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 Family Primary 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 565,500 12,500 miles 2 20,000 km 2 H H H H H H HH 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 & Health Care Team Stroke Recognition Prevention Prehospital EmergencyAcute Rehab Community Transition The Ontario Stroke Strategy Best Practice across the Continuum of Care Stroke Recognition Prevention

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: % 13% 21% HTN treated but uncontrolled Aware but untreated & BP uncontrolled Hypertensive and unaware HTN Treated & BP controlled ~ 2.4 million Ontarians have BP >140/90mmHg (22%)

TIA symptoms 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 % 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 to June

Indicator: KGH Stroke Prevention Clinic waiting times MONTH Number of referrals/mo Ave wait time (days) Aug Oct Dec Aug Mar P2/ 12 P3

SEO SPC Clinic wait times and activity QHC KGH BGH PSFDH

Patient, Family & Health Care Team Stroke Recognition Prevention EmergencyAcute Rehab Community Transition The Ontario Stroke Strategy Best 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 to June 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 to June

tPA - Percentages of ER patients Canadian Stroke Registry - July to June

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

tPA Outcomes: Level of Disability Canadian Stroke Registry - July to June

Patient, Family & Health Care Team Stroke Recognition Prevention Prehospital EmergencyAcute Rehab Community Transition The Ontario Stroke Strategy Best 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 & Health Care Team Stroke Recognition Prevention Prehospital EmergencyAcute Rehab Community Transition The Ontario Stroke Strategy Best Practice across the Continuum of Care Transition management Rehabilitation Community 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) Goal To 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)

DLP: Functional Recovery intervention

DLP: Functional Recovery between Discharge and 3 mths

DLP: Change in Recovery

DLP: Cost Comparisons

“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” “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

The Road Ahead Stroke Best Practice Guidelines Implementation across Ontario