Stroke Network

ANNUAL REPORT 2014 - 2015

INTRODUCTION

Supporting the implementation of Stroke QBP across the regionThe Ontario Stroke Network (OSN) and the Institute for Clinical Evaluative Sciences released the Ontario Stroke Evaluation Report 2014, “On Target for Stroke Prevention and Care” in November 2014. This Report followed the release of the Ontario Stroke Report Cards in June 2014.

The Erie St. Clair LHIN saw improvement on 13 of 18 indicators and Bluewater Health was the high performer in the province for three indicators: the highest proportion of stroke/TIA patients treated on a stroke unit, the highest proportion of acute stroke patients discharged from acute care and admitted to inpatient rehabilitation, and the fewest days between stroke onset and admission to an inpatient rehabilitation unit.

The South West LHIN saw improvement on 11 of 18 indicators and Grey Bruce Health Services (GBHS) (Owen Sound Hospital) was the high performer in the province with the highest proportion of stroke patients with a documented dysphagia screen performed in acute care, and the highest proportion of patients admitted to inpatient rehabilitation with severe stroke.

However, key findings from the Erie St. Clair and South West Local Health Integration Network Report Cards continue to support the need for system improvement by maintaining and reviewing the stroke prevention clinic models of care, consolidating stroke services into designated centres with stroke units, and improving access to inpatient and community rehabilitation.

In February, 2015 Health Quality Ontario (HQO) and the Ministry of Health and Long Term Care (MOHLTC) released an updated Quality-Based Procedures: Clinical Handbook for Stroke (Acute and Post-Acute) with recommended practices for TIA or Minor (Non-

Disabling) Stroke as well as Acute and the Post-Acute Episodes of Care. We were pleased to participate on the expert panel for this updated handbook.

This year we undertook a number of initiatives to drivethe implementation of Stroke QBPs across the region:

1. In partnership with the South West LHIN, all hospitals and CCAC, we led the Regional Stroke Capacity Assessment and Best Practice Implementation Project in 2014-15. This transformational effort examined stroke services across the 28 hospitals currently providing stroke care and made recommendations for the future state of stroke care in the region. On March 17 the South West LHIN Board of Directors approved the following motions: That the South West LHIN Board of Directors accepted the report from the Regional Stroke – Capacity Assessment & Best Practice

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Regional Stroke Team: BR (L to R) - Gwen Stevenson, Jennifer Beal, Paula Gilmore and Gina Tomaszewski

FR (L to R) - Margo Collver, Deb WillemsMissing - Elissa Najm, Dr. Jennifer Mandzia,

Dr. Alexander Khaw and Carol Walters

Implementation Project to realign stroke care from 28 hospitals to 7 hospitals with the addition of another District Stroke Centre in the LHIN.

That the South West LHIN Board of Directors requested LHIN staff to continue to engage health service providers in a facilitated integration process on the realignment of Stroke Care with implementation targeted for fiscal 2015/16 and 2016/17. Next steps include the need for a detailed financial analysis, implementation planning and engagement of impacted organizations prior to implementation

2. Upon our counsel, the Erie St. Clair Quality Council made recommendations to the Erie St. Clair LHIN Board of Directors regarding the need for consolidation of stroke care into stroke units across the LHIN as well as the need for community rehabilitation services. These recommendations led to our development and submission of a business case for Early Supported Discharge Teams. In addition, we supported the Erie St. Clair LHIN Rehabilitation Network to develop a Future State of Stroke Care Pathway for implementation.

3. The March 2014 opening of London Health Sciences Centre (LHSC)’s Hyperacute Stroke Unit, the implementation of in-hospital code stroke protocols at University Hospital and Victoria Hospital, and the opening of a redesigned Acute Stroke Unit (ASU) on April 1, 2015.

4. Huron Perth Health Alliance (HPHA) (Stratford General Hospital) opening of an Integrated Stroke Unit in December, 2014 providing expert acute and rehabilitation stroke care on the same unit.

5. GBHS (Owen Sound Hospital) becoming a Telestroke Hospital in December 2014 as a quality improvement strategy for thrombolysis and opening an ASU April 1, 2015.

6. Sarnia’s Bluewater Health becoming a Telestroke Hospital in June 2014 as a quality improvement strategy for thrombolysis.

Together, we have made great strides forward in 2014/15 towards our vision of “Fewer Strokes, Better Outcomes”. We look forward to continued collaboration in 2015/16.

Paula Gilmore, Regional Program Director

Fewer Strokes. Better Outcomes.

(l-r) Patricia (Trish) Dwyer, outgoing Regional Stroke Steering Committee Chair with incoming Chair, Sharon Jankowski

• Provided leadership and support to the stroke Nurse, Social Work, Speech Language Pathology, Occupational Therapy and Recreation Therapy Networks which each met two or three times per year via videoconference.

• Cathy Vandersluis, Paula Gilmore, Doris Noble, and Carrie Jeffreys completed the Improving and Driving Excellence Across Sectors (IDEAS) Advanced Learning Program on in April 2014 and then shared their learning from the intense nine day quality improvement / change management program in a presentation focused on the South West LHIN Stroke Capacity Assessment and Best Practice Implementation Project.

• Registered Nurses’ Association of Ontario published the Care Transitions Clinical Best Practice Guideline this month. Gina Tomaszewski was part of the Expert Panel that developed the guideline and Paula Gilmore was a reviewer. For a copy of the Care Transitions Guideline please visit www.RNAO.ca

• An abstract entitled “Evaluating the Use of a Logic Model for the Implementation of the Erie St. Clair LHIN Rehabilitation Network Strategic Plan” was presented at the Greater Toronto Area Rehabilitation Network Best Practices Day May 5, 2014.

• Working with the IVEY Business School at Western University we developed a regional marketing campaign on the signs and symptoms of stroke and the importance of calling 911. Three posters were created to engage individuals with relatable scenarios and emphasize the urgency of calling 911.

• Developed “My Stroke Care Binder,” a resource for patients and families, with input from Clinical Neurosciences at University Hospital as well as partners from Parkwood Hospital, St. Thomas Elgin General Hospital, Woodstock General Hospital, Strathroy Middlesex General Hospital, South West Community Care Access Centre and the Community Stroke Rehabilitation Team. For more information contact Gina Tomaszewski.

• The Heart and Stroke Foundation released its’ Stroke Quality Technical Report on June 5, 2014. According to the new Stroke Report from the Heart and Stroke Foundation (Together Against A Rising Tide: Advancing Stroke Systems Of Care) stroke care has improved and death rates from stroke are on the decline. But the Report also shows that the gains we’ve seen in stroke treatment and care will soon be challenged by an aging population, more stroke patients with more complex needs, and an increase in the number of younger people having strokes.

• The Ontario Stroke Network has released a position statement on Regional Stroke Network Infrastructure Funding stating that the Regional Stroke Networks infrastructure hosted by stroke centers must continue to be a region/LHIN-wide resource as despite impressive progress work remains to be done as the Regional Stroke Network infrastructure is vital to the successful implementation of Stroke Quality Based Procedures.

• Participated in the development of the latest issue of the Best Practice Blogger Myth-busting Newsletter for Long Term Care entitled Stroke 5: Perception Issue Summer 2014.

• Education was provided to over 300 front line staff and team Leaders at Cheshire London, an organization supporting adults with physical disabilities in Oxford, Elgin, Middlesex, Huron and Perth counties. Each education session included information on signs and symptoms of stroke, brain functions, and cognition and perception challenges post stroke. Packages were developed and distributed for each staff office which included Best Practice Care Plans and a Tips and Tools Manual and posters that staff can refer to as required when caring for stroke clients.

• On December 1, 2014, the Resident Stroke Care Community of Practice held a webinar on Mobility, Positioning & Transfers hosted by Matt White, a registered Physiotherapist with Revera. The

Stroke Network

ANNUAL REPORT 2014 - 2015

SUMMARY OF ACCOMPLISHMENTS So much to share!

