Page | 1 Organization: Mackenzie Health Address: 10 Trench Street, Richmond Hill, ON L4C 4Z3 Contact Name: Judy Murray, Coordinator District Stroke Centre Contact Information: Email: [email protected]Phone: 905-883-1212 x 3882 Report completed by: □X Same as above with input from other stroke team members: □ Other (please include name, title and contact information) Operational Directors for District Stroke and Chronic Disease: o Frances Reinholdt [email protected]o Treva McCumber [email protected]District Stroke CNS – Laura MacIsaac [email protected]Decision Support Team o Anthony Reddick [email protected]o Juan Li [email protected]Mackenzie Health Stroke Quality Committee (group input). Focus of accreditation (check all that apply) □ X Acute Stroke Services □ X Inpatient Rehabilitation Services Standards □ Standards for Providing an Integrated System of Services to People with Stroke Date accreditation process started (dd/mm/yy): March 1, 2012 Date accreditation process completed (dd/mm/yy): March 6, 2013 Date of report (dd/mm/yy): April 30, 2013 __________________________ 1. Why did your organization decide to embark on the Stroke Distinction process? Mackenzie Health (formerly York Central Hospital) was designated as the District Stroke Centre for York Region in 2004-5. York Central had a history of leading practice in stroke care and was a pioneer in the management and delivery of tPA to stroke patients as a community hospital since 2002. In 2006, the hospital opened a Stroke Prevention Clinic (SPC) to ensure best practice prevention care for patients with TIA/MNDS, and to divert appropriate patients from hospital admission. Over a period of three years, the hospital was able to decrease the admission rate for this population from almost 30% to 15%. In 2009, Mackenzie Health submitted a proposal to the Central LHIN for Aging at Home funding, to establish SPCs in the other 4 main Central LHIN hospitals, and to link ONTARIO STROKE NETWORK STROKE DISTINCTION REPORT
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Organization: Mackenzie Health
Address: 10 Trench Street, Richmond Hill, ON L4C 4Z3
Contact Name: Judy Murray, Coordinator District Stroke Centre
Contact Information: Email: [email protected] Phone: 905-883-1212 x 3882
Report completed by:
□X Same as above with input from other stroke team members:
□ Other (please include name, title and contact information) Operational Directors for District Stroke and Chronic Disease:
Mackenzie Health Stroke Quality Committee (group input). Focus of accreditation (check all that apply)
□ X Acute Stroke Services
□ X Inpatient Rehabilitation Services Standards
□ Standards for Providing an Integrated System of Services to People with Stroke
Date accreditation process started (dd/mm/yy): March 1, 2012
Date accreditation process completed (dd/mm/yy): March 6, 2013
Date of report (dd/mm/yy): April 30, 2013 __________________________
1. Why did your organization decide to embark on the Stroke Distinction process?
Mackenzie Health (formerly York Central Hospital) was designated as the District Stroke Centre for York Region in 2004-5. York Central had a history of leading practice in stroke care and was a pioneer in the management and delivery of tPA to stroke patients as a community hospital since 2002. In 2006, the hospital opened a Stroke Prevention Clinic (SPC) to ensure best practice prevention care for patients with TIA/MNDS, and to divert appropriate patients from hospital admission. Over a period of three years, the hospital was able to decrease the admission rate for this population from almost 30% to 15%. In 2009, Mackenzie Health submitted a proposal to the Central LHIN for Aging at Home funding, to establish SPCs in the other 4 main Central LHIN hospitals, and to link
ONTARIO STROKE NETWORK STROKE DISTINCTION REPORT
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patients to secondary prevention services in established Cardiac Rehabilitation and other community programs. This Aging at Home project was successful and Mackenzie Health received ongoing base funding to continue to lead this program in 2012.
In 2005, acute, rehab and complex continuing care stroke services were combined and the Integrated Stroke Unit (ISU) was established. Over the years, the ISU has delivered many aspects of best practice stroke care. Stroke patients admitted following tPA administration and other stroke patients requiring monitoring, airway management or other high acuity services are initially managed in the ICU or CCU. Richmond Hill patients are transferred to the ISU when clinical stable; patients from bypassed hospitals are repatriated for ongoing care. As the ISU has an eight bed capacity, stroke patients may be managed in medical inpatient areas while awaiting transfer to the ISU. Stroke best practices were not as well-known on these medical units which represented a potential gap in care for those patients.
Mackenzie Health made the decision to participate in the Stroke Distinction program as a Quality Improvement initiative, as a means of validating quality of care delivered to stroke patients throughout the entire continuum, and to build on the great work being done across the hospital, York Region and the Central LHIN community. We reviewed a Gap Analysis of our stroke services completed in 2010 and compared it to an updated 2012 version so we were clear about the gaps that needed to be addressed. An energetic interprofessional team was in place to make this happen. The Stroke Distinction Program afforded us a great opportunity to pull services and people together to further our role as a leader in stroke care in York Region and the Central LHIN.
2. What was the outcome of the accreditation process?
Mackenzie Health was awarded Stroke Distinction status on March 19, 2013.
See APPENDIX A for the final report of results.
3. What organizational changes occurred as a result of your participation in stroke distinction (e.g., processes, policies/procedures, buy-in, attitude, positive or negative unintended consequences) and what was the reaction from those involved with the Stroke Distinction process (e.g., Senior Administration, Staff and Physician Leads)?
A Gap Analysis Template (APPENDIX B) was completed in 2010 to reflect the Accreditation standards and the degree to which we were meeting them. The 2010 version was updated in early March 2012 to launch the distinction process and to inform the work plan which would determine the workgroups required to fill the gaps and achieve the standards The Gap Analysis documents became the working Handbook of the Acute and Rehab standards which guided the education plan and the mock tracer activities prior to the onsite visit. The Gap Analysis proved to be vital in a) deciding to pursue Distinction and b) as a guide to track our progress along the way. This document will be essential in monitoring and maintaining our compliance.
Four Working Groups were established to address identified gaps:
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i. Metrics Working Group –
Purpose: To address the core and optional six month metrics submission required prior to the onsite survey.
