stroke care in saskatchewan · kelly, began work on the acute stroke pathway. the initial focus of...

Stroke Care in Saskatchewan

saskatchewan.ca

Report of the Saskatchewan Stroke Expert Panel 2016-2018

ii Stroke Care in Saskatchewan

Table of ContentsStroke system at a glance .......................................................................... 3

Acute Stroke .............................................................................................. 5

Stroke Prevention .................................................................................... 14

Stroke Rehab ........................................................................................... 16

Stroke Awareness .................................................................................... 18

Data collection and reporting .................................................................. 19

Next steps ............................................................................................... 20

1Report of the Saskatchewan Stroke Expert Panel 2016-2018

Improving stroke care is not new to Saskatchewan. Prior to the Acute Stroke Pathway and establishment of SSEP, a number of local initiatives to achieve excellence in stroke care occurred, setting the stage for province wide improvements. These initiatives included: • an integrated stroke pilot project led by Sunrise

Regional Health Authority 2009-11, • participation of the University of Saskatchewan

ESCAPE clinical research trials for endovascular therapy in 2014-15, and

• implementation of stroke best practices in Saskatoon Health Region leading to achievement of distinction in acute stroke services for Royal University Hospital in 2017.

In addition, provincial collaboration around a Saskatchewan Integrated Stroke Strategy since 2014 has contributed to partnerships among the Heart and Stroke Foundation, the Health Quality Council, the Ministry of Health and the former regional health authorities.

Developing collaborative improvement efforts across regions, disciplines and sectors is complex and can take time to bear fruit. The Saskatchewan Stroke Expert Panel values relationships, dialogue and many incremental changes that have made stroke care better for patients. The time and effort of dedicated health care professionals and leaders, as well as patients and families is greatly appreciated.

Highlights 2016-2018October 2016 Saskatchewan Stroke Expert Panel initial meeting and strategic planning.

January 2017 Saskatchewan Acute Stroke Pathway system-wide launch

June 2017 Heart and Stroke Foundation, University of Saskatchewan and Saskatchewan Health Research Foundation announce renewal of funding for the position of Saskatchewan Stroke Research Chair for a five-year period 2017-2022

September 2017 Canadian Stroke Congress – presentation & poster “The Saskatchewan Acute Stroke Pathway”

September 2017 Canadian Stroke Congress – presentation “FAST-VAN Criteria for Pre-hospital Evaluation of Stroke Patients”

November 2017 Royal University Hospital Saskatoon awarded “Distinction in Acute Stroke Services” by Accreditation Canada

May 2018 launch of tools and process for secondary prevention of stroke with a clinical advisory on TIA non-disabling stroke

Tremendous gains have been made in the past number of years to improve stroke care for the people of Saskatchewan. The Acute Stroke Pathway promotes timely and comprehensive care for patients with stroke. With prompt treatment, the impact of stroke can be reduced.

The Saskatchewan Stroke Expert Panel (SSEP) was established in 2016 to provide advice, monitor quality, and recommend strategies to improve stroke care throughout the province. The SSEP provides oversight and direction for the Acute Stroke Pathway while also bringing attention to opportunities for improvement in other aspects of stroke care.

2 Stroke Care in Saskatchewan

Roles of the Saskatchewan Stroke Expert Panel are: Advise on system improvement • Identify priorities for system improvement • Support implementation of practices • Identify resource requirements for optimum stroke care

and strategies to address gapsReview performance• Monitor progress towards established goals and

objectives • Communicate with stakeholders about performance

metrics and importance of data collection and reporting• Report on the provincial health system performance

against national benchmarks for stroke carePriorities for the SSEP for its first 2-year cycle are to investi-gate and look for opportunities to improve care in areas of:• rehabilitation (specifically access to services between

discharge from hospital and achievement of optimal function),

• secondary prevention (specifically urgent assessment and follow-up for high-risk TIA), and

• hyperacute stroke (specifically refining implementation and sustaining gains of the Acute Stroke Pathway).

The expert panel also deals with on-going challenges of collecting data and communicating internally about stroke system performance.

Stroke Expert Panel members, 2016-2018

Dr. Michael Kelly, SSEP Co-Chair, Saskatchewan Clinical Stroke Research Chair

Pam McKay, SSEP Co-Chair, SHA Executive Director Primary Health Northeast

Dr. Milo Fink, Physiatrist, Regina

Dr. Jason Gatzke, Family Physician & Head of ER, Swift Current

Dr. Brett Graham, Stroke Neurologist, Saskatoon

Dr. Gary Hunter, Director of Acute Stroke Care, Royal University Hospital, Saskatoon

Deb Kennett-Russill, Regional Manager of Therapies, Estevan

Alison Kessler, Regional Director Heart & Stroke Foundation

Dr. Terry Ross, Regina Dept. Head Emergency Medicine, Medical Director STARS Regina Base

Tom Stewart, Manager, Stroke Prevention Clinic, Regina

Ruth Whelan, Stroke Services Clinical Nurse Specialist, Royal University Hospital, Saskatoon

Zenon Markowsky, Patient Representative, Prince Albert

Amanda Horner, Patient Representative, Saskatoon

Dr. Michael Kelly speaks at the launch of the Acute Stroke Pathway in January 2017.