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community of practice targets Long-term Care and Community agency staff who work with stroke survivors, and the over 30 attendees who participated in the webinar included Personal Support Workers, Registered Nurses/Registered Practical Nurses, Educators, Quality Improvement Coordinators and Restorative Care staff.

• Supported Conversation for Adults with Aphasia education workshops took place in Stratford, Owen Sound, and London in February and March 2015, educating 70 health care professionals. This interactive workshop was designed for health care professionals interacting with people who have aphasia, and others who know more than they can say and provide them with innovative communication solutions to increase communicative access for this population.

• Bluewater Health’s Mission Award is for an individual (staff, physician or volunteer) who demonstrates an extraordinary, recognized energy in the way he or she lives Bluewater Health’s Mission. 2014’s Mission Award recipient was Linda Dykes, Manager, District Stroke Centre & Stroke Prevention Clinic. Linda works tirelessly to raise the bar to make Bluewater Health a leader in stroke care in Ontario. She is passionate about doing the right thing to ensure the best care for patients and families. She leads with integrity and believes in collaborative and respectful relationships, supporting her staff and colleagues, and recognizing the leadership of others.

• Hosted Provincial Stroke Rounds with Dr. Alexander Khaw (LHSC – University Hospital) presenting on Intracerebral Hemmorhage.

• Presented a poster entitled, “Acute Stroke Unit Orientation for Health Care Providers,” at the Stroke Collaborative on October 24, 2014 in Toronto, ON.

• Supported the development of an Adult Day Program stroke specific day in Oxford and secured funding for as similar effort in Elgin County.

• Hosted Year of the Brain webinar on Stroke Prevention and Tips for Recovery in February 2014 for an audience of 50.

• Promoted Long Term Care Best Practice Stroke Care Plans to more than 20 LTC Home Administrators and Directors of Care in the Region.

• Published: “Community Stroke Rehabilitation Teams: Providing home-based stroke rehabilitation in Ontario, Canada.” Allen, L., Richardson, M., McIntyre, A., Janzen, S., Meyer, M., Ure, D., Willems, D., & Teasell, R. (2014). Canadian Journal of Neurological Sciences, 41(06), 697-703.

• Abstract “Development of a Hyperacute Stroke Unit at London Health Sciences Centre, Regional Stroke Centre” was presented as a poster at the 5th Canadian Stroke Congress, October 4-7, 2014 in Vancouver.

• Abstract “Therapy Time: Reaching for Best Practice in Stroke Rehabilitation” was presented as a poster at the 5th Canadian Stroke Congress, October 4-7 in Vancouver.

Fewer Strokes. Better Outcomes.

Southwestern Ontario Stroke Network Leadership Team

Meet the Team!

We welcomed new team members and said goodbye to old friends in 2014/2015:

• We welcomed Lyndsey Butler as the interim Regional Stroke Education Coordinator while Jennifer Beal was on maternity leave. Jennifer returned in January 2015 after having a baby girl in 2014.

• We said good bye to Doris Noble on April 30, 2014. Doris served as Manager of the Huron Perth District Stroke Centre since Stratford General Hospital was designated in 2003. We were happy to welcome Ellen Richards to the role in November 2014.

• Dr. Mike Nicolle left the position of Medical Director for the SWOSN in June of 2014 after four years driving stroke care forward in the region. In July 2014, we welcomed two stroke neurologists as Co-Medical Directors, Dr. Jennifer Mandzia and Dr. Alexander Khaw.

• We welcomed Carol Walters to the role of Administrative Liaison for the Regional Stroke Centre in February 2015 when Cathy Vandersluis transitioned to another Directorship within London Health Sciences Centre. We thank Cathy for her dedication and commitment to stroke care both within the Regional Stroke Centre and throughout the region.

• And finally, we say thank you and good bye to Patricia Dwyer for her support and dedication to moving the region closer to our vision of “Fewer Strokes, Better Outcomes” over the past four years serving as Vice Chair and Chair of the Regional Stroke Steering Committee. She has contributed greatly to our accomplishments over the years.

Stroke Network

ANNUAL REPORT 2014 - 2015

COMINGS & GOINGS

(l-r) Patricia (Trish) Dwyer, outgoing Regional Stroke Steering Committee Chair with incoming Chair, Sharon Jankowski

2014-15 Regional Stroke Steering Committee

Fewer Strokes. Better Outcomes.

After four years as Medical Director for the Southwestern Ontario Stroke Network, Dr. Mike Nicolle stepped down from the position on July 1, 2014. It was our absolute pleasure to work with Dr. Nicolle as we have accomplished many quality improvements while he was in the role. We thank Dr. Nicolle for his dedication and commitment to stroke care at London Health Sciences Centre and across Southwestern Ontario. The Southwestern Ontario Stroke Network is pleased to introduce Dr. Jennifer Mandzia and Dr. Alexander Khaw as Co-Medical Directors for the region as of July 1, 2014.

Dr. Alexander Khaw graduated medical school at the Johannes Gutenberg Universität of Mainz, Germany. He is board certified in Neurology after training at Mannheim University Hospital of Ruprecht Karls Universität of Heidelberg, University of Ulm, and Ernst Moritz Arndt Universität of Greifswald, Germany. His residency comprised extensive training in stroke medicine and epileptology. His doctoral thesis on the evolution of glycoconjugate patterns in human vertebral column tissues was rewarded magna cum laude at Johannes Gutenberg Universität of Mainz.He completed an 18-month clinical research fellowship at the Stroke Centre of the Neurological Institute, Columbia University, New York City, with Dr. J.P. Mohr and Dr. Ralph L. Sacco. Dr. Khaw was Director of the Stroke Unit and Neuro-IMC, Ultrasound Laboratory and Cerebrovascular Clinic at the University Hospital Greifswald before joining the University of Western Ontario and London Health Sciences Centre in 2014.

Dr. Jennifer Mandzia completed her PhD training in Neuroscience with Dr. Sandra Black at the University of Toronto. Her doctoral thesis was on functional MRI (fMRI) in patients with Mild Cognitive Impairment (MCI) and structural neuroimaging correlates. She then received her MD from the University of Ottawa and completed her Neurology training at Western University. After residency, Dr. Mandzia undertook a year of fellowship in Cerebrovascular Disease, at the University of Calgary, Calgary Stroke Program, before returning to London to join the department as a staff stroke neurologist.

It is an exciting time for stroke care in the region and there are many opportunities on the horizon for us to work together to help transform stroke care across the region. We look forward to working with Drs. Mandzia and Khaw as we get closer to our vision of: “Fewer Strokes, Better Outcomes”.

Stroke Network

ANNUAL REPORT 2014 - 2015

MEDICAL DIRECTOR ANNOUNCEMENT

Fewer Strokes. Better Outcomes.

Dr. Alexander Khaw

Dr. Jennifer Mandzia

Stroke Network

ANNUAL REPORT 2014 - 2015

REGIONAL PREVENTION UPDATE

This year Regional Prevention has focused on the work plan priorities: implement a process for standardized regional Secondary Stroke Prevention Clinic (SSPC) data collection; implement consistent sleep apnea, cognition, and depression screening; and facilitate a consistent approach to public awareness of the signs and symptoms of stroke.

In the previous fiscal year, the District Stroke Coordinators, Regional Program Director, Regional Acute Care Coordinator, and Regional Prevention Coordinator identified a standard core set of data indicators to be collected at the region’s SSPCs. The intention was to create a picture of the client population served and to identify barriers and successes related to rapid access to specialized stroke prevention services, according to client urgency definition. The data collection tool has been in development since Fall 2014. It calculates timelines when clients access the clinic and diagnostics and whether these meet best practice guidelines. Demographics, final diagnoses, and potential causes of delay are also captured. The tool also calculates summaries of the above. It has been vetted through our Regional and District Stroke Coordinators, Secondary Stroke Prevention Clinic Nurses, and Medical Directors. The final step is to update the urgency definitions and recommended timelines to align with the newly released 2015 Ontario Stroke Network (OSN) Ambulatory Care Triage Algorithm for Patients with Suspected or Confirmed Transient Ischemic Attack (TIA) or Stroke. The goal is to implement the tool in the first half of 2015.

