, 2013. The videoconference was well attended by stroke stakeholders from across the province.

Rehabilitation

• A business case for an Early Supported Discharge Team for Stroke was submitted to the ESC LHIN in early March. If approved, it will begin to address the need for access to rehabilitation in the community.

• Ontario Stroke Network funded research project “The impact of the South West LHIN’s Community Stroke Rehabilitation Teams: An Economic Analysis” was successfully completed and is available online. Findings were presented at the Heart and Stroke Foundation Stroke Collaborative in Toronto in October.

• Analysis of the data from the Community Stroke Rehabilitation Teams has resulted in three

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

2013-2014 Accomplishments

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

• separate project abstracts. “A Comparison of Rural versus Urban Stroke Survivors Treated with a Home-based, Specialized Stroke Rehabilitation Program”; “Evaluating the Effectiveness of Southwestern Ontario’s Community Stroke Rehabilitation Teams”; and “Caregiver Outcomes in a Community-Based Stroke Rehabilitation Setting: Results and Tool Selection”. All abstracts were presented at the Canadian Stroke Congress in Montreal in October.

• Deb Willems presented a poster entitled “Provision of Greater Intensity Therapy in Inpatient Rehabilitation: Three Hours of Therapy per Day” at the Heart and Stroke Foundation Stroke Collaborative in Toronto in October.

• Deb Willems chaired a Provincial Integrated Task Team Working Group to identify and create provincial resources for Stroke Rehabilitation Best Practice Implementation; housed on the Ontario Stroke Network website. The success stories inventory was featured in a presentation by the Ontario Stroke Network at the Ontario Hospitals Association Conference on Rehab/CCC in December. Eight new backgrounders have been created: AlphaFIM, AlphaFIM Special Project 740, Stroke Unit Care, Timely Access to Stroke Rehabilitation, Rehabilitation Intensity, Optimizing the Therapeutic Environment, Access to Inpatient Rehabilitation for Severe Stroke and Community Rehabilitation.

• Abstract entitled “Projecting the Impact of the Community Stroke Rehabilitation Teams: A Cost-Effectiveness Analysis” (authors: Laura Allen, Marina Richardson, Matthew Meyer, David Ure, Deborah Willems, Robert Teasell) was accepted for presentation at the World Congress for NeuroRehabilitation Conference in Istanbul in April 2014.

• Funding approval received from the Heart & Stroke Foundation’s Canadian Partnership for Stroke Recovery for a research project on Tele-Rehabilitation for Stroke involving the South West LHIN Community Stroke Rehabilitation Teams. The research team includes Dr. Robert Teasell, Deb Willems, Southwestern Ontario Stroke Network; JB Orange Western University; Greg Zaric, Western University; David Ure St. Joseph’s Health Care. The project title is STRIVE-HOME: Stroke Rehabilitation

Involving a Videoconferencing Element at Home: The impact and cost-effectiveness of home-based videoconferencing technology for speech language pathology rehabilitation after stroke.

• The SW LHIN Community Stroke Rehabilitation Teams are featured in Accreditation Canada’s Leading Practices Database at http://www.accreditation.ca/community-stroke-rehabilitation-team-csrt.

Community and Long Term Care

• Paula Gilmore and Mary Solomon delivered an oral presentation at the Canadian Physiotherapy Association’s 2013 Annual Congress, held in Montreal, Quebec, May 23- 26, 2013. Title of presentation was “Facilitating Return to Work after Stroke: Creation of a Web- based Toolkit.”

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Paula Gilmore and Gina Tomaszewski at the Community Re-engagement Workshop

in Owen Sound.

• The Southwestern Ontario Stroke Network sponsored a two-day workshop, Collaborative Interprofessional Stroke Care in Community Re-engagement Workshop, for health care providers in Grey-Bruce (Owen Sound). Gina Tomaszewski and Paula Gilmore also facilitated the workshop in Elgin County in December; approximately 25 health care providers from across the continuum of care engaged with learning tools to improve community re-engagement for stroke survivors.

• Tips and Tools to assist with Restorative Care Post Stroke Workshop was completed in Owen Sound in November for staff working in Long Term Care in Grey Bruce Counties. The Workshop incorporates interprofessional collaboration and HSF Tips and Tools resources as well as highlighting the OSN’s LTC Stroke Care Plans.

• The Southwest Healthline (www.southwesthealthline.ca) has launched a “Stroke Resources Micro-site” on its website. This micro-site will help guide the stroke survivor or caregiver to specific services or community resources through choosing from a narrowing set of options. An automated template of the micro-site is being developed and will be marketed to all the heathlines throughout the province. The Stroke Resources Micro-site was a joint project of the Healthline.ca, the Toronto Stroke Network, the Central East Stroke Network, and the Southwestern Ontario Stroke Network. It is based upon the Community Re-Engagement Model, developed in Toronto, and the Huron-Perth Healthline Stroke Minisite Pilot Project developed by the Southwestern Ontario Stroke Network and Huron-Perth District Stroke Centre in Stratford.

Education

• Jennifer Beal lead the completion of the 2013-14 Regional Stroke Education Plan.

• SWOSN hosted Provincial Stroke Rounds in September. Dr. Teasell (St. Joseph’s Health Centre, Parkwood Hospital) presented on the Evidence for Long Term Rehabilitation Management of Stroke.

Prevention

• Paula Gilmore participated as a member of the SW LHINs Chronic Disease Management Network. Network was disbanded by the SW LHIN in Fall 2013.

• In February of 2013, the Regional Prevention and Thames Valley presented the 2012 Canadian Best Practice Recommendations for Stroke Care: Stroke Prevention as part of the Ontario Stroke Network’s Canadian Stroke Best Practice Videoconference Series. The videoconference was viewed by a large audience with representation from within Ontario as well as from other provinces and territories. Feedback on the presentation was very positive.

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

The Southwestern Ontario Stroke Network introduced a number of new members in 2013-14 and said some goodbyes as well.

After completing her term as chair to the Southwestern Ontario Stroke Network Steering Committee, Ferne Woolcott passed the torch to Patricia (Trish) Dwyer. The Committee then welcomed Sharon Jankowski as Vice Chair. Sharon recently retired as Director of Rehabilitation Services from St. Joseph’s Health Care Centre (Parkwood Hospital) and her knowledge and expertise will be invaluable to the Network. In April 2013, we welcomed Elissa Najm to the role of administrative assistant, Jennifer Beal accepted the permanent role of Regional Stroke Education Coordinator, and Margo Collver became our new Regional Stroke Community and Long Term Care Coordinator.

Later in the year, we said farewell to Andrea Drummond, Windsor-Essex District Stroke Centre Coordinator since 2003. Andrea has since accepted the role of Director of Rehabilitation Services at Hotel-Dieu Grace Healthcare in Windsor. Congratulations Andrea! We know you will continue to work with us as we move stroke rehabilitation best practices forward. We welcomed Denise St. Louis into the interim role of Windsor-Essex District Stroke Centre Coordinator in October of last year.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Team Transitions

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Regional Team Back row (left to right) Elissa Najm, Paula Gilmore, Margo Collver, Deb Willems,

Cathy Vandersluis; Front row: Lyndsey Butler, Gwen Stevenson, and Gina Tomaszewski

District Coordinators Back row (left to right): Linda Dykes, Joan Ruston-Berge, Linda Butler; Front row: Doris Noble, Gwen Stevenson, and Denise St. Louis.

On a Personal Note...

On April 30, 2014 Doris Noble retired after over 40 years in health care. She has been the Manager of the Huron Perth District Stroke Centre and member of our team since Stratford General Hospital was designated as a District Stroke Centre in 2003. Doris has made numerous contributions to the care of stroke survivors locally, regionally and provincially. She will be dearly missed and we wish her a very happy retirement and all the golf one can enjoy!

