Context APSS SAP QuICR QI objectives Door-to-needle  #DTN30min Endovascular TIA/minor stroke 23/11/2018

Stroke is a clinical syndrome defined by imaging Ischemia: AIS and TIA (85%) Intracerebral hemorrhage (7.5%) Sub-arachnoid hemorrhage (7.5%) 11/23/2018 Calgary Stroke Program

System-wide Changes in Care #DTN30min Michael D Hill, MD MSc FRCPC Professor, Neurology QuICR Project Grant Lead

In the beginning….we knew we had to be fast In a typical large vessel acute ischemic stroke… 1.9 million neurons 14 billion synapses 12 km of myelinated fibers are destroyed each minute… (Saver et al, 2006)

Case #1 JK. 67 year old man Walking the dog at 0730 Past history – HTN; stroke at age 40 Walking the dog at 0730 0850h develops L hemiplegia NIHSS 21 IV tPA DOOR-TO-NEEDLE time = 14 minutes

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Outcome Dramatic improvement Discharged home in 3 days Ongoing work-up; no obvious cause found - ESUS 23/11/2018

KKY. 86 year old woman Cantonese speaking Found in the morning by a college student boarder Last seen well 2100h the night before – but dressed, had made breakfast. Later confirmed that she was seen well at 0600h NIHSS = 20 IV tPA given DOOR TO NEEDLE = 45 minutes Improved to NIHSS = 8, then worsened back to 20 23/11/2018

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NIHSS falls to 1, post-angio 23/11/2018

Outcome NIHSS remains 1 Recovers Returns to the community Suspected AFIB. Outpatient investigations pending 23/11/2018

Concept: Stroke Unit Care History compared CCU Patients cared for on a stroke unit are: more likely to return to work and/or home less likely to die less likely to suffer complications such as pneumonia or pulmonary embolism more likely to have a better quality of life at 5 years cost the system less by requiring a shorter in-patient stay

Stroke Units prevent death NNT = 11 (95%CI 7-25) to prevent one death

Stroke Unit Care

Age-specific acute vascular event rates in the general population Data from Oxfordshire, UK, 2002-05. Lancet 2005;366:1773-83

All Stroke (430,431,434,436), 1999/00 Canada rate = 151.6 per 100,000

System-wide care change Approach Implementation Ongoing nature of the work Comparisons to other systems of care 23/11/2018

Strategy on Patient Oriented Research (SPOR): Addressing the two Death Valleys Valley 1 refers to the decreased capacity to translate the results of discoveries generated by basic biomedical research in the laboratory to the bedside as well as to successfully commercialize health discoveries. Valley 2 refers to the limited capacity to synthesize, disseminate and integrate research results more broadly into health care decision-making and clinical practice.

Research and Clinical Care Inter-twined Research DRIVES good clinical care New treatments New techniques Quality improvement Outcomes

Innovation in Research Education Program CLINICAL CARE – Quality Improve-ment Clinician Researcher Research drives clinical care Clinical care drives research Good research programs bring the best doctors The best doctors do the best research

System change in ongoing Continue this process Address other aspects of stroke care Population care….. 23/11/2018

System Change Challenging Ongoing Focus – will remain on acute stroke – first 24h as the theme Legacy 23/11/2018

Future Opportunities: Idea generating session DTN initiative, maintenance and legacy Registry – data and feedback. Fully embed this into the care system Saskatoon, Vancouver Inpatient stroke Stroke in the non-stroke centre hospital Consolidation and integration of ERA ACHIEVE the 30 min DNT province-wide 23/11/2018

Legacy Add ICH to the registry. Collect data. TIA and minor stroke Build on the ASPIRE tool Clinical decision support tool Focus on process outcomes and management Focus on diagnostic accuracy and then implementation of beset practices 23/11/2018

Collaborative Sessions Develop a new collaborative focussing on these new initiatives TIA and minor stroke ICH Consolidation of IV alteplase (tPA) and integration with ERA 23/11/2018

New trials TEMPO-2 – tenecteplase for minor stroke ESCAPE-NA1 – novel drugs for acute stroke ICH-ADAPT2 – Blood pressure treatment in the ED DATAS2 – new drugs for TIA/minor stroke PERDIEM – AFIB detection ACHIEVE – stroke ambulance These projects will result in new knowledge that will need to be translated. We need the collaborative and SCN to do this. 23/11/2018