Canadian Best Practice Recommendations for Stroke Care: 2008 An Introduction

1. Canadian Best Practice Recommendations for Stroke Care: 2008 An Introduction

2. Today’s Discussion • Overview of the Canadian Stroke Strategy • Overview of the Canadian Best Practice Recommendations for Stroke Care • Highlights of update for 2008.

3. ~ 50,000 strokes/year 300,000 Canadians living with stroke 16,000 Canadians die from stroke each year 20% chance of second stroke within 2 years Price Tag: $3.6 billion annually For every symptomatic stroke there are 9 ‘silent’ strokes resulting in cognitive impairment Impact of Stroke in Canada Someone has a stroke every 10 minutes

4. Canadian Stroke Strategy • Provides a framework to facilitate the widespread adoption of evidence-based best practices across the continuum of stroke care focusing on two levels of change: • At the national level • At the provincial/territorial level.

5. The Canadian Stroke Strategy Model • Decrease burden of stroke • Improve quality and efficiency of care • Establish Canada as an international leader Provincial/Territorial/Regional Implementation of Best Practice Prevention Prevention Clinics Treatment Protocols, Stroke Teams Rehabilitation Personal Care Plans Reengagement Coordinated Support NationalPlatforms to Support Provincial/Territorial/Regional Strategies Public Awareness Best Practice Guidelines and Standards of Care Professional Development Information/Evaluation Coordinated Research

6. The Canadian Stroke Strategy Model • Decrease burden of stroke • Improve quality and efficiency of care • Establish Canada as an international leader Provincial/Territorial/Regional Implementation of Best Practice Prevention Prevention Clinics Treatment Protocols, Stroke Teams Rehabilitation Personal Care Plans Reengagement Coordinated Support NationalPlatforms to Support Provincial/Territorial/Regional Strategies

7. Public Awareness Best Practice Guidelines and Standards of Care Professional Development Information/Evaluation Coordinated Research

8. National Platforms Best Practices and Standards • Goal is to transform stroke prevention and care. • Development and dissemination of evidence based best practices and guidelines along the stroke continuum of care. • Targeted strategies to increase uptake and implementation • Knowledge translation strategy underway • Long term goal to synthesize more comprehensive list of Canadian best practices and standards with focus on effective dissemination and uptake.

9. National Platforms Information and Evaluation Establish evaluation framework. Focus on data access, surveillance and monitoring. Development of evidenced based performance measures to support monitoring and evaluation of all best practice recommendations. Collaborative initiatives with CIHI and PHAC. Evaluation of stroke strategy overall.

10. National Platforms Professional Development and Training To coordinate and enhance professional development and training opportunities across the continuum of stroke care. Develop point-of-care tools to support and facilitate implementation of best practice recommendations for stroke care. Priority areas identified as focus for creating educational materials.

11. National Platforms Coordinated Research • Leadership from CSN, HSFC in partnership with CIHR, Canadian Stroke Consortium, and others • To assess current status of stroke research • To identify and address gaps that exist in the evidence base Public Awareness • Leadership from Heart and Stroke Foundation of Canada • Public Awareness focus on effective ways of ensuring that the public knows what a stroke is, risk factors, signs and symptoms and the appropriate response.

12. Your Provincial Model

13. Key Provincial Stroke Strategy Resources • Provincial Coordinators • Heart and Stroke Foundation Contacts • Canadian Stroke Strategy • Expertise in strategy development and implementation, best practices and evaluation • Standardized guidelines and tools • Canadian Stroke Network • Links with research and clinical expertise across stroke continuum

14. Canadian Stroke Network HSFC Stroke Survivors Public Health Agency of Canada EBRSR MOHLTC CHEP Canadian Stroke Strategy SCORE Community Care CANN Health Promotion Primary Care CAEP CSQCS CIHI Provincial Initiatives Rehabilitation – all disciplines Accreditation CFPC Establishing Best Practices for Stroke Care in CanadaAlignment leads to great things!! Canadian Stroke Consortium

15. Canadian Best Practice Recommendations for Stroke Care • Synthesis of best practice recommendations across continuum • Address critical topic areas • Commitment to update every two years • First edition released in 2006 • Current update released in 2008 • Refined process • Expansion of recommendations • www.cmaj.ca December 2, 2008

16. Best Practice Recommendations for Stroke Care: Development and Update Process • Utilized conceptual framework to guide identification, selection and development • Ledby a subgroup of the Best Practices and Standards Working Group • Managed by the Performance & Standards Specialist from the Canadian Stroke Network • Identification of interprofessional stroke care experts for task groups and panel membership

17. Best Practice Recommendations for Stroke Care: Development and Update Process • Criteria Identification: • Supported by the highest level of evidence and/or considered essential to delivering best practice in stroke care. • Integral to driving important health system change • Aligned with other Canadian stroke related recommendations • Reflect the continuum of care