It’s a girl! Congratulations to our Regional Stroke Education Coordinator, Jennifer Beal, who gave birth to a baby girl, Dahlia, in January, 2014! We are pleased to introduce Lyndsey Butler in the role of interim Regional Stroke Education Coordinator while Jennifer is on maternity leave.

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

On April 30, the SWOSN Steering Commitee, Regional and District teams celebrated Doris’ retirement at an event at the Stoneridge Inn

Conference Centre in London.

Dahlia hugs her lamb.

Provincially, the Vascular Health Coalition has engaged the Local Health Integration Networks (LHINs) with respect to the Integrated Vascular Health Strategy (also known as the Integrated Vascular Blueprint) and sought their interest in creating LHIN-level Regional Vascular Health Collaboratives (RVHCs).

Four LHINs have expressed interest as “early adopters” in the development of RVHCs, in addition to Central East LHIN, an established early adopter. The Erie St. Clair LHIN is also involved in this early work through membership on a RVHC Development and Implementation Task Group. The South West LHIN has expressed interest in being a part of the next group of RVHC adopters.

The Ontario Stroke Evaluation Report 2013: Spotlight on Secondary Stroke Prevention was released in June 2013. Its release has prompted interest in collecting consistent regional secondary stroke prevention clinic data. Additionally, the Southwestern Ontario Stroke Network (SWOSN) is exploring opportunities to enhance screening for depression, sleep apnea, and cognition as part of secondary stroke prevention in a way that both aligns with best practice guidelines and serves the needs of the client. These will be incorporated into the Regional Work Plan for 2014-2015.

This past fall the SWOSN collaborated with the IVEY Business School at Western University in London, Ontario to develop a regional marketing campaign on the signs and symptoms of stroke and the importance of urgently calling 911. This campaign targets the

general population and its purpose is to improve public awareness and action. The final project included guidelines to implement several low cost marketing options, including strategies for creating effective posters, engaging in guerilla campaigns, and the effective use of volunteers. SWOSN has engaged communications consultants to create posters that align with the recommendations outlined by the IVEY students. The goal is to have the new posters ready for distribution for Stroke Month in June 2014.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Prevention Update

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

1 of 3 posters being distributed for Stroke Month. The posters engage individuals with relatable scenarios and

emphasize the urgency of calling 911.

She does everything for us. I called 911 for her.

Stroke is an Emergency.

Know the signs and call 911 immediately if you see or experience one or more of:

• Trouble with speech, or confusion • Sudden vision problems• Sudden, severe and unusual headache • Sudden weakness or numbness in the arms, legs or face• Unexplained dizziness or loss of balance

Hyperacute Stroke Unit The ‘’hyperacute” phase of stroke refers to care offered in the first 24 hours post stroke (ischemic and hemorrhagic), and the first 48 hours post TIA.

It involves rapid assessment of patients experiencing stroke symptoms with the goal of early intervention in an effort to decrease life-altering effects. Team members immediately come together from different departments to assess and expedite proper treatment, demonstrating how the health disciplines work together to achieve best practice care and optimal results for potential stroke patients.

On March 19, 2014, a Hyperacute Stroke Unit opened with two hyperacute beds plus an additional bed dedicated for tPA recipients. This Unit is housed at the University Hospital campus of London Health Sciences Centre. One bed is always available for incoming stroke patients through the Emergency Department (ED) or via an in-hospital “code stroke”. At UH, and unique to this hyperacute phase, is the

arrival of a tPA Nurse from the CNS unit from the Emergency Department. The tPA nurse will assist with the preparation and administration of tPA if warranted. Improving performance within the hyperacute phase has entailed determining where precious minutes can be saved by eliminating inefficiencies. Changes also include examination of, and changes to, the switchboard stroke call system to ensure prompt arrival of key players to the ED for an incoming stroke protocol. The tPA nurse, along with CT Tech, Labs, Neurologist and on-call Neurology Resident are all notified by Switchboard - giving

them the opportunity to ready themselves for an incoming stroke patient.

The Hyperacute Stroke Unit is a Level 2, monitored unit, and as such nurses have had training with: cardiac monitoring, tPA administration andpreparation, and management and nursing care of the stroke patient in the hyperacute phase. Training

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Acute Care Update

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Panoramic view of the Hyperacute Stroke Unit at University Hospital

of CNS nursing staff took place in CStar with the use of simulation using a Sim Man 3G mannequin. This allowed for the creation of a learning environment as close as possible to the real situation. Just prior to the launch of the new unit, a “mock” patient was also scheduled to provide teams (including the EMS, ED, Labs, Imaging, Neurology resident, Neurology consultant, and tPA nurse) an additional opportunity to clarify any steps, and improve the process. A mannequin from CStar was used for this mock scenario as well.

Dysphagia Screening training for nursing staff at University Hospital occurred throughout the 2013/14 year. The CNS interprofessional team implemented the Acute Stroke Dysphagia Screening tool which is an adaptation of the Barnes Jewish Hospital Dysphagia Screen. The tool is to be completed on all patients with a diagnosis of stroke upon admission. The screen can be repeated at 24 hrs for an assessment of change or if any change in the patient’s medical status is questioned.

Finally, the inaugural meeting of the SWO Regional Stroke Acute Care Advisory Committee took place on June 27, 2013 in London. This Committee, which has now met three times, will advise the Southwestern Ontario Regional Stroke Network (inclusive of Erie St. Clair and South West LHINs), regarding development,

coordination, implementation and evaluation of regional stroke acute best practice initiatives and activities. It will serve as a communication link between the Southwestern Ontario Regional Stroke Network and service providers/stakeholders regarding strategic directions and activities in acute stroke care. The committee meets 3 to 4 times per year via videoconference. For more information please contact Gina Tomaszewski.

Casaubon LK, Suddes M, on behalf of the Acute Stroke Care Writing Group. Chapter 3: Hyperacute Stroke Care. In Lindsay MP, Gubitz G, Bayley M, and Phillips S (Editors) on behalf of the Canadian Stroke Best Practices and Standards Advisory Committee. Canadian Best Practice Recommendations for Stroke Care: 2013; Ottawa, Ontario Canada: Canadian Stroke Network and Heart and Stroke Foundation of Canada.

Acute Stroke Unit Orientation Guide

The Southwestern Ontario Regional Acute Stroke Unit Orientation Guide will be made available to health care professionals across the region in June 2014. This tool was developed by experts in stroke care from the regional and district stroke centres. Composed of eleven modules, as well as supplemental resources, the Guide’s primary intention is to function as a standardized tool for nurses across the region interested in increasing their knowledge of best practice stroke care.

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

5.7.1 Dysphagiai. Interprofessional team members should be trained to complete initial swallowing screening for all stroke patients to ensure patients are screened in a timely manner [Evidence Level C].ii. Patients should be screened for swallowing deficits within the first 24 hours of admission using a valid screening tool [Evidence Level B]. Patients who are not initially alert should be closely monitored and screened when clinically appropriate [Evidence Level C].

Canadian Best Practice Recommendations 2013, Stroke Rehabilitation, p.158.

ACUTE STROKE UNIT ORIENTATION 2014

Stroke Network

* Adapted from Northeastern Ontario Stroke Network (2010).

“My Stroke Care Binder” is a resource that was developed for stroke patients and their families. The binder was developed with input from the University Hospital CNS Interprofessional Stroke team, as well as partners from Parkwood Hospital, St. Thomas Elgin General Hospital, Woodstock General Hospital, Strathroy Middlesex General Hospital, Southwest Community Care Access Centre and the Community Stroke Rehabilitation Team.

