Canadian Best Practice Recommendations for Stroke Care: 2008An Introduction

Today’s Discussion

Overview of the Canadian Stroke Strategy Overview of the Canadian Best Practice

Recommendations for Stroke Care Highlights of update for 2008.

Impact of Stroke in Canada

Someone has a stroke

every 10 minutes

~ 50,000 strokes/year

300,000 Canadians living with stroke

20% chance of second stroke within 2 years

16,000 Canadians die from stroke

each year

Price Tag:$3.6 billion annually

For every symptomatic stroke there are 9 ‘silent’

strokes resulting in cognitive impairment

Canadian Stroke Strategy

Provides a framework to facilitate the widespread adoption of evidence-based best practices across the continuum of stroke care focusing on two levels of change: At the national level At the provincial/territorial level.

PreventionPrevention

Clinics

TreatmentProtocols, Stroke

Teams

RehabilitationPersonal Care

Plans

Best Practice Guidelines and Standards of Care

Professional Development

• Decrease burden of stroke • Improve quality and efficiency of care

• Establish Canada as an international leader

Provincial/Territorial/Regional Implementation of Best Practice

National Platforms to Support Provincial/Territorial/Regional Strategies

Public Awareness

ReengagementCoordinated Support

Information/Evaluation

Coordinated Research

The Canadian Stroke Strategy Model

PreventionPrevention

Clinics

TreatmentProtocols, Stroke

Teams

RehabilitationPersonal Care

Plans

• Decrease burden of stroke • Improve quality and efficiency of care

• Establish Canada as an international leader

Provincial/Territorial/Regional Implementation of Best Practice

National Platforms to Support Provincial/Territorial/Regional Strategies

ReengagementCoordinated Support

The Canadian Stroke Strategy Model

Public Awareness

Best Practice Guidelines and Standards of Care

Professional Development

Information/Evaluation

Coordinated Research

National PlatformsBest Practices and Standards

Goal is to transform stroke prevention and care.

Development and dissemination of evidence based best practices and guidelines along the stroke continuum of care.

Targeted strategies to increase uptake and implementation

Knowledge translation strategy underway Long term goal to synthesize more

comprehensive list of Canadian best practices and standards with focus on effective dissemination and uptake.

National Platforms

Information and Evaluation

Establish evaluation framework. Focus on data access, surveillance and monitoring. Development of evidenced based performance

measures to support monitoring and evaluation of all best practice recommendations.

Collaborative initiatives with CIHI and PHAC. Evaluation of stroke strategy overall.

National Platforms

Professional Development and Training To coordinate and enhance professional

development and training opportunities across the continuum of stroke care.

Develop point-of-care tools to support and facilitate implementation of best practice recommendations for stroke care.

Priority areas identified as focus for creating educational materials.

National Platforms

Coordinated Research Leadership from CSN, HSFC in partnership with

CIHR, Canadian Stroke Consortium, and others To assess current status of stroke research To identify and address gaps that exist in the

evidence base

Public Awareness Leadership from Heart and Stroke Foundation of

Canada Public Awareness focus on effective ways of

ensuring that the public knows what a stroke is, risk factors, signs and symptoms and the appropriate response.

Your Provincial Model

Key Provincial Stroke Strategy Resources Provincial Coordinators Heart and Stroke Foundation Contacts Canadian Stroke Strategy

Expertise in strategy development and implementation, best practices and evaluation

Standardized guidelines and tools Canadian Stroke Network

Links with research and clinical expertise across stroke continuum

Establishing Best Practices for Stroke Care in Canada

Alignment leads to great things!!

CDA

Canadian Stroke Network

CanadianCanadianStroke StrategyStroke Strategy

CANN

SCORE

Provincial Initiatives

Stroke Survivors

Community Care

Rehabilitation – all disciplines

CSQCS

Accreditation

Public Health Agency of Canada

CIHI

CHEPMOHLTC

HSFC

EBRSR

Primary CareHealth Promotion

CAEP

CFPC

Canadian Stroke Consortium

Canadian Best Practice Recommendations for Stroke Care Synthesis of best practice

recommendations across continuum Address critical topic areas Commitment to update every two years First edition released in 2006 Current update released in 2008

Refined process Expansion of recommendations www.cmaj.ca December 2, 2008

Best Practice Recommendations for Stroke Care: Development and Update Process Utilized conceptual framework to guide

identification, selection and development Led by a subgroup of the Best Practices and

Standards Working Group Managed by the Performance & Standards

Specialist from the Canadian Stroke Network Identification of interprofessional stroke care

experts for task groups and panel membership

Best Practice Recommendations for Stroke Care: Development and Update Process Criteria Identification:

Supported by the highest level of evidence and/or considered essential to delivering best practice in stroke care.

