The Experience of the Canadian Stroke Network: Bringing Knowledge to Practice

1. The Experience of the Canadian Stroke Network: Bringing Knowledge to Practice Quebec Summit to Conquer StrokeOctober 7, 2008Montreal, Quebec Antoine M. Hakim CEO & Scientific Director Canadian Stroke Network

2. A Canadian Hospital’s Experience with t-PA (2000) “29 stroke patients received t-PA from 1996-1999. This represents approximately 1.8% of all ischemic strokes seen at our institution” KM Chapman.......P Teal. Stroke 2000;31:2920

3. Risk Factor Management: Control of BP

4. 1999: The Canadian Stroke Network was created To reduce the impact of stroke through: Focused, Collaborative Research Capacity Building Knowledge Application

5. Canadian Stroke Network Goals To reduce the impact of stroke through: Focused, Collaborative Research Capacity Building Knowledge Application

6. CSN Research Covers the Stroke Spectrum Theme 1:Prevention Theme 2:Treatment Theme 3:Reducing Damage Theme 4:Rehabilitation/Recovery • 10 projects underway • Over $8M funded research from 2008- 2010 6

7. Registry of the Canadian Stroke Network • Clinical database of consecutive stroke patients from >20 hospitals across Canada (Phase I & II) • Data is collected by full time nurse specialists • Acute care • Follow-up data (30d, 6m) • Custom software package e-data transfer to Toronto • Linkages of data between administrative databases in progress • ~30,000 patients registered

8. Highlights of the CSN Registry • It is actively being used to improve quality of care. • The Registry forms an integral part of the Ontario Stroke Network in evaluating and monitoring delivery of care. • It is one of the world's richest stroke databases and it is producing valuable research results. For example, recent publications based on Registry data prove the indisputable value of stroke units in saving lives and reducing disability (Saposnik et al), issues around treatment of in-hospital strokes (Silver et al), inadequate treatment of atrial fibrillation (Gladstone et al) • Web-based data collection began this year.

9. Prevalence of WMH (white matter hyperintensities) Prevalence (%) of silent and symptomatic infarcts visible on MRI per 5-year age category Prevalence (%) age (years) Stroke. 2002 May; 33(5): 1179-80

10. Elevated Blood Pressure in Midlife Results in Poor Cognitive function in Later Life

11. Each 1 mmHg increase in BP, over time, increases the risk of poor late-life cognitive function by approximately 1%. Launer LJ, et al. JAMA 1995; 274:1846-1851.

12. Canada’s Population is Sick! 24% adults and 52% of seniors have hypertension* *2005 Ontario data. CMAJ 2008 178:1458 Is getting Sicker! 1995-2005 Prevalence increased by 60%* And is expected to get Worse! Further 60% increase in prevalence projected by 2025 Lancet 2005 365:217

13. Risk of Dementia with Brain Small Vessel Disease (SVD) • In population-based studies (not including imaging), cerebrovascular risk factors alone (Age, gender, BP, DM, smoking, heart disease) are associated with worse cognitive function BMC Neurol 2008; 8:12 • Presence of WMH increases risk of dementia 4-fold Ann. Neurol 2007; 62:59-66 • Cognitive decline is worse in presence of thalamic lacunes • WMH affects executive cognitive (frontal lobe) functions, produce more perseverative errors, and have less effect on attention and working memory

14. Canadian Stroke Network Goals To reduce the impact of stroke through: Focused, Collaborative Research Capacity Building Knowledge Application

15. Training Health Professionals • CSN co-sponsored with the Canadian Stroke Consortium and industry partners theANNUAL NATIONAL STROKECONFERENCE, bringing together emergency room (ER) physicians, internists and neurologists to hear about the latest research in stroke care and find out about best practices. • CSN co-sponsored anANNUAL REVIEW COURSEfor neurology residents and a conference on aphasia. • CSN co-sponsored the National Stroke Rehabilitation Conference to bring together rehab specialists for an intensive course on the latest stroke research. • CSN sponsored theNATIONAL STROKE NURSINGCOUNCIL, which promotes research and education.

16. Developing the Next Generation of Stroke Researchers • Summer studentships every year in stroke research labs across Canada. Since 2001, more than $350,000 has been invested. • Focus on Stroke training program has funded 116 doctoral, post-doctoral and new-investigator awards with a total investment of $9.5 million. • Canadian Stroke Network Trainee Association (CSNTA) is sponsoring learning events; providing representation at CSN meetings; encouraging collaboration; and developing core competencies. • Working with an industry partners to develop a new post-doctoral training program.