Stroke system at a glanceSTROKE STATISTICS

11-12 12-13 13-14 14-15 15-16 16-17 17-18

TOTAL STROKE 1,667 1,669 1,668 1,672 1,680 1,695 1,643

Cerebral Infarction 811 934 1,002 988 1,048 1,102 1,069

Hemorrhagic 367 349 357 395 387 374 393

Unspecified 611 512 462 411 454 322 283

The number of stroke hospitalizations shown as unspecified has declined, which may show more attention to accuracy in charting and reporting stroke diagnoses.

Men are more likely to experience stroke than women. From 2010/11 to 2013/14, for every 1,000 men aged 20 years and older, about four had a first record of stroke; for every 1,000 women aged 20 years and older, about three had a first record of stroke.

Mortality rates for stroke in Saskatchewan continue to exceed national numbers, but trends are toward fewer deaths from stroke and better prospects for survival and recovery.

Age-standardized mortality rate from stroke per 100,000 population

2012 2013 2014 2015 2016

Canada 36.9 36.1 35.4 34.9 33.1

Saskatchewan 41.5 39.3 37.4 37.0 35.6

EMERGENCY MANAGEMENTEveryone who experiences stroke symptoms is encouraged to call 911 for ambulance transport. Ambulance personnel perform on-site triage and can ensure that a stroke patient gets directly to the appropriate facility to provide the best care. In Saskatchewan, 66% of people admitted to hospital with stroke in 2017-18 arrived by ambulance and 34% did not arrive by ambulance – which is no change from 2016-17, but up from 57% in 2015/16.

In 2015 the Heart & Stroke Foundation’s FAST campaign corresponded with significant improvements in public recognition of stroke signs across Canada.

In Saskatchewan, those polled by H&S recognized: May 2015 Nov 2015

All 3 FAST signs 4% 8%

2 of 3 FAST signs 16% 42%

1 of 3 FAST signs 63% 78%

34% No Ambulance

Ambulance 66%


HOSPITAL CARESome quality of care indicators for stroke, such as length of stay, have improved in Saskatchewan hospitals.

12-13 13-14 14-15 15-16 16-17 17-18

Number of hospitalizations 2,051 2,114 2,051 2,169 2,015 1,984

Average length of stay (days) 16.9 16.7 15.3 14.1 13.0 13.2

Per cent 30-day readmission 9% 10% 10% 9% 10% 10%

Per cent 90-day readmission 18% 19% 19% 19% 18% 19%

Number of deaths in hospital 370 369 369 364 359 318

Although roughly equal proportions of men and women are hospitalized for stroke in Saskatchewan, Saskatchewan data reflects nation-wide findings from the Heart and Stroke Foundation that in-hospital mortality for stroke is consistently higher for women than men. Factors such as age and comorbidity must be taken into account -- but is a good reminder to pay attention to breakdowns in gender and economic status when assessing quality of hospital care. Saskatchewan in-hospital mortality for stroke tends to exceed the Canadian average.

Saskatchewan in-hospital mortality from stroke

14-15 15-16 16-17 17-18Female 187 199 202 174Male 182 165 157 144

DISCHARGE The CIHI Discharge Abstract Database shows that of Saskatchewan stroke patients discharged to the community (not to an acute care facility) 65% do not have a referral to home care or any support service at the time of discharge. This gap most likely indicates that information about referrals is not documented at the time of discharge. While it does not necessarily reflect poor service to patients, it demonstrates room for improvement in continuity of information and communication among providers through transitions in care.

12-13 13-14 14-15 15-16 16-17 17-18Discharge to private home without support service/referral 742 728 720 784 698 735

Discharge to private home with support service/referral 103 107 114 111 91 121

Transfer to Continuing Care 356 353 320 317 326 277

Transfer to Acute 455 522 498 567 514 502

Died 370 369 369 364 359 318

Other 25 35 30 26 27 31

Transfer to continuing care - 24% Discharge to

private home

without support service/referral

65%

Discharge to private home with support service/referral 11%


In 2014 the Ministry of Health and health system partners, led by physician champion Dr. Michael Kelly, began work on the Acute Stroke Pathway. The initial focus of the pathway was hyperacute stroke – which refers to care offered in the first 24 hours after a cerebrovascular accident. According to Canadian Stroke Best Practice Guidelines, the principal aim of this phase of care is to diagnose the stroke type, and to coordinate and execute an individualized treatment plan as rapidly as possible.

Prior to the Acute Stroke Pathway, available stroke-mitigating treatment was limited to thrombolytic therapy with intravenous tissue plasminogen activator or TPA. For decades this was the only available treatment and there was little advancement in hyperacute stroke care. However, in 2015 results of several ground-breaking trials showed remarkable benefits of a surgical procedure for endovascular thrombectomy (EVT). Taking advantage of this long-awaited advancement in hyperacute stroke care required significant reorganization of Saskatchewan’s system for early stage stroke assessment.

Because TPA is most effective up to 4.5 hours from stroke symptom onset, emergency stroke response was focused on identifying stroke patients who could reach an appropriate facility within 3.5 hours of symptom onset. Patients outside the 3.5 hour window were transported to the nearest facility and admitted for medical management, but did not receive hyperacute assessment or treatment. Unlike TPA, EVT can be effective for selected patients up to 24 hours from symptom onset. This created a need for new systems to ensure all stroke patients were assessed for treatment eligibility in the hyperacute period.