In the latter half of 2014 the Regional Prevention Coordinator visited the region’s SSPCs to gain understanding of the unique processes of each and to identify barriers to the consistent implementation of client sleep apnea, depression, and cognition screening. The barriers reported were consistent across the clinics.

Upon the suggestion of the SSPC nurses, and with the support of the District Stroke Coordinators, planning began for a regional SSPC Workshop addressing “knowledge to action” challenges and gaps, which took place in May, 2015.

The Stroke Prevention Clinic at Bluewater Health has increased access of strokeclinic physician availability to 5 days/week (Monday – Friday) as of December 1,

2014. This has significantly improved timely access to assessment and care for TIA/minor stroke.

Pictured above (l-r) Tracy Christopher, Administrative

Assistant; Carol Lepore, Stroke Clinical Resource Nurse; Linda Dykes, District Stroke Manager; Angela Small

Sekeris, Stroke Clinical Nurse Specialist.

Fewer Strokes. Better Outcomes.

The District Stroke Centres are making improvements to their stroke units based on the new QBP stroke unit definition. Stratford opened their eight bed Integrated Stroke Unit in December 2014. Grey Bruce Health Services opened their three bed Acute Stroke Unit in April 2015 and University Hospital opened an 18 bed ASU in April as well. All teams continue to evaluate the new process in order to provide comprehensive stroke unit care.

LHSC celebrated their one year anniversary of opening their Hyperacute Stroke Unit (HSU) on March 19, 2015. Since the opening of the unit, their door-to-needle times have improved, median door-to-needle time 41 min., from 63 min; median ED door-to-HSU admission time: 93 min from 9 hours. The implementation of a tPA Nurse has resulted in improved performance and sustainability in the hyperacute phase, as well as increased job satisfaction and staff retention. This role’s scope continues to expand and now includes responding to in-hospital code strokes and providing dysphagia screening. Also implemented in 2014/15 at LHSC was an In-hospital Code Stroke. Between 6.5% and 15% of all strokes occur in hospitalized patients. Regardless of where a stroke occurs, stroke patients should have access to best practice stroke care. The Canadian Best Practice Recommendations state that hospital inpatients with a diagnosis of a new stroke

should be assessed in a timely fashion and receive appropriate access to acute inpatient stroke care dependent upon their level of stroke-related impairment and other presenting medical/surgical conditions [Evidence Level B]. The Critical Care Outreach Team is the key responder for the In-hospital Code Stroke protocol at both LHSC sites.

New in Acute Care! Endovascular Therapy (ET) involves the mechanical extraction of a clot directly from the large artery of the brain to allow for recanalization and restoration of cerebral blood flow. ET can be used in combination with IV thrombolysis with large vessel occlusions. Large vessel occlusion can result in greater morbidity and mortality. This endovascular procedure is carried out by neuroradiologists, neurosurgeons, or neurologists with neurointerventional expertise. Two trials (The ESCAPE trial and Mr. Clean Trial) had overwhelmingly positive results. For patients who arrive outside the 4.5 hour IV tPA window or who have contraindications to IV tPA, endovascular treatment may be another option. The Ontario Stroke Network has struck a provincial working group to develop an implementation strategy.

1 http://apps.elsevier.es/watermark/ctl_servlet?_f=10&pident_articulo=13184839&pident_usuario=0&pcontactid=&pident_revista=602&ty=55&accion=L&origen=zonadelectura&web =www.elsevier.es&lan=en&fichero=602v02n12a13184839pdf001.pdf

2 http://www.strokebestpractices.ca/index.php/acute-stroke-management/stroke-unit-care-2/

3 http://www.appliedradiology.com/articles/emerging-role-of-endovascular-and-acute-ischemic-stroke-treatments

Stroke Network

ANNUAL REPORT 2014 - 2015

REGIONAL ACUTE CARE UPDATE(hyperlinks indicated by red underline)

Dr. Vladimir Hachinski and Co-Medical Directors of Southwestern Ontario Stroke Network, Dr. Jennifer Mandzia and Dr. Alexander Khaw along with the stroke project team

and supporters cut the ribbon for the opening of the Acute Stroke Unit at University hospital.

(l-r) Marie Janssen and Denise Martins, tPA nurses working in the Hyperacute Stroke Unit, University

hospital, London Health Sciences Centre.

Fewer Strokes. Better Outcomes.

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Stroke Network

ANNUAL REPORT 2014 - 2015

REGIONAL REHABILITATION UPDATE

Reporting of the AlphaFIM score, a measure of stroke severity and burden of care, became mandatory for all acute stroke admissions this fiscal year. We have worked to support all acute care facilities in the region to meet the target implementation date. 70 people in the region completed certification or recertification in the AlphaFIM. For Q1-Q3, Alpha FIM data for all stroke cases admitted to the LHSC- University Campus CNS program was analyzed and shared with staff. The data provided insights about stroke severity and disposition that will help inform future development of their new acute stroke unit processes.

As a result of performance on the Ontario Stroke Report Card, stroke was identified as a priority by the ESC LHIN Stroke Quality Council. The ESC LHIN Rehabilitation Network resolved to reach consensus on a future state system of care to improve flow, meet best practice and quality based procedures (QBP) standards, and improve the care and outcomes of persons experiencing stroke. A current state inventory was completed and gaps identified using stroke best practice and QBP recommendations. The provincial Rehabilitative Care Alliance’s new definitions for bedded levels of care framework were used to review bed capacity. An evaluation framework was created, identifying indicators and targets for clinical outcomes and system performance. In August 2014 the Erie St. Clair LHIN Rehabilitation Strategic Plan Implementation Committee approved a Future State Stroke Care Pathway for the LHIN.

Necessary elements included rapid access to inpatient rehabilitation for stroke survivors, a plan to meet the needs of persons with severe stroke and availability of specialized, intensive stroke rehabilitation services in the community. A chart audit has been completed in order to understand the characteristics and service needs of Alternate Level of Care patients in inpatient rehabilitation and a business case for an Early Supported Discharge Team for Stroke was approved in principle.

In the South West LHIN, a Summary Report of the LHIN’s Community Stroke Rehabilitation Teams was completed and distributed to stakeholders in early 2014. We also supported a team retreat for the CSRTs. The retreat focused on what it means to work in a transdisciplinary model of care, and participants had time to identify their strengths as well as areas in which they sought improvement.

The teams also began a research project entitled STRIVE-HOME: Stroke Rehabilitation Involving a Videoconferencing Element at Home; The impact and cost-effectiveness of home-based videoconferencing technology for speech language pathology rehabilitation after stroke. This project, funded by the Heart & Stroke Foundation’s Canadian Partnership for Stroke Recovery recruited 26 clients for the pre-intervention, control phase between September and January. The goal is to provide services via videoconferencing for another 26 clients, then compare feasibility, effectiveness and cost.

Finally, the Rehabilitative Care Alliance, an Ontario-wide collaborative working together with stakeholders to standardize rehabilitative care, completed its first two-year mandate. The Rehabilitative Care Alliance’s final report and recommendations Inspiring New Directions in Rehabilitative Care: Rehabilitative Care Alliance Report 2013-2015 is now available. We participated on the Definitions Task Group which created a Definitions Framework for Bedded Levels of Rehabilitative Care and a Referral Decision Tree for Rehabilitative Care.

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Fewer Strokes. Better Outcomes.

This year we were invited to join a host of brain-related organizations across Southwestern Ontario to raise awareness of brain health during 2015 and explore new services for those affected with a brain condition, their families, and caregivers. Year of the Brain 2015 was initiated by three organizations: Brain Injury Association of London & Region, Brain Tumour Foundation of Canada and Dale Brain Injury Services. It has grown to involve more than 17 neurological organizations. Year of the Brain 2015 is a celebration of all things related to the brain. It features a series of events, information sharing activities and educational initiatives that reach out to everyone from the very young, to their parents and grandparents. It addresses the information needs of those directly affected by brain illness and disease, to caregivers, healthcare professionals, volunteers, educators and government officials.

