Stroke Distinction Report...

Transcription

1 Alberta Health Services, Stroke Program Edmonton Zone Edmonton, AB On-site Survey Dates: February 26, March 2, 2017 Report Issued: April 3, 2017

2 About the Distinction Report Alberta Health Services (AHS) Stroke Program Edmonton Zone (referred to in this report as the organization ) is participating in the Accreditation Canada Distinction program. As part of this ongoing process of quality improvement, an on-site survey was conducted. Information from the on-site survey as well as other data obtained from the organization were used to produce this Distinction Report. On-site survey results are based on information provided by the organization. Accreditation Canada relies on the accuracy of this information to plan and conduct the on-site survey and produce the Distinction Report. Confidentiality This report is confidential and is provided by Accreditation Canada to the organization only. Accreditation Canada does not release the report to any other parties. In the interests of transparency and accountability, Accreditation Canada encourages the organization to disseminate its Distinction Report to staff, board members, clients, the community, and other stakeholders. Any alteration of this Distinction Report compromises the integrity of the process and is strictly prohibited. Accreditation Canada, 2017

3 A Message from Accreditation Canada On behalf of Accreditation Canada, I extend my congratulations to the Stroke Program Edmonton Zone, AHS on your participation in a program that recognizes organizations that demonstrate clinical excellence and an outstanding commitment to leadership. I hope you find the Distinction process to be an interesting and informative experience, and that it is providing valuable information that you are using to plan your quality and safety initiatives. This Distinction Report shows your decision, as well as final results from your recent on-site survey. I encourage you to use the information in this report to guide your ongoing quality improvement activities. Your Accreditation Specialist is available if you have questions or need guidance. Thank you for your leadership and for demonstrating your ongoing commitment to quality by integrating Distinction into your quality improvement program. We welcome your feedback about how we can continue to strengthen the program to ensure it remains relevant to you and your services. Sincerely, Leslee Thompson Chief Executive Officer

4 Table of Contents Distinction Introduction 1 Executive Summary 2 Distinction Decision 2 On-Site Survey Information 4 Overview of Results 7 Summary of Evaluator Team Observations 7 Distinction Standards 9 Standards Set: Providing an Integrated System of Services to People with Stroke 10 Standards Set: Acute Stroke Services 14 Standards Set: Inpatient Stroke Rehabilitation Services 31 Distinction Protocols 36 Performance Indicators 42 Standards Set: Acute Stroke Services 42 Standards Set: Inpatient Stroke Rehabilitation Services 46 Standards Set: Optional 47 Client and Family Education 52 Excellence and Innovation 60 Next Steps 61

5 Introduction Distinction The Accreditation Canada Distinction program recognizes organizations that demonstrate clinical excellence and an outstanding commitment to leadership in a specific field of expertise. The program is developed in close consultation with key stakeholders and content experts to reflect detailed practices and the most up-to-date evidence. It offers rigorous and highly specialized standards of excellence, indepth performance indicators and protocols, and an on-site survey by expert evaluators with extensive practical experience in the field. The program includes an on-site survey every four years. The Distinction program includes the following key components: Standards: Distinction standards are based on the latest research and evidence related to excellence in the field. Protocols: Distinction requires the use of evidence-based protocols to promote a consistent approach to care and increase effectiveness and efficiency. Indicators: A key component of the Distinction program is the requirement to submit data on a regular basis and meet performance thresholds on a core set of performance indicators. Client and Family Education: Client, family and caregiver education and self-management support are integral parts of stroke care that should be addressed at all stages across the continuum of stroke care for both adult and pediatric clients. Education is an ongoing and vital part of the recovery process for stroke, which must reach the survivor, family members and caregivers. Excellence and Innovation: Distinction clients must demonstrate implementation of a project or initiative that aligns with best practice guidelines, utilizes the latest knowledge, and integrates evidence to enhance the quality of care. Introduction 1

6 Executive Summary Distinction Alberta Health Services (AHS), Stroke Program Edmonton Zone (referred to in this report as the organization ) is participating in the Accreditation Canada Distinction program. Accreditation Canada is an independent, not-for-profit organization that sets standards for quality and safety in health care and accredits health organizations across Canada. As part of the Distinction program, the Stroke Program Edmonton Zone has undergone a rigorous evaluation process. External peer evaluators conducted an on-site survey during which they assessed the organization's programs and services. Results are included in this report and were considered in the Distinction decision. Please see Appendix A for a copy of the Decision Guidelines. This report shows the results to date and is provided to guide the Stroke Program Edmonton Zone as it continues to incorporate the principles of Distinction and quality improvement into its programs and services. Both AHS and Covenant Health are represented in the Stroke Program Edmonton Zone. As the two largest health care providers in the province, AHS and Covenant Health work closely together on various health issues to ensure patients get the care they need, when they need it. The Stroke Program Edmonton Zone is commended on its commitment to using Distinction to improve the quality and safety of the services it offers to its clients and its community. Distinction Decision Accreditation Canada is very pleased to recognize The Stroke Program Edmonton Zone, AHS for earning Distinction in Stroke Services for the following locations and services: Providing an Integrated System of Services to People with Stroke Inpatient Stroke Rehabilitation Services Protocols for Stroke Rehabilitation Services Client and Family Education Protocol Acute Stroke Services Protocols for Acute Stroke Services Client and Family Education Protocol Executive Summary 2