The purpose of the Acute Stroke Pathway is to organize the provincial stroke system to meet and exceed Canadian best practice standards for the timely assessment and treatment of stroke patients in the critical first hours after stroke symptom onset.

Stroke alert by-pass to Primary Stroke Centre One of the first priorities of the Acute Stroke Pathway was to identify health facilities in Saskatchewan with 24-hour access to advanced imaging that could serve as primary stroke centres. Emergency Medical Services (EMS) protocols were implemented to ensure that ambulance services considered all stroke patients up to 12 hours from symptom onset as “stroke alert” and transported them directly to a primary stroke centre, bypassing other nearer facilities if necessary. Stroke alert terminology prompts special preparation from the stroke team at the Primary Stroke Centre. Even patients who are not eligible for stroke-mitigating treatment benefit from being transported to a primary stroke centre that offers advanced imaging, specialty assessment and greater stroke expertise.

Primary Stroke Centres

Location Hospital

Estevan St. Joseph’s Hospital

Moose Jaw Dr. F.H. Wigmore Regional Hospital

Swift Current Cypress Regional Hospital

Yorkton Yorkton Regional Health Centre

Prince Albert Victoria Hospital

North Battleford Battlefords Union Hospital

Lloydminster Lloydminster Hospital (operates according to Alberta protocols)

Regina Regina General Hospital (also offers secondary stroke services)

SaskatoonRoyal University Hospital (also offers comprehensive stroke services

Acute Stroke


Over time, designated stroke teams in the seven primary stroke centers plus Regina and Saskatoon have assumed a vital role in stroke leadership regionally and provincially. The teams work with providers in EMS, emergency departments and imaging departments, as well as wards. They help monitor performance, educate about stroke protocols, and promote the importance of a time-is-brain mentality.

A recent improvement event at Dr. F.H. Wigmore Regional Hospital in Moose Jaw was a great example of multidisciplinary providers coming together to ensure the best possible care for the stroke alert patient. The purpose of the 2017 event was to design a process for achieving the fastest possible door to imaging and treatment time while maintaining patient safety at all times. Under the new process, when a stroke alert is announced on the overhead paging system, the Patient Flow Manager (24/7 out-of-scope Nursing Supervisor) immediately attends. The Patient Flow Manager is considered the person with the most knowledge of the hospital bed utilization who can make the decision of which team –ICU or ER – should administer treatment if needed. The team outlined standard work to guide decision making for the Patient Flow Managers, taking into consideration the Stroke Alert patient’s needs, ICU bed availability and Critical Care Nurse availability in the ER and ICU units. This standard work was used to educate the nursing staff on all

units as well as the ER physicians and Internists so that everyone involved was knowledgeable about the new process.

The bypass protocol ensures that more stroke patients benefit from comprehensive assessment and stroke expertise available at Primary Stroke Centres. Data collected from pilot centres during the development of the Acute Stroke Pathway indicated an increase of approximately 25% in the number of people arriving at primary stroke centres as stroke alerts, after implementation of the bypass protocol. Since 2012, the percentage of total stroke hospitalizations that take place in primary stroke centres has increased from 69% to 81%.

12-hour window for stroke alert The 12-hour window refers to the time up to 12 hours from the onset of stroke symptoms within which stroke patients are treated as potentially eligible for stroke mitigating treatment. Implementing the 12-hour window involved system changes in the training of ambulance services, implementation of ambulance bypass protocols, designation of CT angiogram as the imaging standard for evaluation of acute stroke patients, and coordination of multidisciplinary stroke care through order sets and transfer protocols. Stroke

Dr. F.H. Wigmore Regional Hospital- stroke improvement team: Hayley Downton RN, Patient Flow Manager, Jana Kitts ER RN, Mark Shiers ICU RN, Lisa Parker RN Director of ER.

Stroke hospitalization in primary stroke centres


alert data submitted during development of the Saskatchewan Acute Stroke Pathway showed that 90% of patients admitted for stroke reach a facility within 12 hours of symptom onset.

The goal of the Pathway is to have all Saskatchewan stroke patients, even in-patients, identified immediately and transported to a primary stroke centre by EMS as stroke alert. Current data from the CIHI discharge abstract database shows there is still a gap between the total number of hospitalizations for stroke and the number of reported stroke alerts.

CTA –standard for diagnostic imaging While plain non-contrast CT has typically been the standard for evaluation and diagnosis of stroke, Canadian Stroke Best Practice Guidelines note that advanced imaging such as CTA can be considered as part of initial imaging to assist diagnosis of patients with large vessel occlusion, as long as routine use of CTA does not substantially delay decision and treatment in general.

Computed tomography angiography (CTA) is critical to determine if patients have large vessel occlusions, and supports diagnosis of hemorrhagic stroke and other brain disorders. A 2013 review of evidence by the Canadian Agency for Drugs and Technology in Health (CADTH) concluded that techniques such as CTA

can provide a qualitative cerebral blood volume (CBV) map that detects the core of infarction and improves the identification of the tissue at risk for infarction compared with NCT (CADTH, 2013).

