Canadian Best Practice Recommendations for Stroke Care. (Updated 2008) An Introduction

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1 Canadian Best Practice Recommendations for Stroke Care (Updated 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 IMPACT of STROKE in CANADA ~ 50,000 strokes/year Someone has a stroke every 10 minutes 20% chance of second stroke within 2 years For every symptomatic stroke there are 9 silent strokes resulting in cognitive impairment 300,000 Canadians living with stroke 16,000 Canadians die from Stroke each year Price Tag: $3.6 Billion annually

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 National Platforms to Support Provincial/Territorial/Regional Strategies Public Awareness Best Practice Guidelines and Standards of Care Professional Development Information/Evaluation Coordinated Research

6 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

7 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

8 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 Priorities areas identified as focus for creating educational materials

9 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

10 Your Provincial Model

11 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

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

13 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 December 2, 2008

14 Best Practice Recommendations for Stroke Care: Development and Update Process Utilized Conceptual framework to guide identification, selection and development Facilitated by a subgroup of the Best Practices and Standards Working Group Managed by the Performance and Standards Specialist from the Canadian Stroke Network Identification of Interprofessional stroke care experts for task groups and panel membership

15 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

16 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

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

18 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 peerreview publication process (CMAJ) Development of Performance Measures by CSS Information & Evaluation Working Group

19 Reorganization of Recommendations RECOMMENDATIONS: 2008 RECOMMENDATIONS: 1. Public Awareness (1) 2. Patient and Caregiver Education (1) 3. Stroke Prevention (7) 4. Acute Stroke Management (8) 5. Stroke Rehabilitation (6) 6. Follow-up and Community Reengagement (1) 1. Public Awareness and Patient Education (2) 2. Stroke Prevention (7) 3. Hyperacute Stroke Care (7) 4. Acute Inpatient Stroke Management (2) 5. Stroke Rehabilitation & Community Reintegration (5) 6. Selected Topics in Stroke Management (4)

20 Recommendation Format Best Practice Recommendation Rationale System Implications Performance Measures Measurement Notes Summary of Current Evidence

21 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

22 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

23 Canadian Best Practice Recommendations for Stroke Care (2008) Topic Areas 1.0 Public 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 subarachnoid and intracerebral hemorrhage

24 Canadian Best Practice Recommendations for Stroke Care (2008) Topic Areas 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 communitybased rehabilitation Follow-up and evaluation in the community 6.0 Selected Key Topics in Stroke Management Dysphagia assessment Identification and management of poststroke depression Vascular cognitive impairment and dementia Shoulder pain assessment and treatment

25 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: o Cranial Nerves, o Common Stroke Presentations, o Functions of the brain, o National Institutes of Health Stroke Scale, o Canadian Neurological Scale, o Stroke Prevention Card Faaast FAQ s for Nurses National Professional Education Atlas Available at:

26 Best Practice Standards Dissemination National release of Canadian Best Practice Recommendations update in CMAJ on December 2,2008 ( Website Broad dissemination across provinces, national and international meetings Consultation with national and provincial professional associations and groups Inclusion in stroke related newsletters: National Stroke Nursing Council newsletter Canadian Stroke Network Brainwaves

27 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)

28 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 targeted to specific populations, such as aboriginal groups, visually impaired

29 From the Patient and Family s Perspective:

30

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