7 Acute Stroke Services Protocols for Acute Stroke Services Client and Family Education Protocol University of Alberta Hospital Acute Stroke Services Protocols for Acute Stroke Services Client and Family Education Protocol Executive Summary 3

8 On-Site Survey Information On-Site Survey Dates February 26, 2017 to March 2, 2017 Locations The following locations were assessed during the on-site survey. Glenrose Rehabilitation Hospital Grey Nuns Hospital (Contracted Hospital) Royal Alexandra Hospital University of Alberta Hospital Executive Summary 4

9 Overview of Results The following is an overview of the organization s results for each component of the Distinction program. Component Achievement Met Unmet Total % Standards Providing an Integrated System of Services to People with Stroke Acute Stroke Services Grey Nuns Hospital (Contracted Hospital) Royal Alexandra Hospital University of Alberta Hospital Inpatient Stroke Rehabilitation Services Glenrose Rehabilitation Hospital Distinction Protocol Glenrose Rehabilitation Hospital Grey Nuns Hospital (Contracted Hospital) Royal Alexandra Hospital University of Alberta Hospital Distinction Education Executive Summary 5

10 Component Achievement Met Unmet Total % Glenrose Rehabilitation Hospital Grey Nuns Hospital (Contracted Hospital) Royal Alexandra Hospital University of Alberta Hospital Distinction Excellence and Innovation Early Supported Discharge Executive Summary 6

11 Summary of Evaluator Team Observations The evaluator team made the following observations about the organization s overall strengths, opportunities for improvement and challenges. The Edmonton Zone Stroke Program (SPEZ) provides comprehensive stroke care and leadership in stroke care delivery to the North, Edmonton and Central Zones of Alberta, as well as part of British Columbia, Saskatchewan, and the Northwest Territories. It is a complex system, delivered in three acute care and a single rehabilitation centre in the Edmonton Zone, and multiple primary stroke centres in rural Alberta. Extensive use of the RAAPID North hotline and Telestroke, and support for stroke services in rural Alberta are critical parts of the program's mandate. Improvement in access to hyperacute and acute stroke care in rural areas reflects the program's commitment to equal access to care for all Albertans. The leadership and staff are dedicated to excellence in stroke care. There is notable physician engagement in this program with excellent collaboration amongst the specialists providing stroke care. There is a highly motivated stroke care team, many of whom have been providing stroke care for years. Job satisfaction was noted to be uniformly high amongst staff at all sites. They feel well supported by their managers and organization for continuing education in stroke care. The program enjoys an excellent Program Manager who provides strong leadership to the Zone. Unit and site leadership at all sites supports and owns high quality stroke care. There are some key individuals in the management of the stroke program; there is an opportunity for succession planning for these positions. The program uses Canadian Best Practices in Stroke Care, and many of its physicians and staff are contributors to these best practices. These standards of care are embedded in the delivery of excellent stroke care which occurs everyday at all sites. Improvements to the stroke care provided to rural areas has been outstanding. Innovations in care delivery such as the pilot Stroke Ambulance initiative demonstrate the program's continuing commitment to excellence in service to northern and central Alberta. There are capacity issues throughout the system; an opportunity is to review processes as a program to try to find innovative solutions to this problem. There are numerous community resources for stroke survivors and their families, accessed through many interagency partners. These partners collaborate with the stroke program to provide public awareness, and services at graduated levels of care in the community. Management of stroke related risk factors is a significant part of the mandate of the program and its partners. The peer support Stroke Recovery group provides support to patients in hospital, their families, and their peers. A comprehensive database has been developed by the stroke team and the zone informatics and analytics group to inform the program and staff of their performance through stroke indicators and administrative and clinical Executive Summary 7