As many patients begin their journey at University Campus, the binder would be given to them there and then would accompany them as they travel across transition points along the continuum of stroke care whether they go to Parkwood or St. Thomas Elgin, or visit their family physician.

The binder contains information about stroke, their health care team, stroke medications, risk factors for stroke, and tests they may have while in hospital. The pilot is nearing completion, and feedback from both the families and the health care team indicates the resource is valuable. If you are interested in knowing more about the binder please contact Gina Tomaszewski at 519-685-8500 ext. 35268.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

My Stroke Care Binder

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

It is early April 2014. After a winter with unprecedented snowfall, the sun is poking through the clouds and farmers all across Southwestern Ontario can smell the earth. A few more weeks are required to thaw the frozen ground but they are already anxious to return to their fields.

The same is true even for those farmers who have “retired.” Farmers like Dave McCready who operated a dairy and cash crop farm. And who, not finished with agriculture completely, went on to work at the Huron Bay Cooperative, doing deliveries, working in the store and helping out in the warehouse.

For Dave, however, getting back to the business of farming is hindered by the complications of a stroke he experienced in late October, 2013.

Upon reflection, Dave believes he had experienced numerous small strokes over a period of five years. There were times when he was overcome with weakness, and although he had a family doctor, he never mentioned it. It seemed insignificant at the time.

Diana Williamson, District Stroke Educator for Grey Bruce Health Services, says this is fairly common. “There still needs to be more public awareness about the five warning signs of stroke and the necessity of calling 911,” she says. “There is a clot busting drug called tPA that can be given if a patient arrives at the Emergency Department within 3.5 hours of the onset of symptoms. If you recognize the signs and symptoms, call 911.”

“If we know that someone is having ‘small strokes’ or TIAs because they go to the Emergency Department, they can also be referred to the Secondary Stroke Prevention Clinics which will assess their risk factors and support patients in adopting stroke prevention strategies,” adds Williamson.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Spring Back in Step of Durham Stroke Survivor

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

The Recreation Therapist on Dave’s Community Stroke Rehabilitation Team knew he enjoyed time outdoors,

and took him snowshoeing as part of his therapy.

The week prior to his stroke, he had to sit down at work one afternoon as his legs were too weak to hold him. He went to the local hospital, but by the time he saw a physician the symptoms had resolved and he went back home. Two days after that he had another incident in which his wife, Marg, came into the kitchen one morning and found him clutching the counter, unable to stand. An initial CT scan didn’t show stroke but he was referred to a neurologist for follow up care. Before he could have that appointment, however, a third incident led to an MRI of the head and admission to the Intensive Care Unit at Grey Bruce Health Services in Owen Sound (Grey Bruce District Stroke Centre)under the care of Dr. B. Young.

Dave’s condition fluctuated quite a bit in hospital and his health care team spoke to his family about the possibility of further strokes. He couldn’t move his arms or legs. Dave’s wife told him he looked at her like he didn’t know who she was. He remembers almost nothing about that first week.

By week two, Dave had made progress and was moved to the medicine unit, where stroke patients have been clustered together to receive care from an expert interprofessional team. This was followed by five weeks on an inpatient rehabilitation unit. The entire hospitalization was marked by daily visits from his wife and multiple visits from his six children ages 24 – 44.

“It never really occurred to me that I wouldn’t recover,” he recalls. “The one thing I did learn from having the strokes - it made me realize how blessed I am with my family and my wife.”

Dave’s recovery was enhanced by the care he received in a District Stroke Centre, located 40 minutes from his home. “It’s an awesome facility with so many stroke experts - physiotherapy, occupational therapy, speech therapy, nursing – all working together. I had no energy, no stamina. But they got me sitting up in bed, and then walking down the corridor – even when I felt I couldn’t.”

And eventually this interprofessional team got Dave home.

On December 19, Dave returned to the “retirement home” he and his wife bought following the sale of their farm. They were soon joined by members of the Community Stroke Rehab Team (CSRT) who brought rehabilitation services to the home so Dave could continue to gain strength, and the members of the Closing the Gap team who helped Dave’s wife Marg make suitable modifications to the home to ensure her husband’s safety.

“A neighbour picked me up and took me to the walking group hosted by the Durham Legion three times each week and of course, the dog needs to be walked regularly, so I got out a fair bit,” he shares.

He’s returned to Owen Sound for medical appointments as well as for a support group for stroke survivors and their families – most recently as a guest speaker. “My wife found people going through the same thing to be tremendously helpful,” he says in favour of others joining a support group.

Dave would like to return to work this spring – it’s a busy time for the agricultural sector. His boss is supportive of a partial return to work and he has a letter of support from his physician in Owen Sound. Stephanie Hughes, the CSRT Occupational Therapist he worked with, had him complete a self-assessment related to his return to work in order to help him work through the various challenges he would face. They also visited his workplace together to assess necessary task adaptations and strategies for managing fatigue. Now he must wait for his driver’s license, suspended after the stroke, to be reinstated.

Dave and his wife have always been the givers and the doers in their community and family. At a recent meeting of the stroke survivors support group, he said it was difficult to ask for help but that the help he has received from his wife, family and community has been integral for his road to stroke recovery. For Dave, not being able to do the things he used to do has been the most difficult implication of the stroke. However, he knows that in addition to the support of his family and community, time and patience are important on the road to recovery. And if there is one thing farmers have plenty of – its patience.

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Erie St Clair LHIN Chronic Disease Management Request for Proposals

Early Supported Discharge (ESD) is a form of rehabilitation designed to accelerate the transition from hospital to home through the provision of rehabilitation therapies, delivered by an interprofessional team with stroke expertise, in the community. ESD is intended as an alternative to a complete course of in-hospital rehabilitation and is most suitable for patients recovering from mild to moderate stroke. Appropriately resourced ESD services provided for a selected group of stroke patients can reduce long term dependency, admission to institutional care, and hospital length of stay. On March 3, 2014, we submitted a business case to the ESC LHIN for an Early Supported Discharge Team for Stroke. If approved, the next step will be the submission of a full, detailed business case for a pilot program in Windsor.

Community Stroke Rehabilitation Teams

The Ontario Stroke Network (OSN)-funded research project, “The Impact of the South West LHIN’s Community Stroke Rehabilitation Teams: An Economic Analysis” (Authors: Laura Allen, Marina Richardson, Matthew Meyer, David Ure, Deborah Willems, Robert Teasell) was completed and submitted to the OSN in 2013. The results of the research were then presented at the Stroke Collaborative on October 28th, 2013. An abstract entitled “Projecting the Impact of the Community Stroke Rehabilitation Teams: A Cost-Effectiveness

Analysis” was later accepted for presentation to the World Congress for NeuroRehabilitation Conference in Istanbul (April 2014). Analysis of the data from the Community Stroke Rehabilitation Teams’ outcome measures by Dr. Robert Teasell’s research team has resulted in three separate project abstracts to date. “A Comparison of Rural versus Urban Stroke Survivors Treated with a Home-based, Specialized Stroke Rehabilitation Program”; “Evaluating the Effectiveness of Southwestern Ontario’s Community Stroke Rehabilitation Teams”; and “Caregiver Outcomes in a Community-Based Stroke Rehabilitation Setting: Results and Tool Selection”. All were presented at the Canadian Stroke Congress October 16-20, 2013.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Rehabilitation Update

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Angela Cox, 43, a patient in the stroke neurological care unit, selecting her Speech Spot exercises for the evening. “I like having the extra homework because I

want to progress as quickly as possible,” she says

On February 3, 2014, a new research proposal entitled, STRIVE-HOME: Stroke Rehabilitation Involving a Videoconferencing Element at Home; The impact and cost-effectiveness of home-based videoconferencing technology for speech language pathology rehabilitation after stroke,” was accepted for funding by the Heart & Stroke Foundation’s Canadian Partnership for Stroke Recovery. The funding period runs from April 1, 2014 through to March 31, 2015. A team of researchers, lead by Dr. Robert Teasell, drafted the research project using the Community Stroke Rehabilitation Teams. Other team members include Deb Willems, SWOSN; JB Orange UWO; Greg Zaric UWO; David Ure SJHC.