After reviewing medical evidence, the Saskatchewan Acute Stroke Pathway implementation committee selected CTA as the imaging standard for stroke care in the province. Medical leaders agreed that in the Saskatchewan context, performing CTA at the same time as initial CT imaging is an important diagnostic and time-saving measure for those patients ultimately requiring interventions for severe stroke.

Implementation of CTA as an imaging standard for stroke represented a change in practice for most radiology departments. In some centres, the additional volume of patients requiring urgent imaging, as well as the additional time required for interpretation of CTA, added pressure on limited radiology resources. However, with most rural stroke centres seeing an increase of one or two stroke alerts per month, dedicated radiology resources for stroke alerts were not seen as warranted. With support from eHealth Saskatchewan, PACS technology was improved for remote viewing of CT images by on-call radiologists. Several facilities arranged for greater use of tele-radiology supports to meet overall emergency call demands.

In 2017 the Saskatchewan Stroke Expert Panel released a clinical stroke advisory concerning the practice of requiring patient consent for administration of contrast (prior to performing CTA). The advisory clarified that in the setting of acute disabling stroke, CTA should be performed immediately after non-contrast CT head without hesitation, as per existing policy directives for the treating physician to bypass consent in a medical emergency.

Total stroke hospitalizations compared to stroke alerts August 2017-March 2018

Num

ber o

f Pati

ents


In addition to setting standards for the type of imaging, the pathway emphasizes rapid assessment by promoting Canadian Stroke Best Practice standards for stroke alerts of 15 minutes from patient arrival at facility to first cut of CT. Between August 2017 and June 2018 (the longest period for which a complete data set is available from all nine stroke centres) the Saskatchewan median of 21 minutes was close to Canadian Best Practice Standards of 15 minutes.

Data collected by primary stroke centres since the pilot of the Acute Stroke Pathway in 2015 has shown improved access to consistent and timely imaging in most centres. When door to imaging times exceed 30 minutes, local stroke teams and medical leaders can investigate and pursue improvements as required.

Door-to-Imaging Time (DTIT) in Saskatchewan August 2017 - June 2018

Average Door-to-Imaging Time (DTIT) in Swift Current June 2015 - August 2018

Median = 21 mins; calculated based on DTIT between August 2017–June 2018Best Practice Median = 15 mins.

Baseline Pilot median = 44 mins; calcualted based on DTIT between June 2015–Aug 2016New Median = 19 mins; calculated based on DTIT between July 2017–May 2018

Several primary stroke centres have recorded substantial internal improvements in door-to-imaging time over the course of implementing Acute Stroke Pathway protocols. For example the median door-to-imaging time in Swift Current shifted from 44 minutes to 19 minutes.


Access to hyperacute treatmentOne of the main objectives of the Acute Stroke Pathway has been to improve access to stroke mitigating treatments such as tissue-plasminogen activator (TPA) and endovascular thrombectomy (EVT). An estimated 20% of stroke patients may be eligible for TPA or EVT if they are identified, transported and evaluated in a timely fashion. These treatments can significantly improve outcomes for patients and reduce downstream costs to the health system.

Prior to the pathway, the number of patients receiving TPA was not consistently tracked. However, reported numbers indicated that Saskatchewan lagged behind the national

average in percentage of stroke patients receiving this treatment. While TPA can be delivered by emergency department physicians, it requires the whole stroke system to support physicians with rapid identification and transport of patients, appropriate imaging and timely interpretation of imaging, standard dosing and exclusion protocols, and access to specialist advice. Since the launch of the stroke pathway in 2017, stroke centres have recorded and reported on the number of times TPA was administered. In spite of month-to-month variation, the percentage of stroke alert patients receiving TPA has trended slightly upward in Saskatoon and in seven primary stroke centres that do not have in-house neurology.

Per cent of Stroke Alerts who had tPA (target 20%)August 2017 - June 2018

Median = 10.2% of SA in Saskatoon; calculated based on % who had tPA between August 2017–June 2018

Median = .5%; calculated based on % receiving tPA between Aug 2017–June2018


The Saskatchewan Stroke Expert Panel continues to focus attention on the numbers of patients receiving TPA and examine potential barriers and enablers to administration of the medication. Identification of stroke patients and transport to a primary stroke centre within 3.5 hours of stroke symptom onset continues to be the main inclusion criteria for administration of TPA, but indications are that greater stroke awareness in the public and emergency medicine, and presence of a stroke coordinator in emergency

departments can also play an important role in making sure that all eligible patients are considered for this treatment. Facilities that administer TPA are also challenged to do so as quickly as possible. While TPA administered later than 4.5 hours from symptom onset is not correlated with improved patient outcomes, substantial research shows that within the 4.5 hour window, the shorter the time to treatment, the better chance of improved outcomes, including reduced mortality, fewer

Average Door-to-Needle Time (DTNT) in Saskatchewan August 2017 - June 2018

Saskatoon Average DTNT June 2015 - June 2018

Median = 1 hr 7 mins; calculated based on DTNT between August 2017–June 2018Best Practice Median = 30 mins.