Membership: Manager, Decision Support and Stroke Decision Support Analyst (hyperacute, acute and prevention metrics); Director Clinical Utilization; Resource Utilization Coordinator (rehab metrics); District Stroke Centre CNS and Coordinator (Chair)
ii. Acute and Rehab Working Group –
Purpose: To address the acute and rehab standards and ensure compliance, acute and rehab were combined for the following reasons: (1) our ISU is comprised of both acute and rehab patients, (2) there are overlaps in the two sets of standards, and (3) to facilitate understanding of the patient journey in stroke at Mackenzie Health. This committee highlighted the cross-continuum work in stroke and generated staff engagement and buy-in. This group provided an opportunity to integrate the emergency and acute medicine areas in best practices for stroke care.
Membership: Manager, Patient Care Coordinator, PT, OT and Physiatrist from the Integrated Stroke; Unit (ISU); Managers and Patient Care Coordinators of Medicine Units where stroke patients may be admitted; District Stroke Centre Coordinator and CNS (Chair).
iii. Patient and Family Education Working Group –
Purpose: To address stroke prevention, post-stroke education and the need for accessible, appropriate information for patients and families.
Membership: Geriatric Emerg Nurse; Nurse Educators from Emerg, Medicine and Continuing Care; NP Stroke Prevention Clinic; ISU Pharmacist and PT; District Stroke Centre Coordinator and CNS (Chair).
iv. Community Partnerships Working Group–
Purpose: This group met formally once to understand the Distinction process and to create a new Patient and Family Resource Guide for our website. An electronic document and hard copy were developed. Many of these same partners attended a discussion group with our surveyors during the onsite visit.
Membership: Representatives from our District Stroke Planning Council and Stroke Prevention Strategy covering the hospitals, Cardiovascular Rehab and community chronic disease and stroke programming; District Stroke Centre Coordinator (Chair).
These working groups not only participated in the work required to meet the Distinction Standards but more importantly, served to bring the various departments across the hospital together. The end result was a much more “stroke aware” organization.
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The timing of the Distinction onsite survey was determined by several factors:
The need to use the Ontario Stroke Network funds before March 31, 2013;
Mackenzie Health Hospital Accreditation booked for January 28-31, 2013;
The need to have as much time as possible to implement and educate staff about new or revised stroke policies and procedures and not overlap too much with hospital accreditation education sessions.
Initially there was concern that Distinction would be over-shadowed by Hospital Accreditation, however this was not the case. In retrospect we believe that participating in Stroke accreditation shortly after hospital accreditation was beneficial. It allowed us to leverage the ROPs across programs to inform the stroke program. We were also able to carry over the positive energy created by a successful hospital accreditation to a stroke focus while not detracting from either program or confuse the staff.
Our District Stroke Centre CNS is an expert in stroke and the organizational lead for Stroke Best Practices. In this cross-continuum role she develops, provides and coordinates education to patients, families and staff; provides clinical expertise and consultation; and develops policies and protocols to facilitate uptake of best practices. The CNS role was crucial in achieving Stroke Distinction as the standards, metrics and protocols all stem from the current Stroke Best Practice Recommendations. In preparing for Distinction her scope and presence in the general medicine units took on a greater priority. The stroke pathways were pushed out to these areas to ensure that patients waiting for transfer to the stroke unit had access to best practices.
There were several Policies and Procedures that we implemented or revised to meet the Distinction standards:
The Redirect and Repatriation of Acute Stroke Patients in York Region was already being revised to better reflect best practice hyperacute care in our District Stroke role and our rebranding as Mackenzie Health in June 2012.
We were able to complete and implement an Internal Stroke Protocol that had been in development and approval for a long time. Distinction gave us the focused attention we needed across the hospital to make this happen.
The Gap Analysis confirmed that we did not have a regular best practice approach to Cognitive and Depression Screening across the hospital and stroke continuum. These were on the work plan of the Acute and Rehab Working Group and implemented in January 2013.
Guidelines for the treatment of stroke patients with Diabetes were created to more formally reflect the care we were providing. The Mackenzie Health Diabetes Centre is located down the street from the hospital and provides expert consultation as well as rapid access after discharge from the hospital.
As with any large healthcare organization, care-related policies and procedures need to follow a process for approval. Most often there are revisions and numerous drafts along
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the way. With organizational and management support, we were able to expedite the policy and procedure process to obtain full marks in this category.
Partnerships are crucial to the provision of cross-continuum stroke care across our region and LHIN. Formal partnerships that include a written Memorandum of Understanding (MOU) ensure:
Patients with symptoms of stroke are transported to ED quickly for assessment of eligibility for thrombolytics.
Patients ineligible for tPA or those who have completed their 24 hours of monitoring after tPA administration are repatriated back to their community hospitals.
Collaborative operation of five Central LHIN Stroke Prevention Clinics with referral of patients to Cardiovascular Rehab (CVR),
Opportunities to offer community-based models CVR.
Informal partnerships between hospital and community organizations enable access to ongoing stroke survivor and family self-management support and secondary prevention in community centres. Additionally, informal partnerships enable the promotion of the signs of stroke and the awareness of stroke prevention across both York Region and the Central LHIN.
Early in the accreditation process, we asked Accreditation Canada if we could include a Community Partner Discussion as part of the onsite survey to allow the surveyors to meet the representatives and feel the depth of the work being done across the region and LHIN. A separate group of partners, including a CVR patient, were brought in as part of the Innovative Project review of the Central LHIN Strategy. These sessions proved to be very informative and gave the surveyors a first-hand experience of the integrated and comprehensive stroke care we spoke of and displayed.
Promotion and education of Stroke Distinction Accreditation started early and Hospital Accreditation provided us the opportunity to leverage already existing solid work related to evidence-based practice and best practice. The steering committee was initially concerned that staff would be overwhelmed by hearing about the two very different accreditations simultaneously. The proximity of the dates also raised concerns that we would lose out on valuable teaching moments and learning opportunities for stroke. Much of the work in addressing gaps through the development and implementation of stroke policies and procedures went on “behind-the-scenes” at the same time as the hospital accreditation preparation. Overlaps in standards and valuable teaching opportunities were capitalized upon (eg. hand hygiene and best practices in fall prevention, hospital acquired UTI and pneumonia).
