Introduction
Problem description
Stroke is a leading cause of disability in Canada and worldwide. For ischaemic stroke specifically, outcome severity is heavily dependent on the timeliness of treatment. Early, fast and appropriate treatment is essential in order to ensure the best outcomes for patients.1 This means that systems of care need to be in place to ensure patients with stroke are treated quickly and appropriately across entire health regions. In 2014, the province of Saskatchewan, Canada (population: 1.2 million) was one of only three Canadian provinces which did not have a provincial stroke strategy. Following, we will explain the development and implementation of the Saskatchewan Acute Stroke Pathway (ASP) and its impact on the acute treatment of stroke across the province.
Available knowledge
Suspected patients with stroke require urgent attention, evaluation and treatment from the prehospital environment through to acute in hospital treatment. Canadian Stroke Best Practice Guidelines state that the goal of emergency medical services (EMS) on scene of a suspected patient with stroke is to ‘recognise and mobilise’. Patients should be screened for signs of stroke using the Face, Arm, Speech and Time (FAST) assessment and patients exhibiting any FAST symptoms should undergo further screening for stroke severity to assess if the patient could be a candidate for endovascular therapy (EVT).2 Following this transport protocols must be in place to facilitate the transfer of suspected patients with acute stroke who are potentially eligible for alteplase and/or EVT.
Once the patient arrives in the emergency department (ED), they require immediate evaluation. A coordinated response is needed across different healthcare teams to ensure quick access to imaging, vital sign monitoring, neurological exams and lab work so treatment is not delayed. Reducing any delays in patient with stroke treatment is essential as for patients with ischaemic stroke both alteplase and EVT are highly time sensitive. For patients with large vessel occlusions (LVO), every 15 min delay in alteplase treatment results in 8 fewer among 1000 patients achieving an excellent outcome (modified Rankin Scale (mRS) score 0–1 at 90 days).3 The same time delay for EVT results in 25 fewer among 1000 achieving an independent outcome (mRS 0–2 at 90 days).4
Implementing protocols based on best practice guidelines can encourage the prioritisation of the patient with hyperacute stroke in the local ED, leading to decreased treatment times and ultimately resulting in better outcomes for stroke survivors. There have been at least a dozen single-centre quality improvement initiatives in recent years aimed at streamlining and standardising stroke care have been undertaken worldwide.5 This includes the seminal study in Helsinki, Finland where over the course of several years, 12 measures were introduced to reduce door-to-needle (DTN) time in patients with stroke. The initiatives were: education of EMS, hospital prenotification of incoming patient with stroke, preordering lab tests and diagnostic imaging, immediate reading of the CT scan by stroke physician, premixing alteplase, delivering alteplase on CT table, relocation of the CT scanner to the ED, transferring the patient from the EMS stretcher to the CT scanner, patient swarmed on arrival in the CT room, acquisition of patient medical record/history before arrival, performing point-of-care INR testing on the CT table and reserving advanced imaging for unclear cases. The implementation of this protocol reduced median DTN time from 105 to 20 min.6 This model was repeated in Melbourne, Australia where DTN times were reduced from a median of 43–25 min in-hours (off-hours times remained unchanged).7
In Calgary, Canada, the Hurry Acute Stroke Treatment and Evaluation (HASTE) programme implemented similar changes to acute stroke workflow including prenotification from EMS of an incoming stroke alert, sending out a STAT stroke page to all members of the stroke care team, registering the patient as unknown (following processes used in trauma admissions), standardised provincial order sets for patients with stroke, moving the patient directly from the EMS stretcher to the CT, and administering alteplase in the CT/imaging area. This resulted in a reduction of median DTN time from 53 to 35 min.8
Multicentre stroke improvement efforts have been fewer with the majority of published results showing substantially less improvement in DTN than single-centre efforts.9–13 A recent example of a multicentre quality improvement effort which successfully reduced median DTN from 68 to 36 min across 17 hospitals is the Quality Improvement and Clinical Research Programme in Alberta, Canada.14–16
Rationale and specific aims
Given the abundance of evidence for faster stroke treatment and the state of substandard performance in Saskatchewan, we set out to improve stroke treatment across the entire province via the Saskatchewan ASP. The ASP set out to improve stroke care, including consistency in care, for all patients with stroke regardless of geographic location. Specifically, the ASP aimed to: (1) increase the proportion of patients with stroke treated with alteplase and/or EVT and (2) provide these treatments to patients faster through decreasing door-to-imaging times, DTN times and door-to-groin puncture times (DTGT). Canadian Stroke Best Practice Recommendations were used as province wide targets: door-to-imaging time of 15 min, DTN times of 30 min (urban centres) and 60 min (rural centres) and DTGT of 60 min.