Baseline Pilot median = 8 mins; calculated based on DTNT between June 2015–Dec 2016New median = 35 mins; calculated based on DTNT between Jan 2017–June 2018Best Practice Median = 30 mins.

Saskatoon’s median door-to-needle time shifted from 48 minutes to 35 minutes.


treatment complications and a greater likelihood that patients would go home after leaving the hospital. Canadian Stroke Best Practice Guidelines recommend that all eligible patients should receive intravenous alteplase as soon as possible after hospital arrival, with a target door-to-needle time of less than 60 minutes in 90% of treated patients, and a median door-to-needle time of 30 minutes.

While door-to-needle times in Saskatchewan since August 2017 (the earliest point when a complete data set was available) have failed to reach the median time of 30 minutes, several primary stroke centres have recorded substantial internal improvements in door-to-needle time over the course of implementing Acute Stroke Pathway protocols.

Endovascular thrombectomy (EVT) is a procedure in which a blood clot causing large vessel occlusion is mechanically removed. The endovascular stroke team at Royal University Hospital has been a leader in EVT in Canada and participated in ESCAPE international research

trials. EVT is now available to all patients in Saskatchewan. Resources for EVT at Royal University Hospital include cerebrovascular and endovascular neurosurgeons, neuroradiology, stroke neurology, nursing and ancillary support and an upgraded biplane angiography suite. In calendar year 2016, 42 Saskatchewan patients received EVT at the Royal University Hospital in Saskatoon. In 2017, 72 Saskatchewan patients received EVT. Physicians predict over 90 procedures by the end of 2018. According to Patrice Lindsay of the Heart & Stroke Foundation, as many as 20% of stroke patients – approximately 300 people annually – could be eligible in Saskatchewan.

Timely action is also important with the EVT procedure. The faster the brain is reperfused, the greater the chance of a good outcome. The Acute Stroke Pathway continuously measures and implements improvements to these processes. The target for EVT is 60 minutes from RUH door to arterial (groin) puncture.

Average Door-to-Groin Puncture Time Royal University Hospital January 2017 - March 2018

Baseline median = 1 hr 23 mins; calculated based on DTGT between Jan 2017–March 2018Best Practice Median = 60 mins.


EMS stroke screenA key component of the Acute Stroke Pathway has been application of a standard stroke screen by all ambulance personal across the province, as per Canadian Stroke Best Practice Guidelines. In 2018, guidelines were updated to recommend that patients who demonstrate any stroke signs during pre-hospital assessment should then undergo a second screen using a tool to assess stroke severity. The purpose of the second screen is to look for people who may be eligible for EVT.

In Saskatchewan, the FAST tool was adopted as the initial stroke screen. This tool identifies basic stroke symptoms such as facial droop, weakness and slurred speech.

As part of Acute Stroke Pathway development starting in 2014, stroke team leaders have seen the benefit of developing clinical tools for use by emergency medical services to identify potential EVT candidates in the field. The Heart & Stroke Foundation’s list of validated tools to assess stroke severity includes the FAST VAN tool, developed at Royal University Hospital in Saskatoon.

The VAN screen guides pre-hospital personnel in observing and recording anatomically relevant symptoms in the VAN categories of Vision, Aphasia, or Neglect. EMS personnel are taught to observe a forced gaze to the left or right, naming difficulties, or neglect of one side of the body (particularly the left side). If the patient is VAN positive, this information can be used to alert hospital stroke teams to the severity of the stroke in transit, and prompt pre-alerts to air ambulance/STARS, as well as surgical teams.

Ruth Whelan, RN, MSN, Clinical Stroke Nurse Specialist at RUH, is part of the team that developed, tested and continues to educate providers about the FAST-VAN tool.


Based on early evidence of the tool’s efficacy a VAN education package was produced and disseminated to EMS managers province-wide in September 2017. As of October 2017 VAN criteria formed part of standard pre-hospital assessment of acute stroke patients in Saskatchewan. Ongoing evaluation of VAN criteria as applied by EMS personnel demonstrates high sensitivity (94%) to presence of large vessel occlusion or other severe stroke. Authors of the FAST-VAN tool continue to investigate its implementation and improve training materials for ambulance personnel.

Telestroke: support for patients and physiciansTelestroke is the use of real-time two-way audiovisual communication to enable remote clinical assessment of a stroke patient by a consulting stroke expert. It is typically used to support healthcare facilities that do not have on-site stroke specialists (a neurologist or an internist with stroke expertise). Canadian stroke best practice guidelines recommend that the telestroke care delivery modality be implemented across the stroke continuum to bridge any geographic gap between patient and specialist.

In Saskatchewan, telestroke equipment has been put in place in ERs of all primary stroke centres where neurologists are not available on-site. Emergency department teams in primary stroke centres have been trained to initiate communication with consulting specialists using a web-based video consultation technology. On-call neurologists in Regina and Saskatoon have access to telestroke through any Telehealth suite, computer or mobile device.

Prior to availability of telestroke, an ER physician in a primary stroke centre would typically consult an on-call neurologist by telephone. Telephone consultation continues to be the norm for many providers, as the Sask Stroke Expert Panel works to overcome barriers to change, and convince more physicians of the value of video consults.