12 data. Planning for a provincial clinical information system and electronic medical record will allow the program to link guidelines and decision support tools to the data it collects and interprets. Data is critical to ensuring that the program meets standards as measured against other stroke programs provincially and nationally. There is an opportunity for the program to engage stroke survivors and their families in planning for service delivery and stroke education. The program and sites measure patient and family satisfaction, and the rates of satisfaction with care are high. An opportunity is to standardize this process, tailoring it specifically to stroke care across the Edmonton zone. Executive Summary 8

13 Standards Distinction The Distinction standards identify policies and practices that contribute to high quality, safe, and effectively managed care in a specific area of expertise. Each standard is followed by a number of criteria that are statements about the activities required to achieve the standard. High priority criteria are foundational requirements for delivering safe and quality services and are identified by a red exclamation mark in the standards. During the on-site survey, the evaluators assessed the organization s compliance with each section of the standards, and provided the following results. The following tables indicate the criteria in the standards that were rated unmet during the on-site survey. As part of ongoing quality improvement, the organization is encouraged to address these criteria. High Priority Criteria Other Crietria All Criteria Standards Set Met Unmet N/A Met Unmet N/A Met Unmet N/A Providing an Integrated System of Services to People with Stroke 6 (100.0%) 0 (0.0%) 0 35 (100.0%) 0 (0.0%) 0 41 (100.0%) 0 (0.0%) 0 Acute Stroke Services Grey Nuns Hospital (Contracted Hospital) 25 (100.0%) 0 (0.0%) 0 77 (100.0%) 0 (0.0%) (100.0%) 0 (0.0%) 0 Royal Alexandra Hospital 25 (100.0%) 0 (0.0%) 0 77 (100.0%) 0 (0.0%) (100.0%) 0 (0.0%) 0 University of Alberta Hospital 24 (96.0%) 1 (4.0%) 0 76 (100.0%) 0 (0.0%) (99.0%) 1 (1.0%) 1 Inpatient Stroke Rehabilitation Services Glenrose Rehabilitation Hospital 18 (94.7%) 1 (5.3%) 1 66 (100.0%) 0 (0.0%) 1 84 (98.8%) 1 (1.2%) 2 Total 98 (98.0%) 2 (2.0%) (100.0%) 0 (0.0%) (99.5%) 2 (0.5%) 3 Distinction Standards 9

14 Standards Set: Providing an Integrated System of Services to People with Stroke Chronic Disease Management Integrating and coordinating services across the continuum of care for populations with chronic conditions The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The Edmonton Zone Stroke Program (SPEZ) is responsible for the provision of stroke services within and outside the Zone. Services are provided to the northern and part of the central zones, from the Northwest Territories as well as for patients from northern British Columbia and some from Saskatchewan. Data is collected through the provincial and zone databases about the prevalence of stroke, the major risk factors, and the populations served, and this information is reviewed by the team regularly. A Stroke Program Edmonton Zone dashboard provides comparison data on a regular basis. Early supported discharge was based on patient evaluation data from Alberta Provincial Stroke Strategy and is an example of an improvement in service based on performance data. Barriers to access have been identified, particularly in rural areas. Strategies to deal with these barriers have been developed including bypass protocols, education opportunities for primary care providers and staff at rural sites. Comprehensive use of Telehealth, both in acute care and in rehabilitation and the RAAPID consultation hotline have reduced door to needle (DTN) times in rural areas as well as in the city. Telehealth is used by the stroke team in both acute care for follow up and stroke prevention, and rehabilitation. Access to diagnostic services such as CT scans and CT vascular imaging are available readily through twelve primary stroke centres. One innovation is the Stroke Ambulance service, designed to improve access and reduce DTN times in smaller communities without immediate access to CT at up to 250 km. This is a well designed pilot project that has just been rolled out. Four patients have been managed up to via the Stroke Ambulance service. Rigorous evaluation of this project is built into the pilot. Distinction Standards 10

15 A comprehensive project to reduce DTN times has improved communication and feedback and improved DTN times to well below the 60-minute target for thrombolysis across the zone. Another strategy to improve access has been the implementation of stroke prevention clinics in twelve sites across the Zones, supported by the stroke program. Telehealth is used to bring stroke prevention clinic services to up to 100 rural communities. These strategies are reported to have improved access to stroke services in a significant way. There is no integrated clinical information system. The Stroke Program Edmonton Zone has developed a database to support its need for meaningful data with as little delay as possible. This system collates data collected from many databases to provide the team with information related to stroke services provided, including many core and optional indicators. An opportunity for improvement for this Zone is to resource and provide a clinical information system for inpatients which will allow more complete access to available data and decision support, including links to Canadian Stroke Best Practices. This team was an integral contributor to the ESCAPE trial, which showed the improvement in results with endovascular recanalization. A new challenge for the team will be to ensure timely access to the endovascular clot retrieval program, particularly for out of zone patients. The Cardiovascular and Stroke Strategy Network (SCN) has a hyperacute and acute working group discussing and planning innovations to deal with this challenge for Albertans. The Stroke Program Edmonton Zone is well represented on this and the other working groups and committees of the SCN. The program has close links and collaborates with many interagency partners to allow appropriate access to community services for patients being discharged from the stroke program. It works collaboratively with these partners and with the Chronic Disease Management program to provide public awareness and public education, especially in risk factor management. Distinction Standards 11