Year of the Brain provides a platform to bring brain health organizations, healthcare professionals and the community together to share information and expertise, and to explore shared solutions and service improvements. Agencies involved in the campaign have created a Southwestern Ontario Brain Health Network, a collaboration that will improve access to services and information.

We are also pleased to report on Living with Stroke, Stroke Care Community of Practice, the launch of a stroke microsite on thehealthline.ca, and Return To Work updates in the Resources section of the annual report. You can see what else happened in Community and Long Term Care in the Accomplishments and What’s New sections.

Stroke Network

ANNUAL REPORT 2014 - 2015

REGIONAL COMMUNITY & LONG TERM CARE UPDATE

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Fewer Strokes. Better Outcomes.

left: Stroke Survivor Kevin Arding speaking at the Brain Fair on April 1st.

above: Regional Team (l-r) Margo Collver,

Lyndsey Butler, Gina Tomaszewski, Paula

Gilmore, Jennifer Beal, Deb Willems, and

Gwenyth Stevenson at YOTB Kick-off.

Stroke Network

ANNUAL REPORT 2014 - 2015

REGIONAL EDUCATION UPDATE

More than 700 health care professionals from a variety of disciplines participated in the educational opportunities we offered last year. These sessions explored stroke best practices across the continuum of care. It was great to see familiar faces as well as meet many new professionals working within the stroke care field.

One such opportunity was a two-day Collaborative Interprofessional Stroke Care Community Re-engagement Workshop designed for health care professionals and community service providers. Attendees at the Fall 2014 event were provided with training materials and resources to implement a community re-engagement framework and an interprofessional collaborative care approach to improve the day-to-day delivery of care to stroke survivors. This workshop also facilitated relationship building between health care professionals and service providers, assisting to enhance communication across transitions for stroke survivors. The workshop will be repeated in Windsor Essex and Huron Perth in 2015/16.

Another opportunity was the Supported Conversation for Adults with Aphasia workshops which took place in Stratford, Owen Sound, and London in early 2015. This two hour interactive workshop was presented to 70 health care professionals interacting with people who have aphasia, and others who know more than they can say (e.g. people who do not speak English). The workshop introduced innovative communication solutions to increase communicative access for people with aphasia and other language disorders.

We continued our work with the eight-level Hemispheres online stroke education series. A variety of stroke related topics are included such as brain anatomy and physiology, stroke pathophysiology, and stroke prevention. The online format allowed individuals participating in Hemispheres to do so at their own pace and schedule. Along with the Regional Stroke Centre at University Hospital, London Health Sciences Centre, we purchased 100 seats for this series in 2014/15. Education also took place in the form of a number of professional network meetings. The Recreation Therapy Stroke Network covered a variety of topics at their face-to-face meeting, including; Taoist Tai Chi TM Arts for Health and Well-being presented by an instructor and stroke

survivor, Supported Conversation for Adults with Aphasia, Optimizing the Leisure Competence Measure (assessment tool), and Understanding Blood Pressure.

Dr. Mitchell Scheiman OD, FCOVD, a leader in vision therapy, was brought to London in March 2015 to deliver Understanding and Managing Visual Deficits after Stroke for therapists and optometrists interested in developing a comprehensive understanding of vision deficits commonly associated with stroke and reviewing management strategies. The well-received workshop provided therapists with practical skills to take back to their own practice settings.

“Fantastic presentation. We’ve been needing this – thank you!”

“I have a lot of training and experience in this

area but learned a lot of practical info. It helped me integrate knowledge and experience.”

“Really love how Occupational Therapists and Vision Specialists can work together!”

Finally, last year we offered three CME approved workshops focusing on Stroke and TIA Management. Approximately, 130 primary care practitioners (family physicians, nurse practitioners, and internists) attended. The format included an overview of stroke and TIA management, small group case study discussions, and a question and answer period.

“Great discussion facilitating knowledge enhancement and closing the practice gaps in selected areas of

stroke care in the primary care setting.” (Stratford)

“Excellent format using small groups for reviewing cases studies.” (Chatham)

“Very helpful and appropriate for family practice.” (Windsor)

Contact Jennifer Beal, Regional Education Coordinator or visit the Southwestern Ontario Stroke Network’s new online Education Calendar for further information on upcoming educational opportunities provided by SWOSN.

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Fewer Strokes. Better Outcomes.

Stroke Network

ANNUAL REPORT 2014 - 2015

CHATHAM KENT DISTRICT UPDATE

The Chatham Kent District Stroke Centre is very proud of our four-bed integrated stroke unit housed on the Inpatient Rehabilitation Unit as well as our Stroke Prevention Clinics and our partnership with the Coronary Artery Disease Clinics. We work with one internal medicine physician for both clinics under the District Stroke Centre umbrella, and work diligently to reduce vascular disease in Chatham-Kent.

We have advanced our clinics from bi-weekly to daily since January to meet best practices. Our patients are seen efficiently by the nurse and physician and in many cases receive their diagnostics on that same visit. We have worked collaboratively within our own team, our administrative support group, registration, diagnostic imaging and of course our physicians. It has been quite a change in work flow for all but how rewarding to pool resources for the best service to our community!

Prevention and stroke awareness is a strong focus again this year and with the help of our Communications Department we will repeat our basic stroke signs and symptoms awareness presentation that sequences with other health information on the television screens in the Emergency Department. One of our stroke unit nurses was the star of the show in a Chatham-Kent Health Alliance ‘Day in the Life’ series on YouTube, entitled “DITL - Cindy Hewitt, an RN in the Stroke Unit “. She does a two-minute segment on care in the stroke unit and her role as a nurse. The District Stroke Coordinator also had the opportunity to participate in a local Heart and Stroke video production to highlight one of our young local stroke survivors. This was released at the ‘Simply Red’ Heart and Stroke Foundation evening gala and broadcast on the local Cogeco channel. Our stroke survivor did a fantastic job adding to his respectable list of local achievements at the New Beginnings Acquired Brain Injury and Stroke Recovery Association. His pride and aspirations rang clear in his words while his colleagues and peers were humbly inspired.

We utilized the Acute Stroke Unit Nursing Orientation manual this March as we held two, day-long education sessions for nurses and therapists working in our four-bed

Integrated Stroke Unit on Rehabilitation. This was very well-received and has instigated some renewed interest in the Apex Hemispheres online interactive stroke education. Kudos to all staff for their passion for stroke patients; many have participated in Provincial Stroke Rounds and other educational events offered.

We updated our stroke order sets and initiated a hemorrhagic order set to meet best practice care and are examining our processes throughout the continuum ensuring Quality Based Procedure recommendations in our District. We hosted an educational event in June entitled “Stroke Best Practice Update 2014” and 55 health care professionals attended. Our local internal medicine physician Dr. Donald Brisbin was the presenter. Also, in November 2014 the region hosted “Stroke and TIA Management Update” in Chatham and 40 primary health care professionals attended. Both events were instrumental in heightening interest in stroke care.

Our District also had some fun participating in the Big Bike. We raised $3,650 with our best turnout ever. We had a great time getting some ‘exercise’ while wearing scrubs and eating pizza!

We are anticipating an exciting year ahead and have gathered an awesome team together to do our best to reduce stroke and cardiac incidence in Chatham-Kent!

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Fewer Strokes. Better Outcomes.

A successful Big Bike Ride 2014

Stroke Network

ANNUAL REPORT 2014 - 2015

SURVIVOR STORY:KNOWING RISKS & SYMPTOMS

Marjorie Butler has led a big life. Feisty and independent, she’s lived all across Southwestern Ontario with her husband. She helped farm 100 acres, raised chickens and ducks and tended a huge garden at another home, and still keeps busy, gardening, knitting, and doing puzzles.

