The 2017/18 edition of the provincial report card documents significant improvements for ten performance indicators compared to the previous three-year average. Additionally, in comparison to the three-year average, six indicators were unchanged or worsened.
Tissue Plasminogen Activator (tPA) is a time sensitive treatment for a select group of patients experiencing acute ischemic stroke. In 2017/18, significant improvements were noted in the median door to needle time as compared to the previous three-year average rate (45 minutes vs 49.5 minutes), however we are still not meeting the 30-minute target.1
In addition to rapid triage, assessment, diagnosis, and treatment of patients experiencing acute ischemic stroke, increasing public awareness to call 911 may also contribute to more timely access to hyperacute stroke treatment. Ambulance personnel are trained to recognize the signs and symptoms of stroke and to bypass community hospitals to go directly to Designated Stroke Centre capable of providing specialized stroke care. It is therefore, promising to see that in 2017/18 the proportion of stroke/TIA patients who arrived at the ED by ambulance did increase slightly.
Patients who receive stroke unit care are more likely to survive, return home and regain independence compared to patients who receive generalized care.2 In 2017/18 access to this best practice improved significantly, with over half of Ontario’s stroke patients receiving care on a stroke unit. Access to stroke unit care has also been found to influence access to other stroke best practices such as timely and appropriate stroke rehabilitation and applicable diagnostics such as carotid imaging. Further system planning is required to optimize the benefits of stroke unit care and meet the target of 75% access.1
An increased proportion of stroke patients across severity groups are achieving their recommended active LOS targets compared to the previous 3-year average. Correspondingly, significant increases are also seen in FIM efficiency for patients with moderate stroke, which measures the change in functional status during inpatient rehabilitation stay.
The proportion of patients accessing inpatient rehabilitation, however, has decreased in 2017/18 (compared to the previous 3 years). Fully interpreting this trend requires understanding of capacity within the system for community-based stroke rehabilitation services. Patients with severe stroke also had reduced access to inpatient rehabilitation, with a concurrent increase of patients discharged into LTC/CCC. This finding warrants closer monitoring and an understanding of rehabilitation capacity in the system overall, as timely access to appropriate rehabilitation is important for all patients regardless of stroke severity. Further opportunities to enhance integration and access to rehabilitation across the care continuum may be possible as the province moves toward implementation of stroke bundled models of care in fiscal year 2020/21.
Improvements have been made in secondary prevention care, as more ischemic stroke patients with atrial fibrillation filled a prescription for anticoagulant therapy. Referrals are also increasing for secondary prevention clinics; however, the rate at which patients access these clinics is not known, as there is no formalized data collection process or reporting.
There was no change in the overall rate of admission for stroke/TIA in 2017/18, and an increase in 30 day all cause readmission rates for patients with stroke/TIA. Further work is needed to support a coordinated approach to access secondary prevention services and explore the potential impact of integrated care models.
Current or Planned Activities
CorHealth Ontario continues to recommend, initiate and support activities to improve patient access to time dependent stroke therapies such as tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT). Similarly, the Ontario Telestroke Program continues to support access to hyperacute stroke treatment. Expanded use of Telestroke for other services such as rehabilitation and prevention may present an innovative way to address gaps in services in rural and remote areas of the province. To this end, CorHealth Ontario, the MOHLTC and stroke system stakeholders, have bundled elements of best practice care to help ensure that patients experience an integrated and seamless care journey as they transition from acute care to post-acute care. CorHealth has also partnered with the eHealth Centre of Excellence to help primary care providers better identify and manage persons with hypertension, a major risk factor for stroke.
From a stroke system performance and reporting perspective, CorHealth Ontario launched an Information and Digital Strategy in June 2018, to enhance the value of our reporting while reducing the data burden on hospitals. Beginning in 2019/20, new reporting recommendations developed by the Stroke Evaluation and Quality Committee will begin to be implemented to enhance stroke reporting across the care continuum. CorHealth Ontario will also work with the Rehabilitative Care Alliance, the MOHLTC, and stroke providers to improve the quality and availability of outpatient rehabilitation data and patient reported measures.
Over the past year, CorHealth Ontario established an ongoing EVT performance monitoring cycle for Ontario. In collaboration with the EVT Performance Measurement Monitoring Task Group, 2017/18 baseline results for 9 new EVT indicators were produced and made available to EVT hospitals, stroke system stakeholders, and the MOHLTC in the Fall of 2018. Biannual reporting of EVT performance is now available on a dashboard hosted by IDS (Integrated Decision Support), a Business Intelligence Solution, hosted by Hamilton Health Sciences.
CorHealth Ontario will continue to collaborate with Ontario’s 11 Regional Stroke Networks, the MOHLTC and Ontario Health to advance best practice stroke care across the province.
1Heart & Stroke Foundation. Canadian Stroke Best Practices Stroke Quality Advisory Committee. Quality of Stroke Care in Canada. Update 2016 Final (R12). Accessed April 15, 2019 at https://www.strokebestpractices.ca/-/media/1-stroke-best-practices/quality/english/2016strokekeyindicators.ashx
2Boulanger, J., Lindsay, M., Gubitz, G., Smith, E., Stotts, G., Foley, N., … Butcher, K. (2018). Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018. International Journal of Stroke, 13(9), 949–984. https://doi.org/10.1177/1747493018786616