Hospital Accreditation was successfully achieved with exemplary standing on January 31, 2013 and we were able to roll out the education on stroke best practice care and the standards for four weeks before the onsite survey (March 4-6, 2013). We used the fact that February was Heart and Stroke month to formally launch the promotion! Beginning February 4th:
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We sent out daily email messages to all Mackenzie Health staff (APPENDIX C) with nuggets of stroke best practice information;
There were weekly elevator messages related to stroke and keeping the survey date top-of-mind;
An education and mock tracer plan across the hospital was developed for February by the District Stroke CNS and Coordinator in consultation with nursing educators (APPENDIX D), staff and managers. We concentrated on required best practice for stroke care, patient transitions across the continuum (at Mackenzie Health or across the region) and patient and family education;
A large Stroke Prevention/Blood Pressure Screening Clinic was held in the auditorium for staff which coincided with the launch of the annual Richview Manor Strides for Stroke Foundation fund raising campaign;
Mock tracers were conducted by senior management, including our CEO and Executive VP, using a tool based on the Distinction Standards (APPENDIX E).
Staff and physician engagement was a vital part of achieving Stroke Distinction. Aligned with Mackenzie Health corporate goals and Hospital Accreditation goals, everyone worked together to create a culture of pride as we opened our doors to display the good work being done across the organization.
4. What do you feel are the key lessons learned?
Senior Administration Support was crucial to taking on the Stroke Distinction Program. From the outset, every level of senior leadership provided significant support, however in particular, the Executive Vice President, and the Operations Director for the District Stroke Centre were fully engaged and supportive of this process. Their support did not waiver and in fact became stronger as we worked through the preparations. Our Director for the District Stroke Centre also covers Medicine, Emergency and Patient Flow and worked closely with the other Directors (ISU, Rehabilitation, Diagnostic Imaging, Lab). The Stroke Distinction Steering Committee, included cross continuum management. This committee was established early to oversee the accreditation process, ensure any roadblocks were addressed and to facilitate focus on the work that needed to happen.
One of the gaps we identified was the absence of a Mission/Vision/Values statement and Organizational Chart for the Mackenzie Health Stroke Program. Stroke is complex and covers several hospital programs thus the creation of these documents eliminated any, confusion and enabled us to address barriers to care. (APPENDIX F)
Staff engagement has been mentioned already but it cannot be over-emphasized how important this was on every level. There were many activities aimed at optimizing staff engagement:
The CNS had already established real-time audits for tPA in the ED. She built on these and attended unit huddles in medicine, critical care and ED to share the results;
The CNS engaged the Patient Care Coordinators and Nurse Educators and provided best practices in stroke education (related to the units’ part of the continuum)
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o Lunch and Learns o Breakfast sessions o In-services
Engagement of the nursing educators was critical to having the optimal staff attend and to follow through on discussions and information at huddles, staff meetings etc.;
The CNS provided concise one-page handouts of stroke best practices to the units; The DSC Coordinator worked with Decision Support to revise the quality reports with
pertinent Distinction metrics. Stroke Quality Boards existed on the Integrated Stroke Unit and in Emergency but were expanded to include cross-continuum metrics relevant to patient care;
The DSC Coordinator and CNS were available to attend ad hoc meetings with staff at any time to answer questions about the survey visit or about care. The Rehab Team expressed that this was helpful for them and alleviated their anxiety;
The DSC Coordinator and CNS developed questions boxes that were distributed to the units. The question boxes were tailored to each unit to ensure both cross continuum best practices and those that applied to their piece of the continuum.
Mock Tracers were planned from the outset but became more of a priority as we learned from the Kingston General Distinction experience and as we got closer to the survey date. Senior Leaders were assigned to each tracer session, usually on a unit they were not familiar with. Our hospital CEO led a mock tracer on the Integrated Stroke Unit to show his support and encouragement while the VP and CNE led the ED mock tracer.
5. How is your organization planning to sustain the Stroke Distinction momentum?
1. We are using our local and regional work plans to direct our ongoing work. For example, we will set action plans at Mackenzie Health around Dysphagia to consolidate the learning from the chart audits and improve our delivery of care with the intent of increasing our percentage of patients screened with TorBSST.
2. At our Stroke Quality meeting, we will review our local metrics monthly and the Distinction report card quarterly.
3. We will continue our real-time audits of tPA cases in ED and act on fluctuations as required.
4. We are revamping the York Region District Planning Council to include members from the Central LHIN Stroke Prevention Strategy. This will improve our communication and promote the Distinction standards more consistently across the geography we represent.
5. We will be sharing our story in order to help other organizations achieve Distinction.
6. We will be informing Accreditation Canada about the process and, providing feedback about the metric definitions and data collection required.
7. We are increasing our outreach to partner sites with practical support, assistance and mentoring in various aspects of stroke care.
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6. What aspects of the Stroke Distinction process should be improved? (Please list in order of priority and provide recommendations on individuals and/or collaborations that could lead/support these changes)?
Metrics
The Distinction Program is national and the indicator thresholds have been adjusted to reflect this. However, the definitions for the core and optional metrics are not aligned to how a District Stroke Centre in Ontario functions, with redirection and repatriation of patients with or without tPA treatment.
The definition of the swallowing screening metric includes TIA patients since up to 30% of TIA patients may show deficits on MRI. At this time we do not screen swallowing with TIAs and we do not foresee ever being able to do this. Ultimately when patients are diagnosed as having a TIA the patient has totally resolved and is symptom free. If a MRI is completed after discharge it does not change the treatment.
ICD 10 inclusion and exclusion Diagnosis codes for Stroke population 1. Accreditation Canada Stroke Distinction include cases with a most
responsible diagnosis H340 in TIA group , but ICES /OSN doesn’t 2. Accreditation Canada Stroke Distinction include cases with a Most
responsible Diagnosis : Z50*;Z515,Z54* and second diagnosis is one of I60,I61,I63,I64 H431,H340, G45 vs. ICE/ONS don’t.
It would be desirable if there were standard data definitions provincially and nationally. It makes it difficult to compare clinical outcomes for stroke populations across sectors and is inefficient for decision support staff to have to replicate several versions of the various definitions.
7. What advice do you have for other centres considering preparing and applying for stroke distinction?
Start early!