The 81 year old is the mother of 12 children (five sons and seven daughters) born between 1951 and 1976, and she’s the grandmother of 45 grandchildren now spread across the province. “Don’t ask me how many great-grandchildren I have!” she says with a chuckle. She’s borderline diabetic, has pins in her hips and has suffered through the loss of a son and a granddaughter.

It was, however, a series of frightening experiences in December 2014 that led to our conversation. “I woke up December 24 and I couldn’t move my left side at all. I was just trapped there, in bed, with this pain in my side.” Marjorie asked her husband to get her a Tylenol and then she waited in bed until the pain, and the paralysis, subsided.

“It happened again on the 29, 30 and 31. Each time it affected my left side and each time it lasted approximately 4 – 6 hours.”

Marjorie’s mother had her first stroke on Thanksgiving Day when Marjorie was just eight years old. At only 34, her mother was left with paralysis and a lifelong speech deficit. Because her own symptoms didn’t cause any lasting effects, Marjorie didn’t recognize her own symptoms as those of a stroke.

“Now I know that the symptoms can go away – but I didn’t know that at the time. It turns out I was lucky it was just a mini stroke. I learned afterwards that we should have called 911,” she shares.

Following the fourth episode, Marjorie had an appointment with her family doctor in Thamesville who recognized her symptoms as those of a Transient Ischemic Attack and referred her to the Secondary Stroke Prevention Clinic at Chatham-Kent Health Alliance. There, she was diagnosed with severe bilateral carotid artery disease. “Following a TIA, the seven day

risk of stroke for someone with multiple risk factors can be more than 30%,” says Linda Butler, District Stroke Coordinator. “The collaboration between the Chatham-Kent District Stroke Centre and the Enhanced District Stroke Centre in Windsor meant that Marjorie was rapidly assessed, referred and treated for her condition with a carotid endarterectomy, reducing her future risk of stroke significantly.”

A second procedure, on the right side of her neck, is scheduled for June.

Diabetes and a family history put Marjorie at a high risk of experiencing a stroke. She was also experiencing hypertension, which is the single most important modifiable risk factor for stroke. Despite these challenges, the Ontario Stroke System worked for Marjorie by ensuring access to an internal medicine physician with stroke expertise, a stroke prevention nurse, diagnostic testing, an examination by a neurologist and vascular surgeon and a carotid endarterectomy in under a week. Under new guidelines, the District Stroke Centres will strive to achieve these same results within a mere 48 hours.

Marjorie’s message for her loved ones? “Call 911! And look after yourself; eat well and look after your blood sugar and blood pressure!”

Fewer Strokes. Better Outcomes.

Stroke Network

ANNUAL REPORT 2014 - 2015

GREY BRUCE DISTRICT UPDATE

The Grey Bruce District Stroke Centre continued to proceed with the recommended actions outlined in the 2013/14 current state assessment and recommended practices as described in the QBP: Clinical Handbook for Stroke. These actions are supported by the Grey Bruce Stroke Steering Committee and align with the recommendations made by the SW Stroke Regionalization project for consolidating stroke services from 27 hospitals in the SW LHIN to four Stroke Centres of Excellence.

Grey Bruce Health Services, Owen Sound Hospital site became a Telestroke site in December 2014. We had already provided tPA treatment to stroke survivors arriving to hospital within 4.5 hours of the onset of signs and symptoms for many years. Research demonstrates having access to a stroke neurologist 24/7 through Telestroke improves both the speed with which the treatment is provided and the volume of patients who receive this clot busting drug. To support the Telestroke process a Code Stroke team, process algorithm and policy have been implemented and all staff and ED physicians have received NIH Stroke Scale education.

In acute care, our stroke team worked diligently to prepare for the April 1, 2015 opening of a four bed Acute Stroke Unit located on the telemetry unit. A robust education plan was developed and all nursing staff participated in NIH Stroke Scale education. A full interprofessional team started meeting daily to review patients, develop individualized care plans and prepare comprehensive transition plans. Alpha FIM recertification has also taken place this year. A revised and validated dysphagia screening tool has also been implemented. To enhance Data Quality, a new coding summary sheet specific to stroke patients has been piloted and is now fully operational.

The 16 bed Rehabilitation Unit implemented Coordinated Access through CCAC in December 2014.

Our successful collaboration with CCAC ensures that stroke survivors are viewed as a priority admission to Rehabilitation in order to meet the QBP best practice standard for admission on day five for ischemic and day seven for hemorrhagic stroke. A review of current state and required future state as outlined in Project 740 (mandatory reporting of face-to-face time spent between patient and PT, OT or SLP) has taken place.

The Community Stroke Rehabilitation Team continues to travel to stroke survivors in their home and communities. Volume has increased approximately 25%. This team provided two Living will Stroke Education sessions and a monthly Stroke Survivor Group this year.

In conjunction with the SWO Regional Stroke Network, education provided included an EMS workshop (Care of Suspected Acute Stroke), Long Term Care workshop, Physician Telestroke Education session and NIH Stroke Scale education as well as a Supported Conversation (Aphasia) Workshop.

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Community Stroke Rehab Team: (l-r) Kim Dutfield, RN; Stephanie Hughes, OT; Kelly Miller, Rehab facilitator;

Sharon Gray, SW; Jennifer Beaney, RF; Natasha Buchanan, RF; Lynn Curley, TRS; Alison Farrar, PT; Jordan Dyment, SLP;

Stephanie Barker, OT.

Fewer Strokes. Better Outcomes.

Stroke Network

ANNUAL REPORT 2014 - 2015

HURON PERTH DISTRICT UPDATE

It was a year of transitions and exciting progress for the Stroke Program in Huron Perth. New members have joined each of our teams offering excellence across the continuum of stroke care. Building on the strength of the comprehensive plenary work performed in 2013/14, many initiatives are underway to further improve our District’s outcomes.

A significant achievement was the opening of the Huron Perth Healthcare Alliance’s (HPHA) Integrated Stroke Unit at the Stratford General Hospital site. This Unit consists of three acute medical and five rehabilitation beds dedicated to the care of TIA and Stroke patients. The ISU team immersed themselves in stroke best practice, embracing every educational opportunity. Together, they developed processes resulting in a strong interprofessional, collaborative team that employs recognized best practices to achieve patient-specific goals. Exciting outcomes in patient experience and recovery are already emerging.

There was an emphasis on building the teams’ stroke expertise and awareness of advances in TIA/stroke care best practice. A series of Lunch and Learn sessions at HPHA highlighted best practice. National Institute of Health Stroke Scale training sessions were well attended by nursing staff from across the continuum of care. Our nurses also received training in the Barnes-Jewish Hospital Stroke Dysphagia Screen. Also, to better care for our aphasic stroke patients, Supported Conversation for Adults with Aphasia sessions were hosted by Megan Sawicky, Speech Language Pathologist on the CSRT. Concurrently, team members were provided access to Hemispheres online training and used the Acute Stroke Unit Orientation resource. In December 2014, HPHA hosted a Telestroke for Acute Stroke Management session that was well received by a large audience.

The Community Stroke Rehab Team continued to advance stroke best practice within Huron and Perth. As one of three such teams leading community stroke care in Ontario, they looked to strengthen their role to reintegrate the stroke patient back into their life and community. To this end, a Team representative now attends the patient care rounds on the ISU, resulting

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In Occupational Therapy, a stroke patient receives a contrast bath to help with tone & swelling in his arm

A stroke patient prepares to practice walking in Physiotherapy

in more coordinated discharge planning and greater patient engagement in the transition.

Emphasis on prevention and management post stroke or TIA is paramount to the overall goal of fewer strokes. The Stroke Prevention Clinic at Stratford General Hospital saw a significant rise in visits during this year (259 visits verses 214 the previous year). Concurrently, the nurse clinician for the program serves as an invaluable link throughout the continuum from the Emergency Department to the CSRT, further enhancing the patient experience.As the Regionalization Project moves into the second phase, a shared vision for stroke care across the District’s eight hospitals is essential. Following Doris

Noble’s retirement, the role of Manager of the District Stroke Centre was assumed by Ellen Richards. Ellen has been establishing a supportive network of hospitals and service providers, cultivating knowledge of, and implementation of, best practice throughout the District.

