The Ontario Stroke Strategy

Southeastern Ontario (SEO) May 2005

Cally Martin, BScPT, MSc(Rehab)Regional Stroke Coordinator, SEO

Ontario Stroke Strategy

• Stroke = leading cause of death and disability with high health care and human costs (1994 study: direct and indirect cost of stroke care in Ontario approached $964 million a year)

• Report of MOH and HSFO: “Towards an Integrated Stroke Strategy for Ontario”

• May 2000 MOHLTC announced budget for a Provincial Integrated Stroke Strategy

Based on demonstration phase spear-headed by the HSFO

3 components:

• public awareness

• professional education

• systems change

Ontario Stroke Strategy - Funding• KGH designated a Regional Stroke Centre with a

Stroke Prevention Clinic in 2001 (after 3 year demonstration phase)

• Community Stroke Prevention Clinics designated in Perth, Brockville, Belleville in 2003

• QHC designated a District Stroke Centre in 2004

• Funding from MOHLTC Hospitals Branch to hospitals

• Funding from MOHLTC Health Promotion Branch to promote health - this includes funding to HSFO for BP action plan and public awareness campaign.

System Change, Professional Education, Public Awareness

• Regional Stroke Centres• District Stroke Centres• Prevention Clinics• Links with Rehab, Community, LTC• Links with Health Promotion, Primary Care• Access to Best Practice; Build Stroke

Expertise / Professional Education

Patient and FamilyPatient and FamilyPrimary Care PhysicianPrimary Care Physician

Best Practice across the Continuum of Care

The Ontario Stroke Strategy

Stroke Strategy Principles:•Comprehensive•Integrated•Evidence-based•Province-wide

Stroke recognition

Prevention

Prehospital

Emergency Acute

Rehab

Community

Transition

NORTHUMBERLAND

Southeastern Ontario

Population 565,50012,500 miles2

20,000 km2

H

H

HH

H

HHH

H

H

H

Regional Stroke Steering Committee

Full representation:

• across region

• across continuum of care

Subcommittees (prevention, acute, rehab, LTC)

Local area stroke workplans• Perth, Brockville, Kingston/Napanee, Quinte

Regional Stroke Team• Medical Director• Regional Stroke Program Manager• District Stroke Coordinator (Quinte)• Regional and Community Prevention Clinic Staff

(Kingston, Belleville, Brockville, Perth)• Regional Advanced Practice Nurse• Regional Education Coordinator• Administrative support• Enhanced KGH Acute Stroke Unit Team• Long-term Care and Community Specialist• Regional Tele-stroke Pilot Project Leader• ?? in 05/06 Regional Rehabilitation Coordinator

Stroke Best Practice Guidelines

19 Best Practice Guidelines Care Guides Protocols & Guidelines Assessment & Outcome

Measurement Tools Resource Listing CD ROM

Patient, Family Patient, Family & Health Care Team& Health Care Team

Stroke Recognition

Prevention

PrehospitalEmergency Acute

Rehab

Community

Transition

The Ontario Stroke StrategyBest Practice across the Continuum of Care

Stroke RecognitionPrevention

Health Promotion & Stroke Prevention

• Health Promotion

• Risk Factor Management in Primary care (e.g. Blood pressure control)

• Stroke Prevention Clinics– Regional Stroke Centre, KGH – Community hospital prevention clinics in

Belleville, Brockville, Perth

Stroke Risk Factors

Unmodifiable• Age

• Family History

• Ethnicity

• Prior transient ischemic attack/stoke

• Socioeconomic status

• C-reactive protein

Modifiable• Hypertension• Obesity (BMI > 25)• Physical activity• Smoking• Atrial fib/Cardiac disease• Atherosclerosis• Diabetes• Coagulation disorders• Estrogen/progestin• hyperlipidemia

1) What % of Canadians have high blood pressure?

2) Of these, what % are unaware of their BP?

3) Of those who are aware of their condition, what % have their BP treated and controlled ?

Stroke Prevention QUIZ

Awareness, Treatment and Control

22%

Source: Joffres et al. Am J Hyper 2001;14:1099-1105.

43%13%

21%

HTN treated but uncontrolled

Aware but untreated& BP uncontrolled

Hypertensiveand unaware HTN Treated & BP

controlled

~ 2.4 million Ontarians have BP >140/90mmHg (22%)

TIATIAsymptoms

resolve in < 24 hours,

but generally last only a few min

What percentage of those who have a TIA will have a

stroke within the next 48 hours?

a) .01%

b) .1%

c) 2.5%

d) 5%

What percentage of those who have a TIA will have a

stroke within the next 48 hours?

a) .01%

b) .1%

c) 2.5%

d) 5%

Why is there an Urgent Need for TIA Care?