16 Population Health and Wellness for Stroke Integration of stroke services to meet the needs of populations across the continuum. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The Stroke Program Edmonton Zone has comprehensive strategies to improve access to stroke services across the continuum of service, including public awareness, and provider education and support. The stroke program works collaboratively with interagency providers to provide access to care after discharge from hospital. These community partners are actively involved in public awareness and education in stroke. Extensive use of Telehealth is used to support improved access to thrombolysis, and rehabilitation services, early supported discharge, stroke prevention clinics and specialist consultation. There is a close working relationship between the primary stroke centres and the comprehensive centres in this Zone. These centres manage strokes seamlessly in conjunction with the comprehensive centre in Edmonton. Agreement with smaller centres to assure equal rural access are largely protocol driven and involve the primary as well as the comprehensive Endovascular Recanalization Alberta (ERA) stroke centres. There are no formal repatriation agreements with these centres, although these are being discussed as a way of alleviating some of the capacity issues in Edmonton. These agreements will be an integral part of the ERA project underway with the Cardiovascular and Stroke Strategic Clinical Network to improve rural access to endovascular recanalization and are encouraged. Timely access to services is an issue across the zone. This occurs at referral to early supported discharge, stroke prevention clinics and community services. It is most notable at the interface between acute care and inpatient rehabilitation. There appear to be opportunities to improve flow. A project to look at all areas of flow of patients through the services offered by the stroke program at all sites and services is suggested. Stroke survivors discharged from hospital are followed on the acute and rehabilitation teams through stroke prevention clinics and specialist follow-ups, the Glenrose adult rehabilitation outpatient clinic, Community Rehabilitation Interdisciplinary Services (CRIS), and neuroscience physiotherapy clinics. Early supported discharge is used to support both stroke acute and rehabilitation patients and their families for about 10% of acute care patients. Interagency care providers support patients discharged home, particularly from rehabilitation services. There is a Stroke Recovery Association, formed by stroke survivors in collaboration with the stroke program. These volunteers provide support and act as a resource and support group for patients suffering from stroke and their families. An opportunity for the program is to involve stroke survivors and their families in the design and planning for stroke services. Distinction Standards 12

17 Impact on Outcomes for Stroke - System The identification, collection, and monitoring of process and outcome measures to evaluate and improve the quality of stroke services to clients and the impact on client outcomes. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: Data is collected from many sources through a homegrown database which appears to meet the needs of the program. The service compares its performance against provincial and national programs and services. The team works closely with the Cardiovascular and Stroke Strategic Clinical Network (SCN) to provide meaningful performance data and outcomes. The team measures all required and several optional indicators in both acute care and rehabilitation, by site and for the program overall. The Stroke Program Edmonton Zone leadership analyzes this data and tracks its stroke care using the data to advocate for resources. An area for improvement is to use this information to understand variations in service delivery across the sites in the zone and improve service delivery. Distinction Standards 13

18 Standards Set: Acute Stroke Services Grey Nuns Hospital (Contracted Hospital) Clinical Leadership for Stroke Providing leadership and overall goals and direction to the team providing stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The Grey Nuns Hospital is a comprehensive stroke centre for the Edmonton Zone. They are able to provide rapid admission, CT, tpa, post-tpa monitoring, a stroke ward and stroke team. Neurosurgery is not available and clot retrieval is not performed. Vascular surgery is located here for the Zone so carotid disease can be assessed and treated rapidly. Patient education documents are available in seven languages. Data collection on population demographics, stroke prevalence, and rural versus urban incidence is kept by the Stroke Program Edmonton Zone. Outcome information is hospital-specific and collected by the manager of the Grey Nuns Hospital stroke unit. The strategy to increase community awareness of stroke is done by the Stroke Program Edmonton Zone (SPEZ). Distinction Standards 14

19 Competency for Stroke Developing a highly competent interdisciplinary stroke team with the knowledge, skill, and ability to develop, manage, and deliver effective and efficient stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: All new staff undergo a five-day medicine program orientation. There is an additional three-day stroke/geriatrics orientation. All staff also under go a three-day general orientation. Annual performance reviews are on schedule. The team utilizes the Canadian Best Practice recommendations for Stroke Care. Distinction Standards 15