2015-16 promises to be another fantastic year full of exciting changes that advance the provision of Stroke and TIA care throughout Huron and Perth counties.

Fewer Strokes. Better Outcomes.

Members of the new ISU team with a patient

Stroke Network

ANNUAL REPORT 2014 - 2015

SURVIVOR STORY:CONFIDENCE & THE CONTINUUM

Sitting in a sun filled kitchen on a lovely April day, Linda Ashcroft speaks eloquently of her stroke story. This vibrant survivor truly represents the success possible thanks to the advances in stroke care evident throughout Southwestern Ontario.

When Linda experienced sudden weakness and impaired speech, her family quickly alerted 911. This resulted in her timely transfer to the Emergency Department at the Stratford General Hospital site of the Huron Perth Healthcare Alliance. There she was triaged and the Stroke Protocol was initiated within 5 minutes of arrival. Linda is thankful that she arrived in time to be considered for the “clot buster” or thrombolysis that she is certain was critical to her recovery. You have to have “the right care at the right time,” she attests.After a short stay in the Critical Care Unit at SGH, Linda was transferred to the hospital’s brand new Integrated Stroke Unit where she was stabilized medically then transitioned seamlessly into her stroke rehabilitation. She recalls being surprised at how quickly she was being encouraged out of bed and dressed in street clothes. “You don’t come into having a stroke with any experience,” she states and she credits the members of the ISU team with her progress to a timely discharge. Her care in hospital was personalized. She recalls one interaction with the dietitian who assured her she could still bake and eat pies in moderation, as this was one of her life’s pleasures.

During Linda’s rehabilitative journey, she faced many transitions. She recalls that planning to return home was her greatest desire and yet filled with unknowns. She praises the transition planning of the ISU and Community Stroke Rehab teams. She credits SGH’s stroke nurse clinician, Louise Flanagan, with creating the sense of an overlap between the two teams. This was very helpful and she “never felt totally out of the loop.”

Once home, Linda was transitioned seamlessly to the CSRT. She knows that the work required to recover further at home was not in her nature. She praises the CSRT for being “aware of what stroke people go through” and providing the motivational guidance to work on the activities required for her to recover further at home.

“The whole business after you have a stroke is getting your confidence back” she recalls. Prior to having her stroke, Linda was working at her son’s business. Together with her CSRT Rehabilitation Therapist, Chelsea Coghlin, Linda identified returning to work as a goal. Chelsea suggested they use the Southwestern Ontario Stroke Network’s “return to work” online tool. This useful tool was an important “guideline of where you are and where you want to get to” with respect to working toward returning to work. She was able to highlight and reflect upon how to manage tasks she felt less confident in performing.

Linda has successfully returned to work part-time. She is experiencing success in overcoming her challenges and gaining confidence quickly. She notes that recovery after a stroke for her was about getting back to everything she used to take for granted. Linda gives credit to the ISU and CSRT staff and the tools at their disposal for her ability to navigate the unknown post stroke. They help answer “what will life be like?” she recalls. Quietly from the distance in the kitchen, her husband thankfully comments “they were a support to me too.”

Rehabilitation Therapist Chelsea Coghlin guides Linda through the online return to work tool.

Fewer Strokes. Better Outcomes.

Stroke Network

ANNUAL REPORT 2014 - 2015

SARNIA LAMBTON DISTRICT UPDATE

Bluewater Health went “live” with new streamlined processes for hyperacute stroke care in June 2014. Significant collaboration and team work led to the implementation of Code Stroke and Telestroke to enhance timely assessment of all stroke patients arriving within the thrombolytic treatment window. These changes have resulted in decreased door to needle times and an increase in patients receiving tPA. The District Stroke Centre supports the care team and is working with the Emergency Department to monitor the new processes, providing feedback for continuous process improvement.

Acute stroke patients continue to receive care on the clustered Acute Stroke Unit that is within the Telemetry Unit at Bluewater Health. Patient and system metrics, demonstrating enhanced outcomes and performance, have been sustained and improved upon. Mortality decreased and remains below the provincial mean since the unit opened in February 2011 (based on the most current data, FY 2013-14). Bluewater Health leads the province with the shortest access time to admission to inpatient rehabilitation from acute care for fiscal years 2012-13 and 2013-14. Lambton residents who have sustained a stroke also had the greatest access to inpatient rehabilitation across the province for the same time period. While this unit model meets the Canadian Stroke Best Practices definition, it does not align with the newer Ontario Quality Based Funding definition released in 2014.

The District Stroke Centre worked closely with the Southwestern Ontario Stroke Network and the Erie St. Clair LHIN to implement the Erie St. Clair LHIN Rehabilitation Strategic Plan. A future state Stroke Care Pathway was approved by the Rehabilitation Strategic Implementation Network and was accepted for poster presentation at the 2015 GTA Rehabilitation Network Best Practice Day. The Stroke and Rehabilitation Programs at Bluewater Health contributed to business case submissions for the Erie St. Clair LHIN Board that address opportunities to realize best practice care and achieve Health Funding Reform and

Quality Based Procedures recommendations. The business case for an Early Supported Discharge Team for Stroke in the ESC LHIN was short listed and approved in principle by the ESC LHIN Board and Quality Council.

The Secondary Stroke Prevention Clinic at Bluewater Health is funded as a part time clinic. This year we worked with various stakeholders to expand physician appointment hours to permit more timely assessment of referred patients. The clinic is working with the SWOSN to establish a minimum data set for collection across the region. The volume of new referrals has increased more than 25% in this fiscal year to 345, challenging existing part-time resources.

Fewer Strokes. Better Outcomes.

Members of the Acute Stroke Team: Pharmacist Gayathri Radhakrishnan, Physiotherapist Leslie Geddes, and Dietitian Julie LeBlanc

Sarnia Stroke Prevention Clinic: Clinical Nurse Specialist Angela Small Sekeris and Administrative Assistant Tracy Christopher

Stroke Network

ANNUAL REPORT 2014 - 2015

THAMES VALLEY DISTRICT UPDATE

The Urgent TIA Clinic and Carotid Endarterectomy Clinics at LHSC’s University Hospital continue to see high volumes of patients. In the 2014 calendar year, the Urgent TIA Clinic and Carotid Endarterectomy Clinic had a combined total of 1235 new referrals and 2018 patient visits. This is an increase of more than 300 patient visits over the previous calendar year.

In Thames Valley there remains a need for a structured approach to community primary and secondary stroke prevention or vascular health programming. The Thames Valley District Stroke Council supported the Step Up to a Healthier You program that was created in the Brant-Haldimand-Norfolk stroke district. Step Up to a Healthier You takes a vascular approach, has been researched, and has been updated to include a self-management component. There has been engagement with stakeholders about this initiative but, to date, there has been no uptake.

LHSC, University Hospital has participated in an array of quality improvement initiatives over the year that resulted in the reduction of door-to-needle times for tPA, as well as the creation of both a hyperacute and acute stroke unit. The Regional Acute Care Coordinator has been a key stakeholder in these initiatives and they are reviewed in more detail in the Regional Acute Care Update.

Regional team members have participated in efforts to streamline referrals and transfers of stroke survivors between the regional acute care and rehabilitation centres at University Hospital and Parkwood Institute.

The Community Stroke Rehabilitation Team (CSRT) in Thames Valley saw approximately 250 new clients this year. This team was also an active partner in the development of Stroke Day programming within the District. A Stroke Day is a specialized Adult Day

Program (ADP) program that offers slower pacedrehabilitation for stroke survivors who have moved past the active rehabilitation phase. Two Stroke Days opened in Thames Valley this year. The Oxford Stroke Day was launched in Woodstock in September 2014, and the Elgin Stroke Day launched in April 2015. We are currently advocating for additional Stroke Days throughout the SW LHIN, including Thames Valley, to ensure availability of such programming for stroke survivors throughout our District.