• Short term risk of stroke – 10.5 % stroke risk within 90 days

• half < 48hrs • First stroke/TIA

40% have subsequent stroke within 5yrs• 15 - 30% stroke patients had previous TIA

Secondary Stroke Prevention

• Best Practice: Timely identification and management of those at highest risk of stroke

• Process: – TIA Collaborative Care Plans in ER’s– Stroke Prevention Clinics with Case Management by

Advanced Practice Nurse or RN– Full medical management – Education re lifestyle change (e.g. diet)– Timely revascularization

Medications for Secondary Stroke Prevention

• Antihypertensives• Antihyperlipidemic agents• Antiplatelets

– Aggrenox (ASA + ER Dipyridamole) or

– ASA and Plavix (Clopidogrel)• ACE Inhibitors• Anticoagulation, if indicated

% Discharged from ER on Anti-Thrombotics Canadian Stroke Registry - July 1 2003 to June 30 2004

% Discharged on Antithrombotic agents

7176 80

56.5

0102030405060708090

July 2003-June 04

Aug - Sept2004

SEO

Allsites

Indicator: KGH Stroke Prevention Clinic waiting times

MONTH Number of referrals/mo

Ave wait time (days)

Aug 2002 12 24

Oct 2002 26 18

Dec 2003 25 7

Aug 2004 25 8

Mar 2005 50 5P2/ 12 P3

SEO SPC Clinic wait times and activity

ER to SPC FP to SPC # of Referrals # of Visits

6.6 dys 6.2 dys 450 814

6 dys 7 dys 415 995

7 dys 131 411

9 dys 17 dys 102 197

Average wait times and yearly activity

QHC

KGH

BGH

PSFDH

Patient, Family Patient, Family & Health Care Team& Health Care Team

Stroke Recognition

Prevention

Emergency Acute

Rehab

Community

Transition

The Ontario Stroke StrategyBest Practice across the Continuum of Care

EMS

Pre-hospital

Regional Acute Stroke Protocol Southeastern Ontario

For those with Signs and Symptoms of Stroke: A Coordinated system response

Bypass Protocol Implemented July 1999

Access to thrombolytics within a 3-hour time window

Time from LSN/Stroke Onset to ER Canadian Stroke Registry - July 1 2003 to June 30 2004

5.5

2.9

0

1

2

3

4

5

6

LSN to ER (hrs)

SEO

All sites

• SEO time from Last seen normal to ER arrival:

2.9 hrs (N = 401)

• All sites: 5.5 hrs (N = 4872)

Transport - Percentages of ER patients Canadian Stroke Registry - July 1 2003 to June 30 2004

34

73

27

58

29

47

0102030405060708090

100

% arrival < 2hrs transported byambulance

EMS prenotification

SEO (N= 404)All sites (N= 4923)

tPA - Percentages of ER patients Canadian Stroke Registry - July 1 2003 to June 30 2004

34

12.0

27

10.0

5.56.4

05

101520253035404550

arrival % < 2hrs tPA given (ischemics) tPA given (all strokes)

SEO (N= 404)All sites (N= 4923)

ER Door to CT & Door to Needle times (mins) Canadian Stroke Registry - July 1 2003 to June 30 2004

85

33

112

28

75

55

0

20

40

60

80

100

120

ER to CT time, allstrokes (mins)

ER to CT time, IVtPA (mins)

Door to Needle time(mins)

SEO (N= 404)

All sites (N= 4923)

tPA Outcomes: Level of Disability Canadian Stroke Registry - July 1 2003 to June 30 2004

Percentage with Modified Rankin score of </=2 at DC

3633

0

20

40

60

80

100

% MR </= 2

SEO

All sites

Median rankin Score at DC

3.53.5

0

1

2

3

4

5

6

Median Rankin Score

SEO

All sites

Patient, Family Patient, Family & Health Care Team& Health Care Team

Stroke Recognition

Prevention

PrehospitalEmergency Acute

Rehab

Community

Transition

The Ontario Stroke StrategyBest Practice across the Continuum of Care

Acute

Inpatient Acute Stroke Care

• Regional Patient Flow

• Inter-disciplinary teams

• Organised stroke units

• Evidence-Based Stroke Care Pathways

• Regional Acute Stroke APN and stroke case manager

Good Nursing Care Improves Survival & Outcome

• Blood pressure

In ER, do not treat BP

(SBP 220, DBP 140)