20 Episode of Care: Acute Stroke Services Acute stroke services provided for hyperacute and acute phases, from the onset of signs and symptoms to completion of initial assessment and management in the Emergency Department (ED), until the client is stable and able to begin participation in rehabilitation and proceeding to an alternate level of care. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: DTN is consistently done under thirty minutes at the Grey Nuns Hospital. Most stroke nurses are trained to do swallowing assessment on all patients. Nearly all patients are assessed soon after admission to the Emergency Department (ER). 100% of patients have early cognitive evaluation. A "stroke pack" is kept in the ER and is carried by an ER nurse to CT with the patient. The pack contains IV supplies and unmixed tpa. Once the decision to use tpa is made, a bolus dose can be given immediately and the infusion prepared so that the patient begins to receive medication before leaving the CT. All stroke patients at the Grey Nuns Hospital are managed on the dedicated stroke unit. Adult psychiatry is available to do consultations on patients with evidence of depression. Most carotid surgery in the Zone is supplied by vascular surgery at the Grey Nuns Hospital. A formal transfer protocol is followed when patients are transferred to inpatient rehabilitation services. Emergency Medical Services (EMS) staff have protocols and flow charts that they follow when picking up a potential stroke patient. If their assessment suggests the presence of an intracranial hemorrhage, the crew bypasses all sites except the University of Alberta Hospital. Clot retrieval is only attempted at the University of Alberta Hospital. EMS personnel indicated that a neurologist always meets the ambulance in the ER at Grey Nuns Hospital. CT is just down the hall and stroke is given priority over everything except head trauma. All transient ischemic attack (TIA) patients are either admitted or referred to the Grey Nuns Stroke Prevention Clinic for an early assessment. All TIA patients receive acetylsalicylic acid (ASA) before discharge from Emergency Department (ED). Most patients are rehabilitated at Grey Nuns (early rehabilitation), those who are suitable are transferred to Glenrose Rehabilitation Hospital, others are sent home or to suitable placements. There is a rehabilitation room on the ward at Grey Nuns. Distinction Standards 16

21 Decision Support for Stroke Stroke information, research and evidence, data, and technologies that support and facilitate management and clinical decision making. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: There is a desperate need for an Information Management System for the Stroke Program Edmonton Zone. All outcome indicators are reported from the hospital sites. CT for acute stroke patients is a priority for the imaging department 24/7. The current clinical information system is very labour intensive with every entry having to be checked before submission. Some information provided to the teams may be contaminated by incorrect data making it necessary for the unit manager to check every data sheet entry before it is submitted. This is probably best done at the time of patient discharge. Distinction Standards 17

22 Impact on Outcomes for Stroke The identification, collection, and monitoring of process and outcome measures to evaluate and improve the quality of stroke services to clients and the impact on client outcomes. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: All data to be submitted to the database is checked for accuracy by the unit manager at the Grey Nuns Hospital before submission to the database. Clinical trials are performed only after Research and Ethics Board (REB) approval from the appropriate institution. Distinction Standards 18

23 Royal Alexandra Hospital Clinical Leadership for Stroke Providing leadership and overall goals and direction to the team providing stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The Clinical Leadership Priority Process is largely covered off by the Stroke Program Edmonton Zone. Stroke incidence, presence of risk factors in the population, collection of demographic information, rural and urban differences and geographic barriers are present for all the acute sites and therefore are collected and analyzed at the Zone level. The physical space for the stroke unit at the Royal Alexandra Hospital is fairly old but does provide privacy for patients. The delivery of telehealth is effective and available to all stroke specialists. All the necessary medical departments are present either locally or regionally. Community education campaigns are carried out by the Stroke Program Edmonton Zone. Distinction Standards 19

24 Competency for Stroke Developing a highly competent interdisciplinary stroke team with the knowledge, skill, and ability to develop, manage, and deliver effective and efficient stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: Staff performance reviews are done annually with input from the staff encouraged. The complete team is present in this stroke unit except for vasculary surgery which is available at the Grey Nuns Hospital. There is a unique orientation for staff on the stroke unit and educational opportunities are present. Distinction Standards 20