In Prince Albert, telestroke technology includes a cutting edge DX-80 mobile Telehealth cart right in the emergency room. The DX-80 allows ER physicians to easily initiate video connections with consulting neurologists in Saskatoon.

According to emergency physicians in Prince Albert, having video access to a consulting neurologist is reassuring to physicians and family members when making a decision about hyperacute treatment. With telestroke technology, the consulting specialist can speak directly to the family about the risks and benefits of clot-busting medication. The neurologist also asks the family questions that the emergency room doctor may not think of asking, or doesn’t have time to ask.

Stroke neurologists note that the signs of a severe stroke can be quite subtle, and the opportunity to see the patient can significantly assist in diagnosis.

Jacquie Groves, stroke team lead, and Dr. Francois Ros-souw, Co-Chief of the Emergency Department, pose with the DX-80 at Victoria Hospital in Prince Albert.


In 2016, an inventory of Saskatchewan stroke services identified gaps in care related to follow up for high-risk TIA patients. Individuals with transient ischemic attacks (TIA) and minor strokes are at high risk for symptom recurrence and/or progression, and subsequent disability, particularly within the first week of symptom onset. Up to 80% of strokes after TIA are preventable, and patients at highest risk can be identified by obtaining timely CT/CTA. After CT/CTA has been obtained, and imaging has been reviewed, the patient can be appropriately triaged. However, health regions reported that TIA patients were not consistently provided with urgent access to imaging due to unequal access to Stroke Prevention Clinics within the province, and lack of clear protocols to guide follow up by local diagnostic imaging departments and primary care providers.

Stroke Prevention Clinics (SPCs) operate in only four of Saskatchewan’s nine CT-enabled stroke centres. Referrals to SPCs are triaged so patients at highest risk of stroke recurrence are seen first. However, wait times and gaps in service may prevent follow up of high-risk patients within the recommended 24 hours. The Stroke Expert Panel and SPC managers determined that in that absence of SPC access, highest-risk TIA patients should be navigated to the nearest Primary Stroke Centre for urgent CT/CTA.

Based on most recent updates of Canadian best practice guidelines for stroke, the triage tool for TIA and non-disabling stroke provides physicians with guidance to identify highest risk stroke patients and immediately involve on-call neurology in patient navigation. Involvement of neurology serves to confirm the diagnosis of high-risk TIA and ensure urgent (same day) access to appropriate imaging in the nearest Primary/Tertiary Stroke Centre.

In 2018 the Saskatchewan Stroke Expert Panel released a clinical stroke advisory concerning the assessment and triage of high-risk TIA. The system-wide memo serves to clarify the timing of assessment, neurologic consultation, and imaging acquisition for high-risk TIA and minor stroke patients and subsequent triaging throughout the Saskatchewan Health Authority.

Patient presents to non-CT facility or walk-in clinic with symptoms of high-risk TIA

Physician calls ACAL/bedline for urgent consult

with on-call neurologist

Confirm high risk TIA?

ACAL/bedline builds 3-way call with ED physician from

nearest stroke centre

non urgent referral to

SPC, imagingNO

YES

ED physician books CTA within 24 hours

Physician communicates information to patient

Patient goes to stroke centre & registers in

emergency department

Referral sent to ED by fax or with patient (also to

nearest SPC)

TIA triage tool

Referral for TIA non-disabling

stroke

Stroke Prevention


The new standardized referral for TIA/non-disabling stroke can be used to navigate patients to SPCs as well as to a Primary/Tertiary Stroke Centre, and also guides follow up by primary care. In September 2018 the referral and triage tool were made available in all electronic medical records in Saskatchewan for use by acute care and private practice physicians.

The referral also clarifies appropriate follow-up for moderate and lower risk TIA. Investigations for these patients should be undertaken over a two-week period. However, since access to a Stroke Prevention Clinic within two weeks is not guaranteed, physicians in emergency medicine or primary care are requested to initiate treatment and order testing before the patient leaves the office/ED.

The Stroke Expert Panel’s work on secondary stroke prevention has also brought increased attention to the work of Stroke Prevention Clinics. Canadian Stroke Best Practice guidelines consider an SPC to be a critical component of secondary stroke prevention. Stroke Prevention Clinics provide a comprehensive interdisciplinary approach to prevention of first or recurrent stroke, conduct detailed assessments by a range of healthcare disciplines, facilitate timely access to appropriate diagnostic testing and interventions, and provide education to patients and families.

In Saskatchewan SPCs operate five days a week at Royal University Hospital in Saskatoon and Regina General Hospital, weekly at Yorkton Regional Health Centre and monthly at Prince Albert Community Clinic. The Regina Stroke Prevention Clinic started out as a weekly clinic but has experienced significant growth during the development of the Acute Stroke Pathway. The SPC now has a permanent location with four exam areas, and runs clinics with neurologist participation three times per week. The SPC’s Clinical Stroke Coordinator has taken on new roles to support the Regina General Hospital Emergency Department during stroke alerts, and has started doing stroke prevention education with hospital staff and in the community.