Southwestern Ontario Stroke Rehabilitation Knowledge Exchange Forum “Time is Function: Making It Real”

We completed three newsletters this year which focused on changes to programming in inpatient rehabilitation programs across the region. These changes were made as a result of the Knowledge Exchange Forum. In April 2013, Deb Willems was invited to present on Rehabilitation Intensity at “Stroke Rehabilitation and Beyond” in Hamilton.

The Windsor Regional Hospital inpatient rehabilitation team presented “Improving Rehabilitation Intensity - A Common Sense Approach” at the Stroke Collaborative

in Toronto on October 28th, featuring the program improvements and changes they have made to increase therapy time.

We thank the rehabilitation teams across the region for their commitment to the principles and practices developed through the Rehabilitation Knowledge Exchange Forum.

AlphaFIM

The AlphaFIM was implemented at London Health Sciences Centre – University Campus on Jan 31, 2014. As part of Quality Based Procedures (QBP), health records staff agreed to track AlphaFIM scores, commencing April 1. An audit of all stroke cases admitted to the London Health Sciences Centre -University Campus CNS program was completed for the first three months post implementation of the AlphaFIM (Feb-April) demonstrating good uptake. • Annual results from AlphaFIM data collection at Windsor Regional Hospital’s Metropolitan and Ouelette sites were presented to the staff on January 29th to review the results and discuss any issues arising. A teaching review session with case studies was also provided to staff at the Ouelette site.

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Community Stroke Rehabilitation Teams featured online:• Accreditation Canada’s Leading Practices Database

http://www.accreditation.ca/community-stroke-rehabilitation-team-csrt.

• Southwest LHINs e-Exchange Newsletter - April 2013 and website http://www.southwestlhin.on.ca/newsletter.aspx?id=96&nb=8148&cc=8150&tu=2882#6 and http://www.youtube.com/watch?feature=player_embedded&v=0SUeo6q6y1g#!

Physiotherapists lead the group focusing on balance, lower extremity strengthening, and mobility.

• CIHI has approved Special Project 740 which will make the collection of AlphaFIM data mandatory for all stroke admissions. Awaiting final agreement with the US licence holder. • In the last fiscal year, 62 people in the region have completed certification/recertification in the AlphaFIM.

Provincial Stroke Rehabilitation Resource CentreDeb Willems chaired a provincial Integrated Task Team charged with identifying and creating provincial resources for Stroke Rehabilitation Best Practice Implementation. The Stroke Rehabilitation Resource Centre, a web-based toolkit created by this task team, is now available on the Ontario Stroke Network website.

Also available from the Ontario Stroke Network: • AlphaFIM Special Project 740; and Update • Stroke Unit Care • Access to Inpatient Rehabilitation for Severe Stroke

Provincial Rehabilitative Care AllianceThe Rehabilitative Care Alliance, an Ontario-wide collaborative, is working together with stakeholders to standardize rehabilitative care. Deb Willems, Regional Rehabilitation Coordinator for the Southwest Region, attended the first meeting of the new provincial Rehabilitative Care Alliance in May 2013. The group approved the Workplan and Priorities for this LHIN Collaborative: • Definitions Task Group • Frail Seniors/Medically Complex Task Group • Outpatient/Ambulatory Task Group • Capacity Planning and System Evaluation Task Group

Deb is a member of the Definitions Task Group which has completed their preliminary work on creating a definition of restorative potential, creating eligibility criteria for Rehabilitative Care and creating a draft Framework for Bedded Levels of Rehabilitative Care.

OtherAn abstract entitled “Evaluating the Use of a Logic Model for the Implementation of the ESC LHIN Rehabilitation Network Strategic Plan” was submitted to the GTA Rehab Network Best Practices Day 2014 based on work of the Performance Indicators subcommittee of the ESC LHIN Rehabilitation Network. Deb Willems serves on this subcommittee and was listed as an author.

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Occupational Therapists help patients to work in groups on perceptual and cognitive skills, upper extremity func-tional activities and ADLs. Groups have had participants

practice shaving, applying make-up, and combing/braiding hair with their affected hand.

Nicole McLean and Becky Orenczuk with the GRASP and Speech Spot kits that patients use for therapy homework.

The provincial Community & Long Term Care Coordinators partnered with colleagues in Long Term Care to develop stroke care plans for the RAI MDS (Resident Assessment Instrument Minimum Data Set). Twelve Stroke Care Plans, based on the Tips and Tools resource, were developed to facilitate the uptake of stroke best practices for residents in Long Term Care. Evaluation of the pilot phase was extremely positive. Many pilot homes identified that the care plans were helpful and more comprehensive than existing plans. • 95.8% of respondents indicated that the stroke care plans enhanced their ability to care for stroke residents to varying degrees. • Care plans on transfers and mobility, perception, cognition, pain, and communication were found to be particularly useful. • Pilot homes reported an increased awareness and uptake of best practice stroke care.

These care plans have now been released and they are being disseminated and promoted to all provincial Long Term Care homes.

Resources:

• Your Regional Community & Long Term Care Coordinator welcomes the opportunity to discuss how to best support you in the implementation process and is available to provide education to Long Term Care home staff.

• Implementation Tool Kit is available through the Ontario Stroke Network or on the Southwestern Ontario Stroke Network.

Please consider integrating the care plans into your LTC home’s care plan library!

Community Engagement Workshops

Community Engagement sessions took place in Grey/Bruce and Elgin County in 2013. In these two-day workshops, more than fifty participants were provided with education materials and resources to implement a community re-engagement framework and an inter-professional collaborative care approach to improve the day to day delivery of care to stroke survivors. Further sessions are being planned for 2014/15.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Community & Long Term Care Update

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Participants at the Restorative Care Workshop in Grey Bruce.

Analyzing the Return to Work Website

Using Google Analytics, we have learned that the Return to Work page gets 81% (or 242 unique visits in just one month) of the traffic to the www.swostroke.ca website! While the vast majority of the visitors are from Canada, the page gets most of the international visits to the site with traffic from the US, the UK, Australia, Brazil and 132 visits from other countries.

“I am emailing about your excellent Self Assessment Guide for people with Stroke ‘Are You Ready to Return to Work?’ I am a Vocational Advisor for the Stroke Foundation of New Zealand, specifically assisting people with stroke to return to work/re-training/education. I think the Guide would be very useful for people in NZ to use and for me to use with my clients. Rather than re-inventing the wheel I am writing for your permission to utilize this Guide, with some small changes, in New Zealand. We would, of course, reference the Stroke Network as the authors of this document.” - Andrea Heslin, Vocational Advisor, Stroke Foundation of New Zealand.

Return to Work Website Promotion

Marketing of the Return to Work website continues. The website is a self-management tool that helps users find resources specific to their individual needs. The website includes an interactive Return to Work Assessment Guide, links to organizations providing return to work services, government financial support resources and information on volunteering.

In 2013 the website was promoted at many venues, including the GTA Rehab Network Best Practice Day,Ontario Physiotherapy Association Conference and the Canadian Physiotherapy Association Conference. Raising awareness of the Return to Work website continues across the Region, and plans are in place for a complete update of existing information during the coming year.

