Implementation of a provincial acute stroke pathway and its impact on access to advanced stroke care in Saskatchewan

Abstract

BackgroundFor ischaemic stroke, outcome severity is heavily time dependent. Systems of care need to be in place to ensure that patients with stroke are treated quickly and appropriately across entire health regions. Prior to this study, the province of Saskatchewan, Canada did not have a provincial stroke strategy in place.MethodsA quality improvement project was undertaken to create and evaluate a provincial stroke strategy. The Saskatchewan Acute Stroke Pathway was created using a multidisciplinary team of experts, piloted at five stroke centres and then implemented provincially. The number of stroke alerts, door-to-imaging, door-to-needle, door-to-groin puncture times and treatment rates were collected at all centres. Improvements over time were analysed using run charts and individuals control charts.ResultsThe number of stroke alerts province-wide trended upwards in the last 6 months of the study. There were no clear trends or shifts in the proportion of stroke alerts treated with alteplase or endovascular therapy. Across the province, the weighted mean door-to-imaging time decreased from 21 to 15 min, the weighted mean door-to-needle time decreased from 62 to 47 min and the mean door-to-groin puncture time decreased from 83 to 70 min. There was high variability in the degree of improvement from centre to centre.ConclusionsThe implementation of a province wide acute stroke pathway has led to improvement in stroke care on a provincial basis. Further work addressing intercentre variability is ongoing.

Stroke Learning Health Systems: A Topical Narrative Review With Case Examples

“…This was developed in 2014 by a multidisciplinary team of experts and included representatives from the Ministry of Health, the Saskatchewan Health Quality Council, the individual Saskatchewan Health Regions, Emergency Medical Services (EMS), and patient representatives. 21 Process mapping was used to define the hyperacute stroke patient pathway and enabled continued study and refinement that led to a culture of continuous improvement in Saskatchewan. Between June 2015 and December 2016, 5 different centers trialed the proposed pathway using a series of Plan-Do-Study-Act cycles with the final pathway deployed province-wide across 9 centers in January 2017.…”

“…The provincial Acute Stroke Pathway committee provided medical leadership and practical support and feedback to the facility-based stroke teams in supporting their commitment to change. 21 The collaborative nature of the program allowed for process improvements to be discussed regularly with multidisciplinary teams across different centers supporting a shared learning culture. From the successes of this experience, the province committed to developing a centralized dashboard to provide access to real-time data.…”

“…It may have been that in some cases all LHS features were included in the actual implementation of the program, but that these components were not explicitly described in the references. The focus of LHSs for stroke ranged from targeting prevention, 16,18–20 acute treatment of ischemic stroke, 17,21 TIA, 18,22 oral care to prevention of complications after intracerebral hemorrhage, 23 and systems-level adoption to improve the whole patient journey from symptom onset to life back in the community. 15,24,25 Overall, we found more publications from high-income than low-to-middle income countries.…”

Advances in Stroke: Quality Improvement

“…Process mapping was also used in a province-wide stroke system improvement initiative (Saskatchewan Acute Stroke Pathway) in 9 Canadian hospitals which identified QI priorities and resource gaps focused on hyperacute stroke care. 3 The comprehensive QI program included: performance monitoring with audit-and-feedback; standardized order sets; educational workshops; discipline-specific interventions (eg, radiology) to improve timeliness, communication, and documentation; and PDSA cycles. The implementation of this initiative led to improvements for door-to-imaging, door-to-needle, and door-to-groin times across the province.…”

“…Studies sought to understand or support existing stroke system of care in the United States 2 and Canada 3 and to develop new stroke systems of care in China, 4,5 Chile, 6 and Panamá. 7 For example, Zusevics et al 2 used development evaluation to examine the stroke system of care for the Wisconsin Coverdell Stroke Program.…”