25 Episode of Care: Acute Stroke Services Acute stroke services provided for hyperacute and acute phases, from the onset of signs and symptoms to completion of initial assessment and management in the Emergency Department (ED), until the client is stable and able to begin participation in rehabilitation and proceeding to an alternate level of care. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: Most patients with stroke seen at this site are patients brought to the ED by EMS but who are "outside the window" for treatment with tpa. Walk-in stroke patients may receive tpa. If patients are "inside the window" they are usually transported to the University of Alberta (UAH) Hospital or the Grey Nuns Hospital. tpa is available at all sites but neurosurgery is present at the UAH and vascular surgery is at the Grey Nuns Hospital. Whenever possible EMS delivers the patient to the most appropriate ER. A swallowing evaluation is done as soon as the patient is seen in the ER. All RNs and many LPNs are trained to do this assessment. More sophisticated testing is done by a Speech Language Pathologist. Patients who have suffered a TIA may be admitted for observation or discharged to a stroke prevention clinic. Most stroke patients are admitted to the stroke ward. If the ward is full, the patient may be admitted to a medical ward but the stroke team does the ongoing care. Venous thromboembolism (VTE) assessment, falls assessment, and skin assessment are done on all patients admitted to the unit. A dietitian is available to see all patients. A cognitive assessment is done soon after admission. Written educational material (English, French) is provided to patients and family members. The stroke team at the Royal Alexandra Hospital is developing a set of video modules to provide similar information to the written information but in a format that is less overwhelming to patients. Patients referred for in-patient rehabilitation are assessed by a physiatrist who determines whether the patient is an appropriate candidate for inpatient rehabilitation. Distinction Standards 21

26 Decision Support for Stroke Stroke information, research and evidence, data, and technologies that support and facilitate management and clinical decision making. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The current clinical information system is very labour intensive with every entry having to be checked before submission. All data entries are cross-referenced and validated by the Data analyst, SPEZ to ensure accuracy and integrity of the data. This is probably best done at the time of patient discharge. Distinction Standards 22

27 Impact on Outcomes for Stroke The identification, collection, and monitoring of process and outcome measures to evaluate and improve the quality of stroke services to clients and the impact on client outcomes. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: Any indicators that have not met performance thresholds are reviewed in detail. Data provided to the team may not be always accurate, so a case by case review has to be done. This is time consuming and labour intensive and would be better managed with the addition of a proper clinical information system. Research follows all appropriate ethics rules. Patient and family satisfaction is collected in the unit and is unit-specific. This allows the team to modify practice to improve patient/family satisfaction. Distinction Standards 23

28 University of Alberta Hospital Clinical Leadership for Stroke Providing leadership and overall goals and direction to the team providing stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: Clinical leadership for this site is included in the leadership team for the Stroke Program Edmonton Zone. Data for the stroke program and the demographics of the population served flows through the Stroke Program Edmonton Zone. The stroke unit is encompassed in the Neuroscience program, a large service of 81 beds spread over four contiguous units and a twenty-bed unit on the floor above. Stroke patients are admitted primarily to one unit with post thrombolysis beds, and a second neuroscience unit which handles overflow and stable stroke patients. A neuro ICU takes appropriate ICU stroke patients, and the Neurosurgery unit admits primarily hemorrhagic patients such as those with subarachnoid hemorrhage. Telestroke is used extensively by this program. Rural door to needle times for stroke patients have diminished. Stroke prevention clinics are run by telehealth in many small rural sites. Patient follow-up can reduce the need for long trips back to see the specialist. This use of telehealth by the acute stroke services is a strength of this program. There are agreements and protocols for the hyperacute management of stroke patients with EMS, the Emergency department and Diagnostic Imaging. A CT scanner within the Emergency department allows for very fast prioritized service for these patients. A second biplane angiographic suite has reduced delays to access for endovascular clot retrieval. The physical link with Neuro ICU and the Neurosurgery inpatient service aids collaboration with Neurosurgery for the management of stroke patients requiring surgical consultation and intervention. Public awareness is managed by the Stroke Program Edmonton Zone rather than the site, and is a strength of this program. Distinction Standards 24

29 Competency for Stroke Developing a highly competent interdisciplinary stroke team with the knowledge, skill, and ability to develop, manage, and deliver effective and efficient stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: This stroke team has not only implemented the Canadian Best Practice Recommendations for Stroke Care, but a number of team members sit on the standing committees and contribute to the maintenance and updating of these recommendations. The team is well resourced with therapists, pharmacists and nurses well trained and dedicated to the management of patients with stroke. Turnover of therapists and nurses is low and the combined expertise in stroke care is notable. There is a general neuroscience orientation for all staff, which includes stroke. All staff on all five Neuroscience units are well trained and report being comfortable with the management of stroke patients. Learning opportunities for continuing education in stroke care are well supported by the team leadership and the organization. Regular learning sessions such as "lunch and learn" are part of these learning opportunities. The team has developed a customized database which inputs data relating to administrative and clinical data for all their services. Distinction Standards 25