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

The Return to Work website includes helpful tools and resources like a Self Assessment Guide, Job Benefit Questions, Organizations that provide RTW Services, and Community Financial Supports.

For nearly four and a half years, Gary LeBrasceur has been a member at New Beginnings ABI and Stroke Recovery Association in Sarnia. “Stroke survivors should always be sent to a place like this,” he says.

The New Beginnings Club, a day program that operates in Sarnia and Chatham, strives to enhance the quality of life for survivors of stroke and acquired brain injury (ABI). It provides social, recreation, education, and leisure opportunities of all kinds, with the intention of supporting survivors and their families to feel empowered and regain friendship after their injury. For Gary, New Beginnings represents a place of growth and acceptance where he is encouraged to try what he wants, where he can face his challenges, and where he has overcome many of them.

Before his stroke on Christmas morning in 2009, Gary can’t remember ever being sick. And he has always been a hard worker; it’s in his nature. Describing his life before, he simply says, “work, work, work” – with a smile on his face. Even as a husband, and father of two, he’s always had two jobs. Prior to his stroke he worked full-time as a process operator at the plants in Sarnia, and at another job cleaning trucks. If he wasn’t at work or with his family, he was in the garage or on the road with one of his beloved Harley motorcycles or old cars. He’s got an extensive collection of Friday the 13th shirts from many tours to Port Dover, and since his stroke, misses riding his Harley more than anything.

Gary has continued working hard after the stroke that drastically affected his mobility and left him with aphasia. He says his biggest challenges have been walking, talking and writing. He first arrived at New Beginnings in a wheelchair that he was unable to operate, as he could not lift his arms. The staff at the Club encouraged him to try what he could. Over many months, Gary kept trying to walk, practicing a little every day, becoming stronger. He is grateful to have found a place that allows him to keep trying, and to strengthen his arms and legs with exercise. Today, Gary is walking, and he has never fallen. He still moves slowly, and recent TIAs have affected his legs, but he has come a long way. Though he is

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

The Importance of Continued Community Support for Stroke Survivors

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

“Two peas in a pod” – one staff member describes friends Gary LeBrasceur (right) and Larry Spencer. Both

say New Beginnings ABI and Stroke Recovery Association has been very beneficial for them as stroke survivors.

encouraged to test his abilities, he says he always keeps a look out, and knows which surfaces make for easier walking.

New Beginnings offers regular peer supported aphasia classes, and provides programs to work with at home. Everyone has been affected by their injury in a different way, or is at a different stage in their recovery, so the classes are designed to assist people where they are at. “Some can’t talk at all. Some are like me, and some are really good,” says Gary, who is able to express himself verbally, but struggles with full articulation of some words and most numbers. He has iPad apps for practice at home, and says the classes and apps have really helped his ability to speak.

“I believe you should always try and never quit,” Gary says. He admits how challenging it was at first: “Everything you did before yourself, you can’t do. That’s the worst thing.” When he was in the hospital, he admits he felt angry all the time, as he was more restricted from trying the things he wanted to. He was frustrated that he couldn’t get up and try to walk, and felt like he was being told “you can’t this, and you can’t do that.” In contrast, upon his return to the community, the staff at New Beginnings encouraged Gary to try things for himself. He says, “I’ve definitely made the most improvement here. If you want to do it, do it. Always.”

Gary’s experience at the Club has gotten him past his anger, because he’s learned that “you can do other things, or do things differently than you did before.” Gary uses his fingers to describe numbers, points to something to help explain what he means, or uses different words to describe what he’s trying to say. Through a mix of determination and creativity, Gary accomplishes the things he sets his mind to. He attends the Club almost every day, preferring to focus on woodworking and exercising. He spends a few hours on the Nu Step machine and lifting weights, and spends time with other members. “All my friends are here,” he says. In particular, Gary likes to share laughs with his buddy

Larry, another stroke survivor whom he met in the hospital. Larry happens to share Gary’s passion for Harleys, and is also responsible for inviting Gary to check out New Beginnings in the first place.As a stroke survivor, Gary says you’ve got to have something to do; “Sitting around is not good for you.” He says, “This place is very important for me,” adding it’s “very important for my wife too.” Sue can go out with her friends, or go golfing, and doesn’t have to worry about him while he’s at the Club. He says that makes him happy because she does so much for him and their family.

Gary is still working toward many goals, and is looking forward to walking outside as much as he can this spring and summer. He will also use the scooter that New Beginnings helped him acquire. The scooter allows him to visit former work friends, or Harley buddies and their bikes. He is very excited for his son’s wedding this summer; Gary is the “second –best man”, he jokes, and his other son and granddaughter will be in the wedding too.

“Independence is important. Without it, you’re not living.” His advice to himself and to others is, “Always do it yourself. If you can’t, still try. Get help, but keep trying.”

Gary’s story highlights the importance and benefits of community support for stroke survivors. By providing a space to harness your strengths and face your challenges, places like New Beginnings offer a sense of empowerment, assisting stroke survivors to achieve their personal goals for as long as it takes after experiencing stroke.

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

This year, education was offered through a multitude of platforms – online education modules, regional and local workshops, videoconference events and discipline-specific network meetings. Approximately 3000 health care professionals from a variety of disciplines participated in educational offerings through the Southwestern Ontario Stroke Network.

Neurologic Upper Extremity Workshop

Glen Gillen, EdD, OTR, FAOTA, a cross-continuum clinician best known for his contributions to the neurorehabilitation literature, was brought to London to educate therapists to comprehensively evaluate and develop an evidence-based intervention plan for the neurologic upper extremity. The sold-out workshop was extremely well received, providing therapists with practical skills to take back to their own practice settings.

Collaborative Interprofessional Stroke Care - Community Re-Engagement Workshop

These workshops, designed for health care professionals and service providers in the community, took place in Grey-Bruce in the spring and then again in London-Elgin

in the fall. Attendees were provided with training materials and resources to implement a community re-engagement framework and an interprofessional collaborative care approach to improve the day-to-day delivery of care to stroke survivors. The success of these workshops helped build momentum for an upcoming workshop in London.

Stroke Best Practice Recommendations Education Series

With the staggered release of the Canadian Best Practice Recommendations for Stroke Care over the past year, an education series was developed by the Ontario Regional Education Group to communicate the Best Practice updates through monthly videoconference events with stroke expert presenters.

Speech-Language Pathologist Stroke Network Face-to-Face Meeting

The yearly Speech-Language Pathologist Stroke Network face-to-face meeting occurred in March 2014. The workshop covered a variety of topics, including educational resources and interventions being used in practices across the country. The speakers included: Wendy Duke, Clinical Director of Columbia Speech and Language Services, Inc. in Vancouver, BC; Allison Baird, owner of SpeechWorks, Inc. in Winnipeg, MB; and Ajay Mysore Narasimha, a local Speech-Language Pathologist who is significantly involved in the FEES initiative ongoing at University Hospital. In order to access the out-of-town speakers, FaceTime was used for the presentation and question-and-answer period. The recent use of FaceTime has provided an alternative opportunity to recruit speakers who would have previously been cost-prohibitive or inaccessbile via videoconferencing, enriching the educational opportunities for our local health care professionals by pulling in expertise from across the country.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Education Update

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

A full house at the Glen Gillen workshop on November 13, 2013.

Staff from the Southwestern Ontario Stroke Network (SWOSN), London Health Science Centre (LHSC), Huron Perth District Stroke Centre/Huron Perth Healthcare Alliance (HPHA) and SW LHIN are taking steps to improve stroke care across the SW LHIN with the help of a new learning program designed to build capacity in quality improvement, leadership and change management across Ontario.