Integral to driving important health system change

Aligned with other Canadian stroke related recommendations

Reflect the continuum of care

Best Practice Recommendations for Stroke Care: Development and Update Process Extensive literature scan of primary stroke

research reports, international stroke related guidelines and recommendations

AGREE tool for appraisal of guideline quality Content review of core reference guidelines

conducted to identify list of critical topic areas Additional stroke topic areas identified Tables developed to compare content of

recommendations across guidelines

Review of Existing Guidelines

ASA/VADoDASA/VADoD

RCPRCP

AustraliaAustralia

New ZealandNew Zealand

CSQCSCSQCS

SIGNSIGN

CHEPCHEP HSFOHSFO

SCORESCORE

CDCDAA

Best Practice Recommendations for Stroke Care: Development and Update Process Expert task groups convened to review

recommendation tables and research evidence Canadian recommendations were drafted and

updated based on consensus of task groups National Consensus panel to select and refine final

recommendation set External review by stroke experts and peer review

publication process (CMAJ) Development of Performance Measures by CSS

Information & Evaluation Working Group

Reorganization of Recommendations 2008

2006RECOMMENDATIONS

1. Public Awareness

2. Patient and Caregiver Education

3. Stroke Prevention

4. Acute Stroke Management

5. Stroke Rehabilitation

6. Follow-up and Community Re-engagement

2008

RECOMMENDATIONS

1. Public Awareness and Patient Education

2. Stroke Prevention

3. Hyperacute Stroke Care

4. Acute Inpatient Stroke Management

5. Stroke Rehabilitation & Community Reintegration

6. Selected Topics in Stroke Management

Recommendation Format

Best Practice Recommendation

Rationale

System Implications

Performance Measures

Measurement Notes

Summary of Current Evidence

Highlights of the 2008 Update

Revisions to the 2006 recommendations: Minor edits and updates for 21 of the original

24 recommendations. Recommendation related to computed

tomography scanning and carotid imaging were combined to one for Neurovascular Imaging.

Community Rehabilitation recommendation was refocused to include both outpatient and community rehabilitation services.

Highlights of the 2008 Update Additional Amendments:

Discharge planning integrated Pediatric Stroke issues introduced

New Recommendations: Emergency medical services care of stroke

patients prior to hospital arrival or in transport between hospitals

Acute management of transient ischemic attack and minor stroke

Components of acute stroke management to minimize complications

Vascular cognitive impairment and dementia

1.0 Public Awareness and Patient Education Public awareness and

responsiveness Patient and family

education 2.0 Prevention of

Stroke Lifestyle and risk factor

management Blood pressure

management Lipid management Diabetes management Antiplatelet therapy Antithrombotic therapy

for atrial fibrillation Carotid intervention

3.0 Hyperacute Stroke Management Emergency medical

services prior to hospital arrival

Acute management of transient ischemic attack and minor stroke

Neurovascular imaging Blood glucose Acute thrombolytic

therapy Acute Aspirin

therapy Management of SAH

& ICH

Canadian Best Practice Recommendations for Stroke Care (2008) Topic Areas

Canadian Best Practice Recommendations for Stroke Care (2008) Topic Areas 4.0 Acute Stroke

Management Acute stroke unit care Components of acute

inpatient care 5.0 Stroke Rehabilitation

and Recovery Initial stroke rehabilitation

assessment Provision of inpatient

rehabilitation Components of inpatient

stroke rehabilitation Outpatient and community-

based rehabilitation Follow-up and evaluation in

the community

6.0 Selected Key Topics in Stroke Management Dysphagia assessment Identification and

management of post-stroke depression

Vascular cognitive impairment and dementia

Shoulder pain assessment and treatment

Implementation Tools and Resources Point of Care Tools

Acute Stroke Management Resource Toolkit for the Canadian Best Practice Recommendations

for Stroke Care (2006) (2008) Pocket Reference Cards

o Cranial Nerves o Common Stroke Presentationso Functions of the brain o National Institutes of Health Stroke Scale o Canadian Neurological Scaleo Stroke Prevention Card

Faaast FAQ’s for Nurses National Professional Education Atlas

Available at: www.heartandstroke.ca/profed

Best Practice Standards Dissemination National release of Canadian Best Practice

Recommendations update in CMAJ on December 2, 2008 (www.cmaj.ca)

Website www.canadianstrokestrategy.ca Broad dissemination across provinces, national and

international meetings Individual consultation within provinces to address

regional and local issues, challenges and strategies for dissemination and uptake

Consultation with national and provincial professional associations and groups

Inclusion in stroke related newsletters: National Stroke Nursing Council newsletter Canadian Stroke Network Brainwaves

Tips Related to Generally Effective Strategies for Dissemination Educational outreach visits Interactive educational meetings Multifaceted interventions including two or

more of the following: Audit and feedback Reminders Local consensus processes Social marketing

(Ian Graham, 2006)

Ongoing Development of Canadian Stroke Recommendations Suggested topics to consider for future

updates: Family and caregiver support Management of post stroke seizures Discharge planning Management of patients who experience a stroke while in

hospital for other conditions Telemedicine for stroke care across the continuum Primary management of atrial fibrillation in patients who

have not experienced a stroke Management of patients with communicative disorders

resulting from stroke Recommendations for specific populations, such as

aboriginal groups, visually impaired

www.canadianstrokestrategy.cawww.cmaj.ca