The Expert Panel also provided the opportunity for Stroke Prevention Clinics to collaborate on a patient education tool “Information about

Referrals to Stroke Prevention Clinic - Regina General Hospital

Stroke Prevention Clinic staff, Regina General Hospital - Left to right: Shelley Kambeitz RN, Leah Evans RN, Tom Stewart, Manager, Cheryl Loucks, RN Clinical Stroke Coordinator, JoAnne Jacob RN, Rosie Alcantara, Unit Clerk

Dr. Brett Graham and Dr. Jason Gatzke led develop-ment of clinical tools for managing high-risk TIA


A 2016 survey of stroke services in Saskatchewan indicated that therapy services available to stroke patients in Saskatchewan vary widely by location, and that limited resources are often spread thin. The Stroke Expert Panel - Rehabilitation Subcommittee was tasked with collecting more information about therapy services available to stroke patients.

The Rehabilitation Subcommittee found that substantial information is available about inpatient rehab services provided by Wascana Rehabilitation Centre and Saskatoon City Hospital, because information from these facilities is collected in the CIHI National Rehabilitation Service (NRS) database.

In Saskatchewan in 2015/16, these facilities recorded seeing 220 stroke patients, or about 12% of stroke patients discharged from hospital in that year. Canadian Stroke Best Practice Guidelines recommend that 30% of stroke patients who receive acute hospital care should have a referral for inpatient rehabilitation.

However, therapy services in Saskatchewan tend to be decentralized, with a variety of rehabilitation services available in other institutional settings (including acute care wards) and in the community. Stroke patients may access service in a variety of settings along the continuum of care, but the diversity and spread of services can make it difficult to determine how much service is provided, whether it is consistently available, how well it conforms to best practice standards, and whether patient needs are met.

From 2009 to 2011 the former Sunrise Health Region designed and implemented an integrated stroke pilot project, funded by the Ministry of Health and the Heart and Stroke Foundation. The pilot had a significant impact on standards for stroke rehabilitation in Yorkton and area.

Transient Ischemic Attack (TIA)” to standardize information available to TIA patients waiting for a referral to the Stroke Prevention Clinic. Almost 3,000 copies of the resource were distributed to emergency departments and walk-in clinics province-wide.

Outcomes of the Panel’s work in secondary stroke prevention may result in lower rates of readmission for patients hospitalized with TIA. While a large number of TIA cases go unreported, those patients admitted to a Saskatchewan hospital for TIA currently experience 30- and 90-day readmission rates that exceed those for stroke patients.

# of in-patient hospitali-zations

% 30-day re-admission

% 90-day re-admission

2012-13 612 15% 28%

2013-14 545 15% 26%

2014-15 600 13% 25%

2015-16 622 15% 27%

2016-17 617 13% 25%

2017-18 478 13% 20%

Hospitalization for Transient Ischemic Attack

Stroke Rehab


Jowsey House is a continuing care facility that houses an eight-bed inpatient rehabilitation unit, with three beds designated for Stroke Rehab. Services provided include daily physical, occupational, and speech-language therapies, social work, nursing, and work by a continuing care aide to facilitate activities of daily living in the morning routine. The program is client and family centered, providing a multidisciplinary case conference for client and family within two weeks of admission, regular conferences to ensure client/family is able to participate in and direct their care, home assessments with PT/OT during their stay, and weekend passes to ensure successful transition home upon discharge. Staff also collect and monitor information on stroke rehab patients including initial diagnosis, number and type of providers seen, length of stay and change in functional status from admission to discharge.

Province wide, a number of facilities provide similar inpatient access to therapies for stroke patients, and all residents in continuing care are regularly assessed for physical and cognitive deficits. Some stroke patients receive outpatient therapies in their homes or local facilities, and efforts are made to connect stroke patients with local programs such as an Acquired Brain Injury Program, or wellness supports such as Diabetes Education, Cardiac/Pulmonary Rehab programming, Craving Change, and LiveWell with Chronic Conditions. However, collection of data about services to stroke patients in the community has been challenging, and it is difficult to determine whether care meets best practice standards. In the next two years, the Expert Panel will proceed with projects to collect information about the current state of therapy services following stroke.

The rehab committee has also recognized the need to move ahead with some improvements that will foster better teamwork, supports and connections to care that serve stroke patients in the community. In the coming two-year period the Rehab Committee will focus on

transition from institution to community. There is still significant variation across the province in discharge tools and processes. With the consolidation into the Saskatchewan Health Authority, this presents a timely opportunity to clarify best practice and develop standard work for stroke patient discharge, including optimal communications, timing of referrals and reassessments, and referrals to community supports.

Canadian Stroke Best Practice Guidelines recommend the following metrics for monitoring quality of care for people recovering from stroke in the community (patients discharged from an acute hospital or inpatient rehab facility to a home setting):• Percentage of stroke patients discharged

to the community who receive a referral for ongoing therapies

• Median length of time between referral for outpatient therapy and admission to program

• Frequency and duration of therapy services provided in the community

• Magnitude of change in functional status scores, using a standardized measurement tool

• Percentage of persons receiving ambulatory rehabilitation assessment, follow-up and treatment (by Telehealth, clinic, or in-home)

• Number of stroke patients assessed by physiotherapy, occupational therapy, speech–language pathologists and social workers in the community

• Use of health services related to stroke care provided in the community


Saskatchewan’s incidence of stroke (the number of strokes that happen every year) and prevalence of stroke (the number of people currently living in Saskatchewan who have experienced stroke at some time) tend to be slightly higher than the national average. This may be affected by higher levels of other population-based risk factors such as smoking, being overweight and vascular conditions such as hypertension.