Paula Gilmore, Regional Program Director with SWOSN, Cathy Vandersluis, Director of Clinical Neurosciences and Infection Control at LHSC, Doris Noble, Manager for the Huron Perth District Stroke Centre (HPHA) and Carrie Jeffreys, System Design and Integration Lead with the SW LHIN recently completed the IDEAS (Improving & Driving Excellence Across Sectors) Advanced Learning Program. Program participants learn key concepts and tools in quality improvement, leadership and change management and apply their knowledge to a project with the help of advisors. IDEAS is funded by the MOHLTC and is a partnership among seven Ontario universities, Health Quality Ontario, ICES and the Institute of Health Policy, Management and Evaluation at the University of Toronto.

The SW LHIN Stroke Capacity Assessment and Best Practice Implementation Project is looking to transform stroke services across the SW LHIN to ensure that people who experience a stroke receive best practice care optimizing outcomes after stroke.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

IDEAS (Improving & Driving Excellence Across Sectors)

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

The first graduates of the IDEAS learrning program (April 2014)

Far left: Ross Baker, Co-Principal Investigator, IDEAS Team leads (l-r): Cathy Vandersluis, Paula Gilmore, Doris Noble

Far right: Joshua Tepper, CEO, Health Quality Ontario

Local author Marci Maxwell recently published an inspirational/educational, creative non-fiction story, about her family’s stroke journey, told from the support person’s perspective. The title is, Keeping the Crocodiles at Bay.

About the book she reflects, “Although this story is about our family’s journey following an unexpected health crisis, I believe the elements contained within it hold universal appeal. Like an onion being peeled, it’s a rich story about the human condition and complexities of life. It exposes the challenges and blessings of relationships with others, self, God, and the world around us. The clinical aspects of the story will resonate with anyone involved in the healthcare system, as well as those who move through the system as a patient or with a loved one.”

The crocodiles are a metaphor for anything real or imagined that comes against or impedes the healing and recovery process. This book is about love, perseverance, relationships, and advocating for the compromised individual while keeping all of the crocodiles at bay.

Keeping the Crocodiles at Bay is available through Chapters/Indigo, Barns and Noble, Amazon and local Christian bookstores.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Good Reads: Keeping the Crocodiles at Bay

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

“We are forever grateful to the ambulance attendant who boldly took a stance and

delivered Jeff to the emergency department at the Stroke Centre, a decision that saved

Jeff’s life.”

From the dedication to Keeping the Crocodiles at Bay by Marci Maxwell.

The Chatham Kent District Stroke Centre is very proud of our four-bed integrated stroke unit housed on the in-patient Rehabilitation Unit, our TIA/Stroke Prevention Clinics, and our partnership with the Coronary Artery Disease clinics. We share the Internal Medicine physician and administrative staff and operate both clinics under the District Stroke Centre umbrella. We are working diligently to reduce vascular disease in Chatham-Kent!

The District Stroke Centre is pleased to announce that we are have been fully staffed since October 2013. We welcome Janet Shaw, RN, to our team! She is employed in a composite full-time position where she is accountable to both our Stroke Prevention and Cardiac clinics. With more “hands on deck” we look forward to working more closely with our community to improve its health. This is an exciting time for us!

Our tenth annual Stroke Garden Party was held in June 2013 with the theme of, “A Brain, A Heart and Courage; The Yellow Brick Road to Recovery”.

The event was held on the riverbank outside of the Chatham-Kent Health Alliance, Chatham campus and enjoyed by local survivors of stroke and their families. Many staff and volunteers worked together to make this event a successful celebration – inclusive of food, drink and a talented magician!

With Quality Based Procedures on our radar, our Stroke Centre is focused on proper coding for our stroke patients. To do this we’ve been offering education to more of our staff through the Canadian Institute of Health Information’s online training, “Different Codes for Different Strokes.” We are currently updating our stroke order sets to meet best practice care and examining our processes throughout the continuum including diagnostics to ensure we are meeting Quality Based Procedure recommendations in our district.

Finally, we participated in the development of the Acute Stroke Unit Nursing Orientation Guide to be released June 2014. We eagerly anticipate this release and plan on using this tool in our own established unit to foster empowerment and knowledge translation.

We anticipate another exciting year ahead and have gathered an awesome team together to do our best to reduce stroke and cardiac incidence in Chatham-Kent. We know that prevention and stroke awareness will again be a strong focus of our work. With the help of our Communications Department we will repeat our basic stroke signs and symptoms awareness presentation that repeats in sequence with other health information on the television screens across the Emergency Department.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Chatham Kent District Stroke Centre – 2013/14

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Our Garden Party invitation.

10th Annual Stroke Garden Party

Friday, June 14, 2013

1:00 – 3:30 pm Chatham-Kent Health Alliance

Riverbank

EMCEE: David Palmer, CFCO

ENTERTAINMENT: Marien Hopman, Comedy Magician

A Brain… A Heart… And Courage:

The Yellow Brick Road to Recovery

With the introduction of Quality Based Procedures for Stroke, much work is being done to ensure best practice stroke care is optimized. In October, Grey Bruce Health Services (GBHS) formed a Stroke Steering Committee to address QBP. Like many Districts, our team completed a current state assessment using a template for recommended practices for stroke as described in the QBP: Clinical Handbook for Stroke.

The results of this assessment were presented to the Steering Committee and recommended actions were prioritized. The recommended actions touch all aspects of the continuum of care however the largest impact will be realized with the potential implementation of Telestroke and an Acute Stroke Unit at the District Stroke Centre. Planning is underway.

This work also aligns with the September decision by the LHIN/CEO group to support Regionalization of Stroke Care to Centres of Excellence. As a result the Stroke Capacity Assessment and Best Practice Project is underway across the South West LHIN. There is good representation from Grey Bruce at all levels of this project, which will continue into 2015.

With the addition of a new neurologist and a process review of the Secondary Stroke Prevention Clinic patients now have access to the clinic Monday to Friday. This allows urgent and emergent referrals to be seen by a stroke specialist within the timelines identified in the Best Practice Guidelines.

Our interprofessional Acute Stroke Team continues to see patients that are clustered on the medical

or step-down unit at Grey Bruce Health Services - Owen Sound. They provide clinical assessments within 48-72 hours, develop a plan of care based on best practice, assist with transitions, and provide education to patient and family. Our Stroke Team is notified of all stroke admissions via order set. They are also able to reach out to the other ten hospitals in our District to offer telephone assistance and case reviews as required. In February 2014, our Nurse Practitioner led this team in the development of an Acute Stroke Update presentation for 40 physicians at Friday Rounds.

The rehabilitation unit at GBHS is the leader in the province for accepting severe stroke patients. A Rehab Olympics day was held in February and our stroke patients and families enjoyed many events to enhance their therapy. A Weekly Stroke Group has also been developed for inpatient rehabilitation patients and families. Of note – all of our rehabilitation staff completed their FIM recertification this year.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Grey Bruce District Stroke Centre – 2013/14

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Participants in the Rehab Olymics (February, 2014)

The Community Stroke Rehabilitation Team (CSRT) now has base funding to continue with enhanced team members. Volumes have increased and length of stay on service has decreased. Patients are maintaining positive results at their six-month follow up including continued good results for patient satisfaction. An orderable has been created on the stroke order set to alert the CSRT that a stroke patient has been admitted.

Workshops Provided in Collaboration with the Regional Stroke Team

• 45 participants attended Tips and Tools to Assist with Restorative Care Post Stroke Workshop for Long Term Care providers in Grey and Bruce Counties in Fall 2013.

• 30 participants attended the Community Engagement Workshop in Spring 2013.

