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

2. 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

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

4. 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)

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

10. 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
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13. NIHSS falls to 1, post-angio
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14. Outcome NIHSS remains 1 Recovers Returns to the community
Suspected AFIB. Outpatient investigations pending
23/11/2018

15. 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

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

17. Stroke Unit Care

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

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

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

21. 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.

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

23. 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

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

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

26. 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

27. 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

28. 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

29. 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