So far, the Stroke Expert Panel has not addressed primary prevention of stroke in the form of raising awareness about risk factors. However, the panel has supported work by the Heart & Stroke Foundation to raise awareness of the signs of stroke and encourage speedy response by the public. The FAST campaign emphasizes the need to get urgent medical attention for anyone experiencing signs of stroke, and to call an ambulance rather than transporting a stroke patient to the hospital by personal vehicle.

Members of the Stroke Expert Panel have leveraged donations and in-kind support for the FAST campaign by involving ambulance services, government-wide social media, information feeds in physician and clinic waiting rooms, and a variety of other platforms. Zenon Markowsky, a patient prepresentative on the Stroke Expert Panel and former President of the Prince Albert Mintos hockey club, arranged for a banner in Prince Albert’s Art Hauser Centre to promote the FAST pneumonic: F- is your face drooping? A- can you raise both arms? S – is speech slurred? T- time to call 911. Public and private ambulances services in Saskatchewan all

agreed to apply decals to promote the Heart & Stroke Foun-dation’s successful FAST campaign.

Stroke AwarenessAmanda Horner, Patient Representative

As a young career woman with two very young children, I was more than determined to recover after my stroke and subsequent brain surgery. Throughout

my experience I identified what I felt were gaps in our health system and thoughts on how to make improvements. So when the opportunity was presented to be part of the Saskatchewan Expert Stroke Panel, I felt compelled to jump on board. I felt it would be a great avenue to offer my insights and contribute to the improvement of stroke care for anyone who should require it. The work of the panel is challenging as we move through the whole process. While we make rapid gains in some areas, we are diligent about finding ways to achieve goals in others.


The Acute Stroke Pathway requires Primary Stroke Centres to implement several changes in protocol, with the goal of improving stroke patient care and aligning Saskatchewan with national and international best practice guidelines for stroke. It is the role of the Stroke Expert Panel to monitor implementation of these standards and ensure that all patients receive best-practice care.

With the support of Saskatchewan Health Quality Council, Primary Stroke Centres collect and report three data elements on each stroke alert patient: time of arrival, time of imaging, time of administration of TPA. This information is used to track three best-practice targets, as well as for other types of analyses by local stroke teams and at the provincial level.

Collecting data on acute stroke patients is itself a process change, and stroke teams have had to work together with EMS services, admin supports and system leaders to design processes for capturing the information at the most efficient place in the work flow. There is considerable

variation across the province in choosing where the required data elements are most easily harvested.

Hospitals in Lloydminster and North Battleford were the first among Saskatchewan hospitals to begin submitting data regularly to Project 340, a special stroke report in CIHI’s discharge abstract database and ambulatory care reporting system. In order to participate in Project 340 at Battlefords Union Hospital, a stroke team developed work standards and new electronic order sets for stroke management to ensure that data elements were captured by clinicians. The stroke team then created a query within Sunrise Clinical Manager to enable managers to identify and pull charts on all patients triaged with neurological deficits. The stroke team reviews charts before data is reported to Project 340 and to the Acute Stroke Pathway. The stroke team may also audit files of incoming stroke patients for additional information, such as to determine if EMS FAST/VAN screening tool was utilized by EMS.

Data collection and reporting

METRICS TARGETS RATIONALEDoor to imaging time (Time between arrival at stroke centre and first cut of CTA)

Median (50th percentile) < 15 minutes.

These metrics show how well hospital processes are working to ensure rapid assessment and treatment of stroke alert patients.

Door to needle time (Time between arrival at stroke centre and administration of TPA)

Median (50th percentile) < 30 minutes. 90th percentile < 60 minutes

Proportion of patients receiving stroke-mitigating treatment (Saskatoon will track numbers of endovascular therapy and TPA. Other facilities will track number of TPA only.)

Expected levels 20% TPA This metric shows that pre-hospital and hospital processes are working to identify, evaluate and transport all patients who are eligible for stroke-mitigating treatment within the required time frame.


In preparation for the next two-year mandate of the Saskatchewan Stroke Expert Panel, new stroke experts have joined the initiative. Dr. Nicolette Sinclair is a radiologist based in Saskatoon, and Dr. Paul Acheampong is an internal medicine specialist with stroke expertise based in Prince Albert. Lori Garchinski, Executive Director, Provincial Services–Tertiary Care, will assume co-chair of the Panel on behalf of the Saskatchewan Health Authority.

The Panel will maintain its role as a clinical authority on stroke care and continue to promote best practice standards and communicate about new research and clinical updates. This may involve issuing advisories as well as working with teams in emergency medicine, hospitals and community therapies to develop tools and processes that support and enable best practice management.

The Panel will also take the opportunity offered by health region amalgamation to work with patients, providers and system leaders on an integrated stroke strategy that incorporates new and exciting work underway by the Saskatchewan Health Authority to design new models for coordination along the stroke continuum of care.

Next steps

stroke care in saskatchewan · kelly, began work on the acute stroke pathway. the initial focus of...

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