Supported Educational Opportunities for Stroke Providers This Year

• Stroke Congress October 2013; Stroke Collaborative October 2013; Glen Gillen workshop;

• Apex/Hemispheres online Stroke education; FIM recertification for 40 staff (nursing and allied health)

Additional Activities

• Stroke Community of Practice bi-yearly meetings

• Presentation at Physician Rounds – “acute stroke

team updates and why minutes matter for tPA”

• Presentation to Wiarton Physician - Stroke Updates

• Living With Stroke Program – Spring and Fall 2013

• Monthly meetings of the Grey Bruce Stroke Survivor Group supported by the CSRT and Stroke Educator

• Stroke Best Practice Updates to Gateway Haven Nursing Home; Walkerton, Chesley, Wiarton, Meaford, Markdale hospitals

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Participants at the Rehab Olympics (February, 2014)

In the spirit of on-going process improvement, the Huron Perth District Stroke Centre reviewed their program with the intention of meeting Quality Based Procedures recommendations. Even though there are numerous good processes in place that meet best practice recommendations, there were and are always opportunities to make the program even better.

On September 5, a local stroke meeting was held with clinical leaders from Stratford General Hospital in attendance. At this meeting we reviewed our stroke data from the Stroke Report Card and discussed a number of opportunities to improve our district outcomes. In follow-up, on December 9, a Stroke QBP Assessment and ISU Recommendation Steering Committee met, with additional representation from diagnostic imaging, internal medicine and AMGH, the telestroke site for Huron County.

The planning for an Integrated Stroke Unit at the Stratford General site is in full swing. We anticipate a fall 2014 opening. In alignment with the planning, process mapping of the patient’s journey has taken place – starting in the ED with patients that walk in, patients that come in by stroke protocol, patients that are not stroke protocol, and those patients transferred from other hospital sites in Huron and Perth. As the team looked at various opportunities to improve this journey, it was identified that the stroke order sets needed to be updated. Louise Flanagan, nurse clinician for the program, will lead the update of the stroke order sets. In line with this, the Speech Language Pathologists are implementing the Barnes Jewish Swallowing Screening Tool this spring by providing education for a core group of nurses. PDSA cycles will be conducted to ensure a full roll-out to all nursing staff in the ISU.

In the fall a retreat was held in Stratford for the three SW LHIN Community Stroke Rehabilitation Teams. The purpose

of the retreat was to look at similarities and differences among teams and to learn from each other about the delivery of care to stroke survivors in the community. It has been decided to hold monthly meetings with the disciplines from each team to build common tools and a similar model of care delivery.

Doris Noble attended the first cohort of IDEAS with Paula Gilmore, Carrie Jeffreys and Cathy Vandersluis. IDEAS: Improving & Driving Excellence Across Sectors is a provincial applied learning strategy. It provided a great learning platform for process improvement, leadership development, change management and skills sets to deliver better quality care and outcomes. As a team, we can use these tools for the larger regionalization project. Locally, these tools will be used as we continue to make positive changes to our own stroke program.

Finally, Doris Noble is retiring from the role as Manager of the District Stroke Centre for Huron and Perth. The program has helped stroke survivors return home with better outcomes and a better quality of life. This is largely due to the infrastructure of the Ontario Stroke Network and the strong, passionate and dedicated Southwestern Ontario Stroke Network team. The Huron Perth program will continue to expand and improve under the leadership of a new manager to be announced summer of 2014.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Huron Perth District Stroke Centre – 2013/14

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Congratulations Doris!

The clustered Acute Stroke Unit within the Telemetry Unit at Bluewater Health has been providing excellent care to acute stroke patients for the past three years. Patient and system metrics, demonstrating improved outcomes and performance, continue to be sustained and improved upon. Bluewater Health shared its model of care at the Stroke Collaborative hosted by the Heart and Stroke Foundation in October. Linda Dykes, Angela Small Sekeris, and members of the Acute Stroke Team co-presented.

More recently, Linda shared quality improvement efforts with regard to stroke coding with the Central East Stroke Network. Health Records, decision support, physicians, and the stroke program teamed up to decrease the use of “code I64” (Unspecified Stroke) from 58% in 2009-10 to less than 1% over the past two fiscal years! The improvements made to the coding selection better reflect the acuity of stroke patients and the care they received at Bluewater Health.

Improvement of hyper-acute stroke care has also been a priority of the District Stroke Centre. A LEAN review of the current state was undertaken with the assistance of the Transformation Management Department in June 2013. Key recommendations, resulting from the value stream mapping process, were the implementation of Telestroke and “code stroke”. Considerable collaboration and team work has allowed us to realize these enhancements. In November, Bluewater Health received approval to become a Telestroke referring site. We worked closely with the Ontario Telemedicine Network and the Regional Program to fulfill the requirements for a “go live” date of late spring 2014.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Sarnia Lambton District Stroke Centre – 2013/14

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Health Records, Bluewater Health

Acute Stroke Team on the Stroke Unit at Bluewater Health

The District Stroke Centre has also worked closely with the Southwestern Ontario Stroke Network and the Erie St. Clair LHIN to implement the Erie St. Clair LHIN Rehabilitation Strategic Plan. The Stroke and Rehabilitation Programs at Bluewater Health have contributed to business case submissions to the LHIN Board that address opportunities to realize best practice care and achieve Health Funding Reform and Quality Based Procedures recommendations. Locally, the Stroke Recovery Association has officially amalgamated with Acquired Brain Injury Services and the programs are now known as New Beginnings, ABI and Stroke Recovery Association. The District Stroke Centre works closely with this organization in Sarnia-Lambton to enhance services for stroke survivors returning home. The community agency continues to host the Living with Stroke Program, offering sessions each spring and fall. Tracy Christopher, the Administrative Assistant for the Stroke Program, co-facilitated the fall sessions with Barb Robinson at the Centre.

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Members of the Acute Stroke Team: the pharmacist, physiotherapist and dietitian

The Urgent TIA Clinic and Carotid Endarterectomy Clinics at University Hospital in London continue to see high volumes of patients. From April 1, 2013 to March 14, 2014, the Urgent TIA and Carotid Endarterectomy Clinics had a combined total of 1240 referrals and 1612 patient visits.

In Thames Valley there remains a need for a structured approach to primary and secondary stroke prevention programming in the community and the Thames Valley District Stroke Council has been considering options to help fill this gap.

In the summer of 2013, the Emergency Department-to-Emergency Department transfer algorithm for tPA candidates was released after approximately a year in development. This algorithm was created in response to consistent requests from hospital stakeholders for a clearly defined process to facilitate the transfer of potential tPA candidates to University Hospital.

London Health Sciences Centre has been actively engaged in Continuous Quality Improvement procedures for stroke this past year. LHSC is in the process of revising its rapid response process for strokes that occur in-house. University Hospital, the Designated Stroke Centre for the district as well as the Regional Stroke Centre, has also begun its staged opening of a “hyperacute” stroke unit. The Southwestern Ontario Stroke Network and University Hospital have also led a district-wide initiative to create and implement a patient education and transition binder. This initiative is currently being piloted at several hospitals across the district. More information

can be found in the Regional Acute Care report.

The Community Stroke Rehabilitation Team (CSRT) in Thames Valley saw over 250 patients this past fiscal year.

In fall 2013 the South West LHIN approved a funding proposal for a Stroke Day which had been submitted by the Thames Valley CSRT, the Oxford Victoria Order of Nurses (VON), and the Southwestern Ontario Stroke Network. A Stroke Day is a specialized Adult Day Program (ADP) program that offers slower paced rehabilitation for stroke survivors who have moved past the active rehabilitation phase. It is based on the successful model at the One Care ADP in Clinton, ON.The Stroke Day rehabilitation is monitored and

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Thames Valley District Stroke Centre – 2013/14

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

London Health Sciences Centre (LHSC)- University Hospital.

supported by the CSRT and it is provided by the ADP staff. It is anticipated that the weekly Stroke Day will be a transitional program between active rehabilitation and community programming. It is anticipated to launch at the Woodstock ADP in mid-2014.