• Fever >37.5• Blood glucose > 8.5

– Rx aggressively

• Hypoxia

• DVT / PE– DVT 20-70%– PE 10% mortality– Heparin prophylaxis DVT

50%

• UTI/Incontinence UTI ~40% Urinary Incontinence 32%-

79%

• Dysphagia • Depression

Patient, Family Patient, Family & Health Care Team& Health Care Team

Stroke Recognition

Prevention

PrehospitalEmergency Acute

Rehab

Community

Transition

The Ontario Stroke StrategyBest Practice across the Continuum of Care

Transition managementRehabilitationCommunity re-engagement

Transition Management

• Transition protocols• Documented standardized team

approach– include client centred goals

• Plan with primary provider• Ongoing access to rehabilitation

and community services

Transition

Rehabilitation Management

• Evaluate rehab potential of each client– team assessment and planning

• Access to appropriate rehab intensity across the continuum

• Assess and address caregiver burden

• Timely discharge from rehab units

Rehabilitation

Community Re-engagement

• Family centred care planning & follow-up• Develop stroke expertise in community

and LTC• Support caregivers

– community programs– respite care– Education

• Social support networks

Community

Rehabilitation: Key Points

• Start early

• Team approach– Expert assessment

• Patient/family centered

• Goal Oriented

• Communication

> 80% benefit from rehab

Rehabilitation: Start Early

• Acute Care– Early rehab in acute care prevents

• Skin breakdown• Falls• Pain/spasticity/contractures• Injuries

• Inpatient Rehab– Early admission to rehab improves

functional outcomes (level 2 evidence)

Rehabilitation Assessment

EXPERT REHAB ASSESSMENT

Who Should Receive Inpatient Rehab?

Impairment type & severity Moderate to severe

Ability to learn

Physical endurance (3hr/day)

• 6 Ontario Stroke Rehab Pilot projects approved by MOHLTC May 2002

• SEO pilot: – transition from rehab unit to own home– Stroke Care Diary

Stroke Rehabilitation Pilots

The Discharge Link Project (DLP)

GoalTo investigate best practice related to stroke client transition from inpatient rehabilitation to the community by:

• enhancing therapy• augmenting provider

communication

DLP: Community Provider Service (First 2 months, incl. 12 Link Meetings)

16.1

22.4

3.5

11.3

0 5 10 15 20 25

Usual CareEnhanced

DLP: Functional Recovery

70

80

90

100

110

Admiss

ion t

o reh

ab

Discha

rge f

rom Reh

ab

3 mon

th fo

llow up

6 mon

th fo

llow up

12 m

onth fo

llow up

Mea

n FIM

sco

re

Usual CareEnhancedintervention

DLP: Functional Recoverybetween Discharge and 3 mths

76.3

107.5105.5

74.4

99.4

108.3107.7

109.2107.9107.5

70

80

90

100

110

Mean

FIM

score N

E

DLP: Change in Recovery

25

7.3

11.5 11

31.3

-2.1

0.2

-2-5

0

5

10

15

20

25

30

35

ADM - DIS DIS - 3mths

DIS - 6mths

DIS - 12mths

Mean c

hange in

FIM

sco

re

Usual CareEnhanced

DLP: Cost Comparisons

1,298

2,146

3,4443,646

509

4,155

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

$4,500

ave. re-admission

cost

ave. cost ofcommunity

therapy

net cost

cost

per pers

on

Usual CareEnhanced

““A cycle of discontinuity”A cycle of discontinuity”

“You get so used to working within a system that you … you forget that there might be something better out there...”

“I finally get to do real OT!”

Key informant interviews:Voices of Providers….

Key informant interviews:Voices of clients….

“I am totally overwhelmed”

““Horrific”Horrific”““Hell on earth”Hell on earth”“It was hard. It was tough”

“if spouses become therapists… it really degrades and demises the personal

relationship.”

“What do you do?”

Long Term and Community Care

•Education

•Communication: Need for better information at transition points

•Rehabilitation expertise

•Support Networks: community programs

Community/Long Term Care

• Tips and Tools for Everyday Living: A resource for Stroke Caregivers

• LTC Resource teams work with LTC Specialists

• Community Care Stroke Service Guidelines

• Educational opportunities

• Communication Tool for Acute to LTC: “Transition Information Plan”

• Building LTC stroke network via “Linkage Luncheons”

Professional education

HSFO Prof Ed Web site

www.heartandstroke.ca/profed

The Road AheadStroke Best Practice GuidelinesImplementation across Ontario