17. Canadian Stroke Network Goals To reduce the impact of stroke through: Focused, Collaborative Research Capacity Building Knowledge Application

18. “Knowing is not enough; we must apply. Willing is not enough; we must do.” Johann Wolfgang von Goethe

19. The Canadian Stroke Strategy Model “The Canadian Stroke Strategy (CSS) is a framework to change policy and practice where health care is delivered…this is about real health systems change.”

20. Canadian Stroke Strategy Provincial/Regional Implementation of Best Practice Reengagement Prevention Treatment Rehabilitation National Pillars to Support Provincial/Regional Strategies Public Awareness Best Practice Guidelines/Standards Professional Development Information Platform Coordinated Research

21. National Pillars: What Needs to Happen • Large scale public awareness campaign of the signs and symptoms of stroke • Making best practices and standards of care in stroke accessible, reinforced by stroke centre accreditation • National tracking of key performance indicators • Novel stroke training programs for health professionals, including team-based approaches for stroke care • Coordinated research in stroke, including clinical trials

22. Recommendations across the continuum of prevention through to community reintegration Rationale and summary of the evidence provided Implications to the healthcare system described Performance measures defined Consumer-friendly versions in development Used as the content for hospital accreditation and point-of-care tools Canadian Best Practices Features:

23. Identify a Clinical Area to Promote Best Practice • Schedule Review and Revision of Local Guideline Best Practice Development & Evaluation Cycle 2. Establish an Interdisciplinary Guideline Evaluation Group • Obtain Official Endorsement and Adoption of Local Guideline 8. Finalize Local Guideline • Establish Guideline Appraisal Process • Seek External Review – Practitioner and Policy Maker Feedback; Expert Peer Review • Search for and Retrieve Guidelines • Assess Guidelines • Quality • Currency • Content • Adopt or Adapt Guidelines for Local Use (Adapted from Graham et al, 2005)

24. International Collaboration • Endorsement of the CSS Best Practices by World Stroke Organization • WSO leading international effort to align guidelines and support less developed countries in organizing stroke care based on best practice standards

25. Key Performance Indicators Stroke Unit CT/MRI before D/C Discharge Location SPC Referrals Time to CEA Antiplatelet Rx Anticoags for A-Fib Arrival time to ED Prevention Stroke Pre Hospital Hyper acute Acute Rehab Community Risk Factors Public Awareness Incidence Mortality tPA rates CT Scan DTN Time Admit rates for inpt rehab Wait times Change in FIM D/C Disposition LTC admit Rates Home care service rates Home care duration/intensity

26. Organizing Provinces/Regions Regional Stroke Centre • Neurosurgeon • MRI • Angiography • Leadership for regional plans District Stroke Centre • Neurologist/ Stroke Expert • 24/7 CT Scanner • Leadership for district plans Community Network • Local Hospital • CCAC • Primary Care Practitioner • LTC/Rehab/CCC • PHU • Support groups DSC RSC DSC DSC

27. Impact of the Canadian Stroke Strategy • Average tPA rate increased to 11.2% in designated regional stroke centres (some sites as high as 30%) • Inpatient admissions for stroke decreased by 11%, mostly attributable to a decrease in admissions for transient ischemic attacks (TIA) or small strokes • 54% increase in patients receiving referrals to stroke prevention clinics following initial stroke/TIA to prevent more serious event (there are now 19 prevention clinics in Ontario) and spreading across Canada

28. Number of patients now managed on specialized stroke units increased from 9% to 42% Physiotherapy assessments before hospital discharge have increased from 47% to 75%, and occupational therapy consults from 38% to 71% 85% of patients discharged from regional stroke centres on antiplatelet medications to help prevent another stroke 8.7% of patients require admission to long-term care following stroke - a major decrease from 2 years previously Impact of the Canadian Stroke Strategy

29. Economic Impact • Based on current Canadian population, widespread access to organized stroke care would, over next 20 years: • Prevent 160,000 strokes • Prevent disability in 60,000 Canadians • Achieve net savings of $8 billion

30. The CSN is Making a Difference • A leading funder of multi-disciplinary stroke research in Canada • Moving research to the bedside • Transforming patient care in all parts of Canada • Developing critical tools for researchers and the public • Leading efforts in stroke prevention • Expanding the world’s richest stroke database • Training health professionals • Mentoring and supporting the next generation of researchers • Forging national and international collaborations • Getting the message out

31. Leadership commitment and support Key stakeholder involvement Simple changes in practice should be introduced first. Regular communication must convey the evidence It takes money…and patience. Data gathering, evaluation and monitoring of outcomes. Educate, educate, educate. What you Need to Change the Healthcare System 31