Finally, we were pleased to host a Collaborative Interprofessional Stroke Care in Community Re-engagement Workshop for the City of London. In this workshop, healthcare and service providers were provided with training materials and resources to implement a community re-engagement framework and an interprofessional collaborative care approach to improve the day to day delivery of care to stroke survivors. The response to this Workshop was very positive and feedback included a request for periodic meetings among participants in the future.

(hyperlinks indicated by red underline)

Fewer Strokes. Better Outcomes.

DID YOU KNOW? Across the District, there were approximately 1900

ED visits and 950 admissions for stroke and TIA. Of these, approximately 50% were seen

at the designated stroke centre.

Stroke Network

ANNUAL REPORT 2014 - 2015

WINDSOR ESSEX DISTRICT UPDATE

Two significant changes happened at the team level this year. Denise St. Louis became permanent District Stroke Coordinator on September 2, 2014 and Rachel Holmes became permanent Stroke Resource Nurse on February 14, 2015.

The realignment of the hospitals has presented some opportunities as well as challenges for our Centre. Windsor Regional Hospital has agreed in principle that all stroke patients in Windsor Essex need to be treated at a designated stroke center for the duration of their hospital stay. To prepare for these changes, and to ensure that our stroke patients receive the best possible care at both sites, the Stroke Resource Nurse is now providing patient and family education and offering clinical support to the nurses at the Metropolitan campus. The acute stroke admission order set has been updated and rolled out at both campuses as well.

We formed a tPA process improvement team in spring of 2014 with the goal of improving our “door to needle” times and increasing the number of patients who receive tPA. We made changes to our order entry system, updated order sets and implemented a one call process for code stroke in the Emergency Department. As of February, all departments involved are notified via a single call when a possible tPA enters Emergency. We have already seen significant improvement in our “door to needle time.” If this pace keeps up we will see a significant increase in patients who benefit from this life altering treatment.

The Urgent TIA clinic continues to provide support to our partners at Chatham Kent Health Alliance. We are collecting metrics to examine timeliness of referrals and diagnostics according to risk, in order to achieve best practice. We are increasing access to CT Angiogram and working closely with the Emergency Departments to ensure efficiency and appropriateness of referrals. The option of telemedicine follow up with an Advanced Practice Nurse is under exploration. Blood pressure

screening for staff and the public is offered monthly at both campuses of Windsor Regional Hospital. In November 2014, our partners in rehab at Hotel Dieu Grace Healthcare (HDGH) implemented a Rehabilitation Intake Nurse role based in acute care. Her role is to support safe, quality transitions and early identification of appropriate rehabilitation candidates. HDGH is also increasing physiatrist presence in acute care to four days per week and is monitoring process indicators with particular attention to time ready for rehabilitation to time admitted to rehab. Our acute and rehab teams are working closely to ensure timely access to inpatient and outpatient rehabilitation. We have already seen a significant reduction in wait time to admission to rehabilitation. HDGH has implemented an rehabilitation stroke order set and Lisa Halley, the Advanced Practice Nurse for Rehabilitation is collecting FIM scores post

Debbie Berthiaume, TIA Clinic Clerk, Dr. Michael Winger, Medical Director District Stroke Centre, Sandra Rebner,

Stroke Prevention Nurse in the TIA Clinic at the Ouellette Campus of Windsor Regional Hospital

discharge to monitor if patients have maintained or improved their FIM score since discharge from rehabilitation.

On November 26 we offered a workshop on stroke and TIA management, targeted to primary care physicians. Thirty-three primary care physicians attended.

Finally, our stroke teams in acute and rehabilitation are looking forward to fundraising and increasing awareness by participating in the Big Bike for Heart and Stroke. Staff and stroke survivors are both participating. We anticipate a little friendly competition between the stroke and cardiac departments at Windsor Regional Hospital!

Fewer Strokes. Better Outcomes.

Christina Sandor, Dietitian and Rachel Holmes, Stroke Resource Nurse at our monthly BP screening clinic

offered to staff and visitors.

Stroke Network

ANNUAL REPORT 2014 - 2015

WHAT’S NEW?

Getting on with the rest of your life following stroke - A Randomized Trial of a Complex Intervention Aimed at enhancing Life Participation Post Stroke Parkwood Institute’s Dr. Robert Teasell was part of a team of researchers who published a study that looked to enhance participation post stroke through a structured, community-based program. Eleven community sites in seven Canadian cities comprised the study setting, and included community dwelling persons within five years of stroke onset, cognitively intact, and able to toilet independently. The interventions used were an evidence-based program delivered in three 12-week sessions including exercise and project-based activities, done as individuals and in groups.

The aim was to estimate the extent to which participation in personal, family, social, and community life be enhanced, over a one-year period, through the provision of a community-based structured program providing the opportunity for exercise, leisure enhancement, life-long learning, and social interaction. A secondary objective was to estimate the extent to which health-related quality of life (HRQL) was impacted on by the program.

Explanatory questions related to the extent to which internal barriers to participation (mobility, symptoms of depression, and apathy) were impacted upon positively by the structured program. Of the 186 persons who were randomized, there were statistically significant increases in all study outcomes on average over all persons. More than 45% of people met or exceeded the pre-specified target of a three hour per week increase in meaningful activity and this most often took a full year of intervention to achieve. Greatest gains were in satisfaction with community integration and stroke-specific health-related quality of life.

“Community based programs targeting participation are feasible and effective but stroke survivors require time to achieve meaningful gains.”

Messages for clinicians:

• Engagement in evidence, needs, and preference-based community rehabilitation program was associated with an increase in the hours spent in meaningful activity.

• Gains in meaningful activity took one year to achieve and were accompanied by changes in satisfaction and health-related quality of life.

• The program was also associated with a reduction in many of the barriers to participation, such as mood, apathy, and mobility.

Provincial Stroke Rehabilitation Resource CentreDeb Willems, Regional Rehabilitation Coordinator chaired a provincial Integrated Task Team charged with identifying and creating provincial resources for Stroke Rehabilitation Best Practice Implementation. The Stroke Rehabilitation Resource Centre, a web-based toolkit on the Ontario Stroke Network website was officially launched in October 2014.

Telestroke Update & New Sites

Telestroke is an emergency medicine application which allows for the assessment and treatment of patients experiencing acute ischemic stroke via consultation with a remote on-call telestroke neurologist. The participating neurologist can review the results of a patient’s CT scan electronically and “see” a patient at the referring site using live video. Referring telestroke sites have a CT scanner, telemedicine network infrastructure, and telemedicine equipment and protocols. Currently, there are 25 referring Telestroke

(hyperlinks indicated by red underline)

sites provincially and 14 consulting neurologists. In Ontario there is a systematic process to assist with the selection of new Telestroke sites.

The SWO Stroke Network has three telestroke sites: Sarnia’s Bluewater Health (June 2014), and Owen Sound’s Grey Bruce Health Services (December 2014) and Goderich’s Alexandra Marine and General Hospital (2010). In the 2012 report, Expanding Telestroke in Canada, telestroke was associated with increasing access to tPA as well as other benefits such as improved clinical collaboration and better use of human resources; and increased patient satisfaction with the health care system. Telestroke can be used to provide hyperacute stroke

care and then ship the patient to a stroke centre for follow-up stroke care referred to as a “drip and ship.” Telestroke can also be used to access 24/7 stroke neurologist coverage or to provide hyperacute stroke coverage for complex cases. The organization decides which model best fits their needs. The team in Owen Sound has reserved telestroke for complex cases. At Bluewater Health telestroke is routinely used. Between April 1st 2014 and March 31st 2015, Bluewater Health had 30 calls and gave tPA 12 times. Goderich had 46 calls and gave tPA 15 times. We anticipate that the Southwest Region’s next telestroke site will be at Stratford General Hospital, the Huron Perth District Stroke Centre.

Fewer Strokes. Better Outcomes.