Engage senior clinical and administrative leaders as champions
Create the appropriate project management structure to ensure oversight and execution of the plan
There are many details to this kind of work and things can take much longer than expected (eg. Policy approvals)
Staff and management have many balls they are juggling and patient care cannot suffer;
Last minute work creates anxiety and a poor learning atmosphere.
Assign a designated Coordinator for the program who buys in to the process and the goal. Ensure close access to a Nursing Best Practice expert.
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For Mackenzie Health, the District Stroke Coordinator and CNS team worked very well together and were a consistent thread through all the work across the organization and community.
Attend to the details of the Portal and the on-site survey.
The designated Coordinator needs to be on top of the details from the start so consistency and communication is vital.
The Portal contains the first information that Accreditation Canada receives and there are timelines associated with completion of fields.
Based on your particular organization, there may be additions or deletions you want to suggest to the Accreditation Canada schedule that is prepared for you.
Ensure visibility
Short frequent interactions with the CNS (ie: huddles); Our daily Stroke of Genius messages provided a daily reminder with a very short but
important best practice message; Presence of senior leaders as needed and for tracers and trouble-shooting.
Use positive messaging
Positively promoting Distinction as a Quality Improvement Initiative rather than thinking you need to be “perfect”;
We ensured that staff did NOT see this project as extra work; rather work they were already doing. The Distinction was a formal process for our establishing our credibility and building on existing successes;
We recognized staff who went the extra mile through emails to their superiors. Being recognized made staff want to do even more.
Build on staff pride!
Relieve Anxiety
Mock Tracers really helped in alleviating the anxiety about speaking to a tracer.
Engagement of senior leaders and staff.
Gap Analysis gave us objective proof of where we were solid or in need of work. These were updated regularly and addressed at the Steering Committee meetings and work groups.
Promote cross-continuum care
Always promote the journey of the patient from ED to community reintegration and the transitions required for patient, family and staff.
Build on existing successes
This is where the Gap Analysis is so helpful as you see where you are performing well as an organization and what needs to be done to close the gaps;
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Use local, regional or provincial work in stroke to advance other work in the organizations eg. Stroke Report Card.
8. Which resources at Accreditation Canada did you find most helpful?
Our Hospital and Distinction Accreditation Specialist was Genevieve Martin. She was very helpful to us through the entire process, answering questions quickly, clarifying discrepancies and generally easing the burden of the many administrative details that are a necessary part of the program. There were some discrepancies we found in what was published versus what was said and Genevieve was able to deal with these quickly and satisfactorily.
The Standards and other expectations for the program were very clear as far as expectations for the organization. It would be helpful to have them more plainly dated (ie. version 2010, 2011) and to highlight the priority standards within the standards document, rather than in an email separately.
The Portal was well laid out and it was easy to enter information. We heard from Kingston that the surveyors were not able to see the metrics online so we were prepared with a spreadsheet. It would be helpful if this was corrected to allow the surveyors full access to our information ahead of the visit.
9. Have you developed any resources that you would be willing to share? If so please describe, attach and/or provide links:
APPENDIX A - Final Report for Mackenzie Health Distinction
APPENDIX B – Blank Gap Analysis
APPENDIX C – Sample Stroke of Genius messages
APPENDIX D – Education Calendar
APPENDIX E – Mock Tracer document
APPENDIX F – Stroke Program goals and objectives
APPENDIX G – Metrics Submission Spreadsheet
10. Any other information you’d like to share?
Through the Distinction journey, Mackenzie Health truly became a “stroke aware” hospital. Our success was a result of leadership engagement, engaged champions, strategic partnerships, and an effective project leadership and management model.
Mackenzie Health would like to thank the Ontario Stroke Network for making such generous funding possible for us to pursue Stroke Distinction Accreditation.
About the Stroke Distinction Report This report includes the official stroke distinction information based on the evaluation of the organization’s stroke services. The report can be used to communicate the success of stroke services to the public and staff. Please visit the Organization portal (https://www3.accreditation-canada.ca/) for details of findings. The detail on the Organizational Portal will allow the organization, sites, and teams to review the stroke distinction results in detail and use the information for ongoing quality improvement initiatives and to monitor improvements.
Stroke Distinction Report
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Stroke Distinction Decision
Accreditation Canada is very pleased to recognize Mackenzie Health for earning Distinction in Stroke Services for the following site and program: Mackenzie Health, 10 Trench Street. The national standards for Stroke Distinction were developed with input from key content experts and in collaboration with the Canadian Stroke Network. The Accreditation Canada Stroke standards are based on the best available evidence for stroke services, including the Canadian Stroke Strategy Best Practice Recommendations for Stroke Care (2008). In order to achieve Stroke Services Distinction, you must have at least 75% of criteria rated as “Met” and at least 90% of high-priority criteria rated as “Met”. The following table summarizes your achievement of these thresholds.
Mackenzie Health Achievement Met Unmet Total % Standards ✔ 174 3 177 98.3%
Excellence & Innovation ✔ 5 0 5 100.0%
Education ✔ 8 0 8 100.0%
Protocols ✔ 11 0 11 100.0%
Results Summary
Acute Stroke Services Standards
The following section of the report summarizes your achievement of the standards for acute stroke services, organized by standards subsection.
Mackenzie Health Criteria met High priority criteria met
Unmet criteria
Investing in comprehensive acute stroke services
4/4 100.0% 1/1 100.0% 0/4 0.0%
Engaging a prepared and proactive acute stroke services team
16/17 94.1% 2/2 100.0% 1/17 5.9%
Providing safe and appropriate hyper-acute and acute stroke services
34/35 97.1% 8/9 88.9% 1/35 2.9%
Helping clients and families live with stroke
24/24 100.0% 2/2 100.0% 0/24 0.0%
Maintaining accessible and efficient clinical information systems
7/7 100.0% 0/0
0/7 0.0%
Monitoring quality and achieving positive outcomes
7/7 100.0% 2/2 100.0% 0/7 0.0%
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Inpatient Stroke Rehabilitation Services The following section of the report summarizes your achievement of the inpatient stroke rehabilitation services standards, organized by standards subsection.