30 Episode of Care: Acute Stroke Services Acute stroke services provided for hyperacute and acute phases, from the onset of signs and symptoms to completion of initial assessment and management in the Emergency Department (ED), until the client is stable and able to begin participation in rehabilitation and proceeding to an alternate level of care. Criteria (Unmet) High Priority Criteria 7.0 The stroke team provides comprehensive inpatient acute stroke services. 7.3 The stroke team has a process to identify and list all stroke clients daily, including those on the stroke unit or stroke ward, new in-house admissions since previous rounds, and strokes that occur in clients already admitted within the organization for other initial health condition. Evaluator Comments: If the clients are on internal medicine or other non neurology services they are not identified by the team unless consultation from the admitting team is requested. The evaluators provided the following overall comments for this section: EMS and the Emergency Department protocols for the hyperacutre care of suspected stroke patients appear to be effective and are part of the reason for a significant improvement in door to needle (DTN) times for eligible patients. Despite the protocol, Emergency personnel report that notification of the stroke team does not always take place during the transit of the patient to the ED. Infrequently, a wait for the stroke fellow after patient arrival occurs. Opportunities for improvement in these areas are noted. There can be significant waiting times from the decision to admit stroke patients to their arrival on the unit. There has been some improvement noted, but these long wait times are cited as causing assessment delays, such as in the initial assessment of rehabilitation needs. Reviews of patient flow, in conjunction with process reviews of all bottlenecks in the system through to rehabilitation are suggested as an area for possible improvement. It is noted that the Stroke Prevention Clinic has diverted patients with TIAs from the inpatient service, but the neuroscience beds remain at high capacity. Emergency nurses would welcome additional educational opportunities in understanding both changes and innovation in stroke care, and awareness of ongoing research and clinical trials affecting the stroke patients under their care. EMS is evaluating the use of a Stroke Ambulance for rural areas. This vehicle has mobile CT capability and tpa can be given to the patient, if ordered by a neurologist while the patient is being transported. It is hoped that this service will shorten the time to diagnosis and tpa injection for rural patients. Distinction Standards 26

31 There are no formal repatriation agreements with referring primary and rural centres, who also suffer overcapacity issues. Repatriation agreements with these centres may help to free up a small number of beds and improve wait times for those patients awaiting a place on the neuroscience unit. Stroke patients are admitted generally to one of two Neuroscience units and the Neuro ICU with appropriate patients such as patients with subarachnoid hemorrhage admitted to the neurosurgery unit. They are admitted to the Stroke Neurology service. When there are no beds, a small number are admitted off service to other units under Stroke Neurology. Rather than clustering these patients, they are moved as soon as possible to the Neuroscience beds and the stroke unit. There have been discussions about the pros and cons of further consolidation of the stroke unit. The existing arrangement is an approach to deal with fluctuating numbers of stroke patients who cannot be housed on a single unit. The staff of all the neuroscience units are well trained in stroke, and experienced in the care of these patients. The same stroke protocols and stroke specific care pathways such as order sets are found on all of these units. Stroke best practices are clear that a single dedicated unit for acute stroke patient care is optimal for patient outcomes after stroke. However, the current arrangement may be the best possible for the neuroscience unit at this site. Continued discussion and attention to this issue is recommended. Comparison of results with those outcomes from single dedicated units may be useful in this discussion. The team is aware that some stroke patients are admitted or remain on other services than Stroke Neurology. These patients are not afforded the benefits of a dedicated stroke unit, such as a team experienced in the management of stroke, stroke order sets, and stroke best practices. The team does not have a method for seeking out these patients on a regular and daily basis. An opportunity exists to develop in conjunction with Internal medicine and other services, a stroke team response to these off service patients, so that they may benefit from the application of stroke best practices and the efficiencies that result. The development of the capacity to identify and reach out to these patients is recommended. The Stroke Prevention Clinic provides followup for discharged patients. It operates in a small facility with limited human resources. It does not routinely meet its targets for urgent and semi-urgent patients. The SPC is an important source of followup for patients, such as for education and management of risk factors for stroke. It is cost effective. A review of the current and anticipated needs of this vital clinic as part of stroke care delivery, is recommended. The team puts in place early plans for the continuing care of all its stroke patients, with several possible arms of care, including Early Supported Discharge (ESD), referral to the stroke prevention clinic, the Glenrose Rehabilitation Hospital adult outpatient clinic, other outpatient options such as CRIS, as well as tertiary inpatient rehabilitation care and long term care. Patients from out of zone, and farther away, such as those from the NWT and other provinces are repatriated to facilities able to care for their individual needs. The ESD Distinction Standards 27

32 program from acute care managed 125 patients last year, and is a popular option for those patients able to transition home. Distinction Standards 28