The Grey Bruce District Stroke Centre stroke team participated in a Telestroke Mock prior to

their Go-Live in December 2014 (left).

Above is the Telemedicine equipment used for telestroke, displaying referring and consulting sites.

Stroke Network

ANNUAL REPORT 2014 - 2015

RESOURCES

Quick Reference Guide for Primary Care Providers – UpdatedThe Southwestern Ontario Stroke Network’s Quick Reference Guide for Primary Care Providers was revised to align with the December 2014 Canadian Best Practice Recommendations in Secondary Stroke Prevention. This resource succinctly summarizes the Canadian Best Practice Recommendations and includes medical targets, online resources, recommended actions for patients presenting with current or recent TIA/stroke symptoms, and contact information for each of the specialized Secondary Stroke Prevention and Urgent TIA Clinics in the region. This resource was voluntarily retired in 2012 to promote the national Quick Reference Guide but was revived this year after multiple requests from Southwest Stroke Region providers.

Stroke Care Community of PracticeThe Stroke Care Community of Practice is a group of health care providers who share a passion for providing best practice stroke care. The group was originally formed to deliver education to long-term care staff but has since evolved to include community support service agency staff as well. The concept of community of practice is increasingly being used in health care as a forum to:

• share and promote best practices, • develop consistencies in practice, and • enhance care at transition points across the continuum

Hour- long webinars providing best practice stroke care

(hyperlinks indicated by red underline)

education are currently offered twice annually and have had an average of 35 attendees. If you would like to be added to the dissemination list for the Stroke Care Community of Practice please contact Margo Collver, Community & Long Term Care Coordinator.

Acute Stroke Unit Orientation We rolled out the Acute Stroke Unit (ASU) Orientation in June 2014. This resource is currently available online and is also structured to be printed and housed in a binder. The purpose of this standardized orientation resource for nurses is to assist them to engage in learning about acute best practice stroke care, whether self-directed or with the support of their organization. Other interprofessional team members are also encouraged to access the resource which consists of eleven stroke care topics that can be completed in any order and are arranged as separate modules, each with its own quiz. Those participating in the ASU Orientation are encouraged to take the online pre-test before starting the orientation, and the post-test upon completion. In addition, an evaluation of the resource should be completed online to assist the SWOSN in making future revisions or updates to the resource.

Return to Work Website Update & PromotionIf you haven’t already, please visit the newly updated Return to Work website. If features new fact sheets on Organizations that Provide Return to Work Services, and Financial Resources. Next year the goal is to include stories of stroke survivors who have benefited from this resource and are excited to share its benefits with you.

Living With Stroke: A Resource for SurvivorsThe Heart & Stroke Living with Stroke workshop (LWS) is an interactive program that has been developed for stroke survivors and their caregivers. The sessions include discussion, videos and activities to help participants learn more about coping with stroke in the community. It also allows stroke survivors to ask questions and hear other peoples’ stories in order to learn how to deal with the impact of stroke. The goal of the LWS program is to improve stroke outcomes by:

• Providing stroke survivors and caregivers with tools• Assisting stroke survivors and caregivers to cope• Facilitating engagement in adjustment and recovery

If you would like information on LWS in your community, or if you would be interested in attending a training session, please contact Margo Collver, Community & Long Term Care Coordinator.

Stroke Micro Site on thehealthline.ca Thehealthline.ca is an accessible resource that provides up-to-date health and social service information from across the province. The website allows users to find information by geography, postal code, and category or keyword search tool.

Our collaboration with the South West and Erie St Clair Healthline sites led to an organized stroke related resource for stroke survivors and caregivers looking for reliable resources. Stroke resources are specifically arranged in a format that supports re-engagement in meaningful activities, life roles and management of stroke risk factors and prevention. Now when you search “stroke”, you will find a micro site packed with useful information on topics including:

• My Health • Getting Around • Social Support • Communication • Care Giver Support

By June 2015 it is expected that each of the stroke regions across Ontario will have their own micro sites dedicated to ensuring stroke survivors have access to necessary resources regardless of where they live. All health, social and community support service organizations are encouraged to register their profiles at www.thehealthline.ca.

F.A.S.T. CampaignWith Heart and Stroke Foundation’s release of the F.A.S.T. campaign in 2014, we have updated our own regional stroke awareness materials to incorporate F.A.S.T. Stroke awareness posters have been updated and distributed, and banners have been created for use across the region. District Stroke Coordinators shall be exploring ways to promote F.A.S.T. in their stroke regions. It is our goal to extend the reach of this campaign and encourage the timely recognition of stroke symptoms and increase the proportion of individuals rapidly calling 911.

F.A.S.T., which is the English version of the bilingual, national campaign, stands for:

Fewer Strokes. Better Outcomes.

Face – is it drooping?Arms – can you raise them?Speech – is it slurred or jumbled?Time – to call 911 right away

The acronym for the French version is V.I.T.E. with corresponding descriptions and call to action. F.A.S.T. has proven to be a successful campaign abroad. The UK saw a large increase in the number of individuals recognizing the signs of stroke and rapidly seeking medical attention after implementing F.A.S.T. This success has led the campaign to be adopted internationally (Medical News Today, May 1, 2014, www.medicalnewstoday.com/articles/276240.php). The UK, Australia, and United States are among the countries currently using F.A.S.T. We hope F.A.S.T. will help Ontarians more easily remember the signs of stroke and call 911.

Ontario’s Ministry of Health has funded television advertisements promoting awareness of F.A.S.T. promotional materials and resources are available at Heart and Stroke Foundation of Canada.

2014 Canadian Best Practice Recommendations in Stroke Care: Secondary Stroke Prevention GuidelinesIn December 2014 the Heart and Stroke Foundation of Canada released the updated Canadian Best Practices Recommendations in Stroke Care for Secondary Stroke Prevention. As the title indicates, this version focuses solely on Secondary Stroke Prevention and refers readers to the best practice recommendations for individual risks factors (i.e., CHEP, CDA, etc.) for guidance on primary prevention. Unlike recent years, the latest guidelines were released in the International Journal of Stroke and can be accessed, via a link, from www.strokebestpractices.ca, which also houses updated supplementary content, such as rationale, summary of the research, and knowledge and implementation tools. There are several major additions to the best practice guidelines. Most notably the addition of the risk stratification criteria for those presenting with TIA or mild, non-disabling stroke, and recommendations for immediate medical management for those falling within each urgency level. A new section on the management of patent foramen ovale and aortic arch atheroma was introduced. Recommendations for secondary stroke prevention in the presence of recreational drug use are a new sub-section added under Lifestyle Risk Factors. Updated diagnostic recommendations have been made for symptomatic carotid stenosis and atrial fibrillation. As well, management guidelines for non-valvular atrial fibrillation have been revised to include newly available novel oral anticoagulants. Anticoagulation therapy for atrial fibrillation in the presence of mechanical heart valves has not been included.

A summary of line-by-line changes between the 2014 Canadian Best Practice Guidelines in Stroke Care: Secondary Stroke Prevention Guidelines and the 2012 Canadian Best Practice Guidelines in Stroke Care: Stroke Prevention is a available from the Southwestern Ontario Stroke Network. Please contact Gwenyth Stevenson, Regional Prevention & Thames Valley Coordinator.

Stroke is an Emergency.

Stroke Network

I said I was fine. He knew the signs & called 911.

Stroke Network

ANNUAL REPORT 2014 - 2015

WATCH FOR IT!

Stroke Rehabilitation Unit Orientation DevelopmentA Stroke Rehabilitation Unit Orientation is in development. This resource is a standardized evidence-based education program for nurses. Stroke experts from across SWO meet monthly to review orientation content and hope to complete the resource for delivery to the region in early 2016/17.

Provincial Stroke Units Implementation ResourceA Stroke Unit Implementation Resource is being developed by several Ontario Stroke Network experts. The resource will be web based and will assist stroke centres with stroke unit implementation. The committee is still in its early stages and hopes to have the resource available late 2016.

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Fewer Strokes. Better Outcomes.