Mackenzie Health
Criteria met
High priority criteria met
Unmet criteria
Investing in comprehensive stroke rehabilitation services
4/4 100.0% 1/1 100.0% 0/4 0.0%
Engaging a prepared and proactive acute stroke rehabilitation team
17/17 100.0% 4/4 100.0% 0/17 0.0%
Providing safe and appropriate inpatient rehabilitation services
32/32 100.0% 5/5 100.0% 0/32 0.0%
Helping clients and families live with stroke
16/17 94.1% 0/1 100.0% 1/17 5.9%
Maintaining accessible and efficient clinical information systems
7/7 100.0% 0/0
0/7 0.0%
Monitoring quality and achieving positive outcomes
6/6 100.0% 2/2 100.0% 0/6 0.0%
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The Stroke Standards Acute Stroke Services This part of the report provides information on the delivery of high quality and safe acute stroke services. Specific priority process areas that are evaluated include: clinical leadership, competency, episode of care, and impact on outcomes. Improvements Following the on-site visit is the opportunity to address the unresolved criteria. Below are criteria that were rated not met:
Criterion Evaluator Comment
(3.6) The team uses telehealth to increase access to stroke specialists. (6.8) The acute stroke team screens and documents the client's swallowing ability using a simple valid and reliable bedside testing protocol as part of their initial assessment, and prior to initiating oral intake of medications, fluids, or food.
This is not widely applicable to the district which is largely urban, but the stroke neurologist provides robust and just in time decision support to hospitals for patient redirection.
The needs-based innovation project is supported by the CIS. Real-time audit/huddles in the ED drive PDSA cycles for CQI and are exemplary.
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Inpatient Stroke Rehabilitation Services This part of the report provides information on the delivery of high quality and safe inpatient stroke rehabilitation services. Specific priority process areas that are evaluated include: clinical leadership, competency, episode of care, and impact on outcomes. Improvements Following the on-site visit is the opportunity to address the unresolved criteria. Below are criteria that were rated not met:
Clinical Leadership Mackenzie Health conducted an analysis of its stroke bed map and realigned the beds to meet increased demand for inpatient rehabilitation. The organization collects and reviews data about the population it serves as is evident in the innovation project. The innovation project has addressed barriers to service in the community, providing increased access to early rehabilitation within the expanded Chronic Disease Management Model. Follow up research is planned to identify social determinants of health and inform development of content for the population’s different cultures. There is a dedicated stroke unit, staffed with an inter- professional team with expertise in stroke care. The team has a dedicated coordinator. The team provides care to patients during both the acute and rehabilitation or complex continuing care (CCC) component of their stay. This is an integrated unit combining acute, rehab and CCC beds which contributes to smooth patient flow between levels of care and providing access to the right level of care for each patient. The unit layout promotes patient care and safety. In a patient care redesign initiative and using LEAN methodology the team reconfigured the location of nursing areas, bringing staff closer to the patient. Huddles are held daily by the team. Safety crosses are posted on the unit to display incidence of falls.
Criterion Evaluator Comment
9.1 The team screens and documents the client's swallowing ability using a simple valid reliable testing protocol as part of their initial rehabilitation assessment.
The SLP conducts a screen in acute care. The SLP managing the patient in acute care continues to be the treating SLP in rehab. A second formal assessment is not completed in rehab, rather the SLP progresses swallowing issues from acute admission to discharge from the system.
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Stroke Distinction Report
Competency Team member roles are posted in the unit hallway and are available to staff, patients and visitors. New staff members receive stroke specific orientation and training on the unit and through broader stroke specific education opportunities. New staff members are assigned a preceptor. The clinical nurse specialist (CNS) works closely with the team and provides both real time learning and formal learning around identified learning needs. The CNS and unit educator work together to meet the education needs of the unit. The team participates in Ontario Telemedicine Network sessions for education and has access to conferences and workshops that are specific to stroke. The organization supports learning through education funding. Episode of Care: Inpatient Stroke Rehabilitation Services The unit is dedicated to stroke care. Assessment begins in the ED and patients are progressed to the stroke unit when ready. Stroke patients admitted to an alternate location (medicine or CCU) are followed by the stroke team and stroke assessments/protocols are initiated. Psychiatry consultation is available across the hospital. Admission to the stroke unit is primarily from within the facility although other hospitals are able to access the stroke beds to facilitate care closer to home. Daily bullet rounds assist in monitoring patient progress; these are attended by a representative of the Community Care Access Centre (CCAC). There is frequent communication between team members. Patients participate in therapy as prescribed. Therapy is provided through a combination of direct provision by a health care professional, sessions with an occupational therapy assistant/physiotherapy assistant and group therapy sessions. The pharmacist works closely with the unit physicians to manage medications and dosage. The dietician works closely with patients/families. Speech-language pathology and specialized diabetic services meet the needs of stroke patients. There is a policy for assessment of depression in all stroke patients at admission and as needed, using PHQ -9. The Montreal Cognitive Assessment (MoCA) is used as the standard assessment for cognitive impairment. There is a corporate falls policy which is followed on the unit. Rehabilitation plans are developed for each patient and are based on goals. Discharge dates are estimated on admission and reviewed at weekly rounds. Rounds are interdisciplinary and comprehensive. Patients are aware of their discharge date and provide feedback to the team following a day or weekend pass. The CCAC provides in-home assessments as needed. Patient flow between acute care and rehabilitation is seamless. A discharge checklist is used. The patient care coordinator calls patients and families following discharge and uses the checklist to review the status of in-home services, medication management, follow-up tests and appointments as well as other issues the patient or family may identify. Decision Support There is an electronic system that captures patient information along the continuum of care. Information can be retrieved from one episode of care to another. This clinical information includes medical information, patient progress details and a clinical pathway. A decision support system produces data reports, for example CIHI NRS information, for analysis and to inform decision making. Acute care and rehab data can be linked in this system within the same report. Data is posted on the integrated stroke unit. Impact on Outcomes Clinical data are posted on the stroke unit. Utilization data were used to inform a decision to increase the number of rehabilitation beds on the stroke unit. The organization accesses information about comparator rehabilitation facilities through eNRS and monitors specific indicators.
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Demonstrating Excellence and Innovation
Excellence and innovation are key components of effective stroke services. Accreditation Canada supports excellence and innovation by requiring stroke services to implement projects or initiatives that utilize the latest knowledge, integrate evidence, and align with best practice guidelines. Below are the results from organization implementation of excellence and innovation in stroke services.