33 Decision Support for Stroke Stroke information, research and evidence, data, and technologies that support and facilitate management and clinical decision making. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The Edmonton Zone Stroke Program has developed a customized database with the Zone analytics team. This provides administrative and clinical data on all stroke services delivered within the zone. It is linked to Canadian Best Practices for stroke. Data and information is analyzed and discussed with program and units managers to ensure accuracy. Distinction Standards 29

34 Impact on Outcomes for Stroke The identification, collection, and monitoring of process and outcome measures to evaluate and improve the quality of stroke services to clients and the impact on client outcomes. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: Clinical and service utilization data, and reports on performance processes and indicators, are shared with the team. This data is used to drive improvements and decision making. An example has been improvements in processes leading to a reduction in door to needle times for eligible stroke sufferers. Research by stroke neurologists is a major strength of this team. They participate in original research in stroke, and have recruited a new neurologist with 80% protection of time for basic stroke research. They were a major player in the important ESCAPE trial on endovascular clot retrieval, and participate in many clinical trials as well as basic and clinical research in stroke. An area for improvement is in research by the other members of the team. With this rich research environment, and large and varied clinical volumes there are opportunities to share experiences with partners in stroke through local or national forums such as the annual Stroke Congress. The team is encouraged to consider research as a worthwhile endeavour and the stroke neurologists are encouraged to engage with other team members who may be interested in stroke research. Evaluations of care at this site are done by the hospital and the results are shared with staff. An opportunity is to standardize the surveys across the sites and thus to improve the quality and usefulness of the information obtained from these surveys. Distinction Standards 30

35 Standards Set: Inpatient Stroke Rehabilitation Services Glenrose Rehabilitation Hospital Clinical Leadership for Stroke Providing leadership and overall goals and direction to the team providing stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: Glenrose Rehabilitation Hospital's strengths are related to the dedicated clinical leadership which is committed to deliver best practices in Inpatient Stroke Rehabilitation Services. The organization has sophisticated processes and partnerships which are focused on common service delivery goals. The organization is challenged with ongoing measuring and monitoring of its performance in the absence of an integrated information/data system. The AHS Stroke Program Edmonton Zone has developed a stroke specific data base which supports the sites with analytics staff who develop administrative and clinical reports for the Edmonton Zone stroke sites. Distinction Standards 31

36 Competency for Stroke Developing a highly competent interdisciplinary stroke team with the knowledge, skill, and ability to develop, manage, and deliver effective and efficient stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The inpatient rehabilitation stroke program at the Glenrose Hospital has recently developed a revised learning needs assessment tool for nursing which will be incorporated as one tool that contributes to the nurses performance reviews. Professional Practice Leaders have a system in place to identify therapy staffs' learning and training needs. Distinction Standards 32

37 Episode of Care: Inpatient Stroke Rehabilitation Services Stroke inpatient rehabilitation services from the first encounter with a rehabilitation health care provider through the completion of the last encounter related to stroke. Criteria (Unmet) High Priority Criteria 5.0 The team coordinates timely access to inpatient stroke rehabilitation services for clients and families and caregivers, service providers and referring organizations. 5.4 The wait time from when a client has met criteria for being rehab ready by inpatient rehabilitation services until admission to inpatient stroke rehabilitation is not more than two business days. Evaluator Comments: The team works hard to meet the wait time target from the patient's rehabilitation ready designation to admission to the Inpatient Stroke Rehabilitation unit. With increasing Length of Stay on the inpatient Stroke Rehabilitation Unit and the increasing number of Alternative Level of Care patients, this has presented challenges for the team to meet the expected target. The team recognizes this as an opportunity improvement area to work on with stakeholders and partner organizations. The evaluators provided the following overall comments for this section: The team has a well-structured system for receiving and tracking stroke patient referrals from various agencies. There are dedicated resources to ensure that stroke patients have access to specialized inpatient rehabilitation to meet their recovery needs. There is regular monitoring and review of capacity and flow to inpatient rehabilitation to "pull" acute stroke patients to inpatient stroke rehabilitation in a timely fashion. The challenge is that at times demand is greater than supply which leads to wait times for access to inpatient stroke rehabilitation services. The team is addressing this issue as an area for improvement and rehabilitation problem solving with partner organizations. Distinction Standards 33

38 Decision Support for Stroke Stroke information, research and evidence, data, and technologies that support and facilitate management and clinical decision making. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The strengths of this priority process is that the Stroke Program Edmonton Zone team has resourced an analytics team which is available to support the Edmonton Zone stroke provider organizations with their data, measuring and monitoring needs. The opportunity for improvement is in the area of implementation of an electronic medical record for inpatient services. The more global opportunity is for the AHS to develop and implement a system wide Clinical Information System. Distinction Standards 34