The Southwestern Ontario Stroke Network hosted a Collaborative Interprofessional Stroke Care in Community Re-engagement Workshop in Elgin County last year. In this workshop, health care and service providers are provided with training materials and resources to implement a community re-engagement framework and an interprofessional collaborative care approach to improve the day to day delivery of care to stroke survivors. This event was well attended with cross-continuum representation. One outcome of the workshop was the creation and submission of a funding proposal for a Stroke Day (as described above) for Elgin County.

Also in 2013/14, additional initiatives impacting stroke care were implemented in Thames Valley beyond the work of the Southwestern Ontario Stroke Network. HUGO, a series of common electronic order sets, was implemented in Thames Valley acute care facilities in 2013/2014, with the exception of LHSC and St. Joseph’s Health Care London (Parkwood Hospital). LHSC and SJHC will launch HUGO in early 2014/2015. The CCAC is now functioning in its enhanced role as point of access for inpatient rehabilitation and CCC beds in both in Oxford and Elgin Counties. The CCAC has been functioning in its enhanced role in Oxford County since 2012 and assumed this role in Elgin County in the early fall of 2013.

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

With the hospital realignment in Windsor, Windsor Regional Hospital became the Designated Enhanced District Stroke Centre for Windsor Essex. Another significant transition saw Andrea Drummond, District Stroke Coordinator, move to a new role as Director of Rehabilitation at Hotel Dieu Grace Hospital. Although we miss Andrea, we are excited to partner with her on the rehab end of the continuum. Denise St. Louis became the new Interim Coordinator and we hired a new Interim Stroke Resource Nurse, Rachel Holmes. We also welcome a new neurologist to our physician team - Dr. Alex Tsiaprailis.

The District Stroke Centre presented a case for regionalization of stroke services to senior management in December and we were given the “go ahead” to start the work. We are presently completing a business case that would see all stroke patients seen at an Acute Stroke Unit at the Ouellette campus of Windsor Regional Hospital.

In the meantime we have been making improvements in aligning stroke care and improving best practices at both the Ouellette and Metropolitan sites. Dr. Michael Winger, our Medical Director, has worked with the ER physicians at both sites on improving physician practices and communication. We also updated our acute stroke order set according to best practice so that it is ready for use at both sites. We continue our work with decision support to improve accuracy of data collection.

In regard to professional education we are participating in the orientation of new hires, critical care and neurosciences continuing education days, and have plans to support Emergency Department education

days at the Met site. Development of an Acute Stroke Unit Orientation Guide with the Southwestern Ontario Stroke Network is almost completed and we are planning to roll it out in June 2014.

We have implemented Alpha FIM in real time for all ischemic and hemorrhagic strokes. We also created a project team and are actively engaging in a tPA time process improvement project and have set targets for the next two years. Our internal stroke scorecard is in development.

A Gap analysis for QBP for the District was completed and presented to the ESC LHIN Quality Council. Participation continues in the ESC LHIN Rehabilitation Strategic Plan Implementation Committee: implementing best practices, stroke one of three top priorities. LEAN work completed to meet stroke rehabilitation best practices around increasing therapy intensity and weekend therapy. Rehab is working to meet LOS targets by RPG.

Along with our rehabilitation and community partners we submitted a business case for early supported discharge for stroke patients. In regard to our community work, all DSC staff members are working with the LHIN CDM group in submitting business cases.

Last but not least, Lisa Halley, Stroke Rehab Nurse received the Heart and Stroke Foundation’s Heart and Soul Award for putting her heart and soul into volunteering and/or supporting the work of the organization. Congratulations to Lisa and we appreciate your soulful contributions to the DSC team as well.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Windsor Essex District Stroke Centre – 2013/14

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Quality Based Procedures: Clinical Handbook for Stroke will be updated to include post-acute, community based care for stroke patients

The updated HQO and MoHLTC “Quality-Based Procedures: Clinical Handbook for Stroke” which will include post-acute, community-based patient care (including the community treatment and cross continuum secondary prevention processes) will be released in 2014/2015. The Southwestern Ontario Stroke Network will continue to work with the South West and Erie St. Clair LHINs and other partners to promote best practice stroke care across our region. For assistance, please reach out to the SWOSN and access online resources at www.strokebestpractices.ca and the Ontario Stroke Network.

Rehabilitative Care Alliance (RCA)

The RCA is a province-wide collaborative that was established in April 2013 by Ontario’s 14 Local Health Integration Networks (LHINs) to focus on supporting improved patient experiences and clinical outcomes

through improved access, efficiency, effectiveness, quality, integration, value and equity in the delivery of rehabilitative services across the care continuum. The Rehabilitative Care Alliance is a task-oriented group with a two-year mandate (2013-2015) to effect positive changes in rehabilitative care. The work of the Alliance focuses on the following four priorities:

1. Provide clarity for patients, families and referring professionals through the development of common terminology, clear definitions and standards of practice for all levels of rehabilitative care across the continuum.

2. Develop a rehabilitative care approach for frail senior/medically complex populations to support operationalization of priority elements of the “Assess and Restore Framework to Support Aging in Place”.

3. Inform evaluation and planning at the provincial, regional, organizational and program levels through development of a comprehensive and standardized minimum dataset for outpatient/ambulatory rehabilitation and a mechanism for collection, analysis and sharing of the data.

4. Support monitoring and evaluation of rehabilitative care services, programs and system performance through development of a standard rehabilitative care capacity planning and evaluation toolkit.

Physician Stroke Primary and Secondary Prevention Education Sessions

We are currently organizing this education series for the fall 2014 with a target audience of family physicians, nurse practitioners and secondary stroke prevention nurses.

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Looking Ahead

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca

Click the image to view the Quality-Based

Procedures Handbook for Stroke online.

Regional Stroke Team:

Elissa Najm Administrative Assistant519.685.8500 x32462

Paula GilmoreRegional Program Director519.381.5705

Jennifer Beal (Maternity leave until January 2015)Regional Education Coordinator519.685.8500 x34899

Lyndsey ButlerInterim Regional Education Coordinator519.685.8500 x34899

Gina TomaszewskiRegional Acute Care Coordinator519-685-8500 x35268

Deb WillemsRegional Rehabilitation Coordinator519.646.6100 x42681

Gwenyth StevensonRegional Prevention & Thames Valley Coordinator519.685.8500 x32264

Margo CollverRegional Community & Long Term Care Coordinator519.685.8500 x32050

Mailing address:London Health Sciences CentreUniversity Hospital – Room B10 – 104339 Windermere RoadLondon, ON N6A 5A5

General enquiries:swostrokestrategy@lhsc.on.ca

District Stroke Coordinators:

Denise St. LouisInterim Windsor-Essex District Stroke Centre519.973.4411 x 3770

Linda DykesSarnia-Lambton District Stroke Centre519.464.4400 x4465

Louise FlanaganHuron-Perth District Stroke Centre (Interim)519.272.8210 x2295

Joan Ruston-Berge Grey Bruce District Stroke Centre & Manager of Rehabilitation 519.376.2121 x2920

Linda ButlerChatham-Kent District Stroke Centre519.352.6401 x6900

Fewer Strokes. Better Outcomes. ANNUAL REPORT 2013 - 2014

Contact Us (Click a name to email that person directly)

Full Annual Report available at www.swostroke.ca/annual-reports email swostrokestrategy@lhsc.on.ca