Project Name
Central LHIN Stroke Prevention Strategy - Stroke Prevention Strategy: An Interdisciplinary and Community Approach to Emergency Diversion through Stroke Prevention and Health Promotion. Description Mackenzie Health (MH) is the District Stroke Centre providing emergency, acute and rehabilitation services to York Region. In 2009, MH (then York Central Hospital), submitted a proposal to the Central Local Health Integration Network (C LHIN) for Aging at Home program funds to support the project: Stroke Prevention Strategy: An Interdisciplinary and Community Approach to Emergency Diversion through Stroke Prevention and Health Promotion. Since receiving this funding, the three-year project established Stroke Prevention Clinics (SPC) in all 5 of the C LHIN hospitals to provide rapid triage, assessment and interventions for patients presenting with Transient Ischemic Attack (TIA) and minor non-disabling stroke based on the immediate period of high risk for progression to stroke and the high recurrence rate for stroke. The model of care then proceeds to refer SPC patients to local Cardiovascular Rehabilitation (CVR) services based on research that shows comparable outcomes for stroke patients to the benefits for cardiac patients and the commonality of risk factors among both populations. The project has increased community capacity for CVR by planning and implementing two new CVR programs in partnership with Carefirst Seniors & Community Services (at Bayview Hill Community Centre) and with UHN-Toronto Rehab and York University (at Toronto track and Field Centre, York U campus). From CVR, the patients are further referred to chronic disease management services as needed (e.g. Diabetes education) and/or linked to appropriate community programs to support risk reduction, secondary stroke prevention and ongoing chronic disease management. Comments The Central LHIN Stroke Prevention Strategy innovation initiative entitled: An Interdisciplinary and Community Approach to Emergency Diversion through Stroke Prevention and Health Promotion is aligned precisely to The Ontario Stroke Network vision. The project targets appropriate resource utilization for cost benefit, was developed as a phased implementation, and has realistic deliverables targeting an outcome of reduced TIA admissions, which has now been achieved. The 2009-2013 period of development has seen a five-fold increase in Stroke Prevention Clinics, a three-fold increase in vascular rehabilitation sites, and a five-fold increase in chronic disease self-management program sites. Six blood pressure screening clinics (up from none in 2009) and six programs for clinician training for self-management (up from none in 2009) are now in existence. The success of this project has translated from Central LHIN project funding to base (program) funding commencing in the 2013-2014 fiscal year. It is a testimony to the tenets of implementation science where practice-informed policy, demonstration project, has translated to policy-enabled practice, program. This program is an exemplar well positioned for scaling to other LHIN's.
Stroke Distinction Report
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Client and Family Education about Stroke Client, family and caregiver education is an integral part of stroke care that should be addressed at all stages across the continuum of stroke care. In order to achieve Stroke Services Distinction, the following targets for providing client and family education that is an integrated component of stroke care and is consistently documented must be met. Comments: The portfolio of materials available for client education is comprehensive. It consists of an education needs survey for the client (patient and family) which is reviewed by the team, documented, and directed to the appropriate resource(s). The resources include: Let's talk about Stroke, eight internet presentations with evaluation checklist surveys, overall needs assessment for the client; client fact sheets, and education pamphlets (multiple languages reflective of the demographic), a Living with Stroke document, and client decision-making tools. Note is made of Mackenzie Health diabetes program, featured on its website, which serves clients in a number of languages. During the tracer activity, a regular team meeting was held where patient progress was discussed, and documentation of components of care including education was carried out. One client discussed in the meeting had been interviewed earlier the surveyor; there were no team-client inconsistencies noted.
Stroke Distinction Report
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Stroke Services Protocols Implementation of stroke protocols is a key component of excellence in stroke services. Using protocols helps stroke services remain consistent, high quality, and evidence based. Accreditation Canada supports excellence by identifying stroke protocols that are in place to achieve Stroke Distinction. Comments: There was an opportunity during the tracer activity to review all protocols and then see them implemented with emergency medical services (EMS) direct (bypass) arrival of an acute stroke patient. Door to CT imaging time was 10-12 minutes; the patient returned to the emergency department (ED) and was prepared for tPA administration some 15 minutes later and re-assessed. As symptoms had resolved (TIA), the decision not to proceed with tPA administration was made. Discharge of protocol and its documentation was appropriate and faithful to the requirements listed. During this time in the ED, a daily huddle with available ED staff focused on ED performance indicators including door-to-needle time for tPA. With respect to stroke, these huddles have been used for case by case rapid audit driving PDSA cycles for CQI to achieve targets. Noteworthy with respect to swallowing assessment for stroke patients in the ED is that the speech language therapist (SLP) makes twice daily rounds in the ED, and 24/7 coverage of the ED is provided with critical care unit (CCU) nurses charged with swallowing assessments in off hours.
Stroke Distinction Report
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Performance Measures The following section provides a comparison of the performance measures (indicators) collected for stroke services and the measures collected nationally.
Core Performance Indicator Results – Acute Care Services Below are the results from core performance indicators. Overall performance is based on data submitted by the organization for each indicator.
Mackenzie Health indicators: Stroke / TIA mortality rates Purpose and Rationale: In-hospital stroke mortality is a valid outcome measure for effectiveness of hyper-acute and acute stroke services. Numerator: Number of stroke clients who died while in hospital (ED or inpatient) for an acute stroke event within the first 30 days of hospitalization. Denominator: Number of all stroke clients who are admitted to the emergency department and/or acute inpatient services. Threshold: 30 day in hospital all-cause mortality <22% of all stroke/TIA admissions
Stroke Distinction Report
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Proportion of ischemic stroke clients who receive acute thrombolytic therapy (tPA)
Purpose and Rationale: All eligible clients with disabling acute ischemic stroke should be treated with intravenous tissue plasminogen activator (tPA). Numerator: # of ischemic stroke clients who receive acute intravenous thrombolysis at stroke site. Denominator: # of all ischemic stroke clients presenting to the stroke site. Threshold: 7% of all ischemic stroke clients, regardless of time from stroke onset to tPA administration.