18. Best Practice Recommendations for Stroke Care: Development and Update Process • Extensive literature scan of primary stroke research reports, international stroke related guidelines and recommendations • AGREE tool for appraisal of guideline quality • Content review of core reference guidelines conducted to identify list of critical topic areas • Additional stroke topic areas identified • Tables developed to compare content of recommendations across guidelines

19. Review of Existing Guidelines ASA/VADoD CSQCS SCORE Australia CDA CHEP HSFO RCP SIGN New Zealand

20. Best Practice Recommendations for Stroke Care: Development and Update Process • Expert task groups convened to review recommendation tables and research evidence • Canadian recommendations were drafted and updated based on consensus of task groups • National Consensus panel to select and refine final recommendation set • External review by stroke experts and peer review publication process (CMAJ) • Development of Performance Measures by CSS Information & Evaluation Working Group

21. Reorganization of Recommendations 2008 • 2006RECOMMENDATIONS • Public Awareness • Patient and Caregiver Education • Stroke Prevention • Acute Stroke Management • Stroke Rehabilitation • Follow-up and Community Re-engagement • 2008 • RECOMMENDATIONS • Public Awareness and Patient Education • Stroke Prevention • Hyperacute Stroke Care • Acute Inpatient Stroke Management • Stroke Rehabilitation & Community Reintegration • Selected Topics in Stroke Management

22. Recommendation Format

23. Highlights of the 2008 Update • Revisions to the 2006 recommendations: • Minor edits and updates for 21 of the original 24 recommendations. • Recommendation related to computed tomography scanning and carotid imaging were combined to one for Neurovascular Imaging. • Community Rehabilitation recommendation was refocused to include both outpatient and community rehabilitation services.

24. Highlights of the 2008 Update • Additional Amendments: • Discharge planning integrated • Pediatric Stroke issues introduced • New Recommendations: • Emergency medical services care of stroke patients prior to hospital arrival or in transport between hospitals • Acute management of transient ischemic attack and minor stroke • Components of acute stroke management to minimize complications • Vascular cognitive impairment and dementia

25. 1.0Public Awareness and Patient Education Public awareness and responsiveness Patient and family education 2.0 Prevention of Stroke Lifestyle and risk factor management Blood pressure management Lipid management Diabetes management Antiplatelet therapy Antithrombotic therapy for atrial fibrillation Carotid intervention 3.0 Hyperacute Stroke Management Emergency medical services prior to hospital arrival Acute management of transient ischemic attack and minor stroke Neurovascular imaging Blood glucose Acute thrombolytic therapy Acute Aspirin therapy Management of SAH & ICH Canadian Best Practice Recommendations for Stroke Care (2008) Topic Areas

26. 4.0 Acute Stroke Management Acute stroke unit care Components of acute inpatient care 5.0 Stroke Rehabilitation and Recovery Initial stroke rehabilitation assessment Provision of inpatient rehabilitation Components of inpatient stroke rehabilitation Outpatient and community-based rehabilitation Follow-up and evaluation in the community 6.0 Selected Key Topics in Stroke Management Dysphagia assessment Identification and management of post-stroke depression Vascular cognitive impairment and dementia Shoulder pain assessment and treatment Canadian Best Practice Recommendations for Stroke Care (2008) Topic Areas

27. Implementation Tools and Resources • Point of Care Tools • Acute Stroke Management Resource • Toolkit for the Canadian Best Practice Recommendations for Stroke Care (2006) (2008) • Pocket Reference Cards • Cranial Nerves • Common Stroke Presentations • Functions of the brain • National Institutes of Health Stroke Scale • Canadian Neurological Scale • Stroke Prevention Card • Faaast FAQ’s for Nurses • National Professional Education Atlas • Available at: www.heartandstroke.ca/profed

28. Best Practice Standards Dissemination • National release of Canadian Best Practice Recommendations update in CMAJ on December 2, 2008 (www.cmaj.ca) • Website www.canadianstrokestrategy.ca • Broad dissemination across provinces, national and international meetings • Individual consultation within provinces to address regional and local issues, challenges and strategies for dissemination and uptake • Consultation with national and provincial professional associations and groups • Inclusion in stroke related newsletters: • National Stroke Nursing Council newsletter • Canadian Stroke Network Brainwaves

29. Tips Related to Generally Effective Strategies for Dissemination • Educational outreach visits • Interactive educational meetings • Multifaceted interventions including two or more of the following: • Audit and feedback • Reminders • Local consensus processes • Social marketing (Ian Graham, 2006)

30. Ongoing Development of Canadian Stroke Recommendations • Suggested topics to consider for future updates: • Family and caregiver support • Management of post stroke seizures • Discharge planning • Management of patients who experience a stroke while in hospital for other conditions • Telemedicine for stroke care across the continuum • Primary management of atrial fibrillation in patients who have not experienced a stroke • Management of patients with communicative disorders resulting from stroke • Recommendations for specific populations, such as aboriginal groups, visually impaired

31. www.canadianstrokestrategy.cawww.cmaj.ca