Stroke Distinction Report
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Median time to administration of acute thrombolytic agent
Purpose and Rationale: All eligible clients with disabling acute ischemic stroke should be treated with intravenous tissue plasminogen activator (tPA). Time is brain and tPA should be administered as soon as possible to eligible stroke clients. Canadian Best Practice Recommendations for Stroke Care state that eligible clients should receive intravenous thrombolysis within one hour of arrival to hospital. Numerator: sum [# minutes from ED arrival (registration) to start of administration of intravenous tPA]. Denominator: # of ischemic stroke clients presenting in ED or inpatient services who receive tPA through an intravenous route.
Threshold: 50% of all tPA clients have door to needle time of <60 minutes.
Stroke Distinction Report
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Porportion of clients treated on stroke unit
Stroke Distinction Report
Purpose and Rationale: Evidence shows better outcomes for clients who are treated on a designated stroke unit (defined as being a geographically defined unit with dedicated beds for stroke clients in acute care it has a core interdisciplinary team to formulate a treatment plan and provide care for stroke clients; teams meet regularly to monitor client progress and adjust treatment plans*). This indicator applies to acute inpatient care, inpatient rehabilitation settings, and clients managed on an integrated stroke unit (combines acute management and sub-acute intensive rehabilitation during a single stay). It is important to identify which model is relevant to the setting being monitored. Numerator: # of stroke clients admitted to hospital and treated in an acute stroke unit, a rehabilitation stroke unit or an integrated stroke unit at any time during hospital stay. Denominator: total # of stroke clients admitted to a hospital (TIA, ischemic, hemorrhage). Threshold: Proportion of stroke clients managed on an acute stroke unit or integrated stroke unit for some part of acute inpatient stay ≥ 75%.
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Length of stay in an acute care hospital setting for clients admitted following an acute stroke event
Stroke Distinction Report
Purpose and Rationale: Length of stay is an important indicator of hospital efficiency and system responsiveness. Numerator: total number of acute care hospital days for all stroke clients admitted to an acute care setting following an acute stroke event and discharged alive. Denominator: total # of stroke clients discharged alive from an acute care hospital. Threshold: Median acute services total length of stay ≤ 14 days.
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Readmission to acute care for stroke related causes
Stroke Distinction Report
Purpose and Rationale: Readmission is an important metric of effectiveness of stroke services. Numerator: number of acute stroke and TIA clients that are discharged alive that are then readmitted to hospital with a new stroke or TIA diagnosis within 90 days of index acute care discharge. Denominator: total # of stroke clients discharged alive from the emergency department or inpatient care following an index stroke event.
Threshold: 90 day readmission rate to acute services for stroke related causes less than or equal to 12%.
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Proportion of acute stroke clients discharged to inpatient rehabilitation
Stroke Distinction Report
Purpose and Rationale: Evidence supports the importance of stroke rehabilitation being provided in an inpatient setting where rehabilitation is formally coordinated, organized and delivered by a multidisciplinary team with expertise in stroke rehabilitation. Numerator: # of stroke clients admitted to inpatient rehabilitation following discharge from acute services for a stroke. Denominator: total # of stroke clients discharged alive from an acute services hospital following an index stroke event. Threshold: Proportion of stroke clients admitted to inpatient rehabilitation ≥ 15% of all stroke patients discharged alive from acute care.
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Proportion of acute ischemic stroke and TIA clients prescribed antithrombotic therapy (acute stroke services)
Stroke Distinction Report
Purpose and Rationale: Best practice evidence has shown that antithrombotic medications reduce the risk of further vascular events following an initial ischemic stroke or transient ischemic attack. This indicator applies to acute care (ED and inpatient) and inpatient rehabilitation. Numerator: # of ischemic stroke/TIA clients who are discharged from the emergency department or inpatient acute services or inpatient rehabilitation services on antithrombotic therapy. Denominator: total # of ischemic / TIA stroke clients discharged alive from the ED, acute services or inpatient rehabilitation. Threshold: Proportion of ischemic stroke clients prescribed antithrombotic before discharge ≥ 90%.
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Proportion of clients with initial dysphagia screening at admission (acute stroke services)
Stroke Distinction Report
Purpose and Rationale: Difficulties in swallowing following a stroke occurs in more than half of all stroke clients and may lead to aspiration, dehydration and poor nutrition. This indicator applies to acute care (ED and inpatient) and inpatient rehabilitation. Numerator: # of stroke clients who receive dysphagia screening in the ED, acute inpatient services or in inpatient rehabilitation. Denominator: total # of stroke clients admitted to ED, acute inpatient services, or inpatient rehabilitation. Threshold: Proportion of stroke / TIA clients with documentation of screening for dysphagia ≥ 90%.
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Core Performance Indicator Results – Inpatient Rehabilitation Services Below are the results from core performance indicators. Overall performance is based on data submitted by the organization for each indicator. Porportion of clients treated on stroke unit (inpatient rehabilitation)
Stroke Distinction Report
Purpose and Rationale: Evidence shows better outcomes for clients who are treated on a designated stroke unit (defined as being a geographically defined unit with dedicated beds for stroke clients in inpatient rehabilitation; it has a core interdisciplinary team to formulate a treatment plan and provide care for stroke clients; teams meet regularly to monitor client progress and adjust treatment plans*). This indicator applies to acute inpatient care, inpatient rehabilitation settings, and clients managed on an integrated stroke unit (combines acute management and sub-acute intensive rehabilitation during a single stay). It is important to identify which model is relevant to the setting being monitored. Numerator: # of stroke clients admitted to hospital and treated in an acute stroke unit, a rehabilitation stroke unit or an integrated stroke unit at any time during hospital stay. Denominator: total # of stroke clients admitted to a hospital (TIA, ischemic, hemorrhage). Threshold: Proportion of stroke clients managed on an inpatient rehabilitation stroke unit or integrated stroke unit for some part of the inpatient rehabilitation stay ≥ 80%.
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Length of stay in an inpatient rehabilitation setting for patients admitted following an acute stroke event
Purpose and Rationale: Length of stay is an important indicator of hospital efficiency and system responsiveness. Numerator: total number of inpatient rehabilitation hospital days for all stroke clients admitted to an rehabilitation setting following an acute stroke event and discharged alive. Denominator: total # of stroke clients discharged alive from an inpatient rehabilitation program. Threshold: Median inpatient rehabilitation services total length of stay ≥ 14 days.
Stroke Distinction Report
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Proportion of acute with antithrombotic therapy (inpatient rehabilitation)
Purpose and Rationale: Best practice evidence has shown that antithrombotic medications reduce the risk of further vascular events following an initial ischemic stroke or transient ischemic attack. This indicator applies to acute care (ED and inpatient) and inpatient rehabilitation. Numerator: # of ischemic stroke/TIA clients who are discharged from the emergency department or inpatient acute services or inpatient rehabilitation services on antithrombotic therapy. Denominator: total # of ischemic / TIA stroke clients discharged alive from the ED, acute services or inpatient rehabilitation. Threshold: Proportion of ischemic stroke clients prescribed antithrombotic before discharge ≥ 90%.
Stroke Distinction Report
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Proportion of clients with initial dysphagia screening at admission (inpatient rehabilitation)
Purpose and Rationale: Difficulties in swallowing following a stroke occurs in more than half of all stroke clients and may lead to aspiration, dehydration and poor nutrition. This indicator applies to acute care (ED and inpatient) and inpatient rehabilitation. Numerator: # of stroke clients who receive dysphagia screening in the ED, acute inpatient services or in inpatient rehabilitation. Denominator: total # of stroke clients admitted to ED, acute inpatient services, or inpatient rehabilitation. Threshold: Proportion of stroke / TIA clients with documentation of screening for dysphagia ≥ 90%.
STANDARDS FOR INPATIENT STROKE REHABILITATION SERVICES – DISTINCTION PROGRAM Standard Note: PRIORITY
Current Status
Notes
INVESTING IN COMPREHENSIVE ACUTE STROKE SERVICES1.0 The site collects and analyzes information about the need for inpatient stroke rehabilitation services. 1.1 The site annually collects information about stroke incidence in the population
it serves.
1.2 When planning stroke services the site collects information about the prevalence of major risk factors for stroke in the population it serves.
1.3 The site collects demographic information about high-risk and hard-top reach populations.
1.4 The site uses information about demand for inpatient stroke rehab services to identify and analyze barriers that prevent access to services.
ENGAGING A PREPARED AND PROACTIVE STROKE REHABILITATION TEAM 2.0 The stroke rehabilitation team uses an interprofessional approach to coordinate and deliver inpatient stroke rehabilitation services. 2.1 The team has expertise in stroke care & uses an interprofessional approach to
deliver inpatient stroke rehab services to clients & families.
2.2 The team has clearly defined roles and responsibilities for delivering stroke services to the client, family and caregiver.
2.3 Each team member has the necessary credentials or license from the appropriate professional college or association.
2.4 The team orients new staff & service providers about the unique aspects of stroke rehab services.
2.5 The team receives ongoing professional development & training to deliver current evidence based stroke rehab services.
2.6 The team uses information from performance evaluations to improve stroke rehab services, and identify support, training, or development needs for the team.
2.7 The team has adopted & implemented the Canadian Best Practice Recommendations for Stroke Care for the assessment and management of stroke clients.
3.0 The interprofessional team providing inpatient stroke rehabilitation has support from leadership and resources to provide effective services. 3.1 The interprofessional team providing stroke rehab services has a designated
coordinator.
3.2 The team works with staff, other service providers, and community partners to develop goals & objectives for stroke rehab services that are aligned with the site’s strategic & operational plans.
3.3 Goals & objectives for stroke rehab services are specific & measurable.
STANDARDS FOR INPATIENT STROKE REHABILITATION SERVICES – DISTINCTION PROGRAM 3.4 The team has resources to establish & support dedicated stroke units for stroke
rehab services.
3.5 The layout of the physical space contributes to the effectiveness & safety of stroke services.
3.6 The team uses telehealth to increase access to stroke specialists. 3.7 When delivering stroke rehab services, the team has access to equipment &
supplies appropriate to the needs of the stroke clients & the population it serves.
4.0 The stroke rehabilitation team collaborates with other services, providers and organizations to coordinate inpatient stroke rehabilitation services and meet the needs of stroke clients and the community
4.1 The team collaborates with acute stroke services, inpatient rehab services, programs and providers within their site to coordinate rehab services for stroke clients.
4.2 The team collaborates with acute hospitals, other rehab sites including sub-acute centres providing CCC or rehab, primary care practitioners, LTC, home care, and community-based services to coordinate and plan inpatient stroke rehab service in the site’s service boundary.
4.3 The team works with community agencies to sponsor public campaigns to raise awareness about stroke rehab services available in the community, the impact of stroke and living with stroke.
5.0 The team coordinates timely access to inpatient stroke rehabilitation services for clients and families and caregivers, service providers, and referring organizations.
5.1 The team has formal intake criteria and processes based on standardized assessments.
5.2 The team communicates referral processes and intake criteria for inpatient stroke rehab to all referring centres, including acute care providers, CCC, LTC homes, home care services, as well as to clients & families.
5.3 The team contacts referring centres and responds within 48 hours to requests for rehab services..
5.4 The wait time from when a client has met criteria for being “rehab ready” by inpatient rehab services until admission to inpatient stroke rehab is not more than 2 business days.
5.5 The team monitors its responsiveness by setting and tracking times for responding to requests for services and information.
5.6 The team regularly reviews the needs of stroke clients waiting for services & responds quickly to those who are in ED or crisis situations.
STANDARDS FOR INPATIENT STROKE REHABILITATION SERVICES – DISTINCTION PROGRAM 5.7 The team establishes partnerships or collaborations required to regularly
monitor and reassess survivors of moderate or severe strokes who did not meet the criteria for inpatient rehab at the first assessment, and provides input on the client’s status and ongoing rehab needs.
5.8 The team has a process for stroke survivors to re-access stroke rehab if clinically indicated regardless of the time that has elapsed since the stroke.
6.0 The stroke rehabilitation team accurately and appropriately assesses clients to develop an individualized care plan for stroke rehabilitation. 6.1 From the time of first contact, the team informs the client & family of the
interprofessional team member who has primary responsibility for coordinating the stroke rehab services and provides information on how to contact that person.
6.2 The team assesses the client’s stroke related impairments and functional status within 24-48 hours of admission.
6.3 The team conducts functional assessments using standardized and valid assessment tools.
6.4 The team develops an individualized rehab plan based on the clients’ functional assessment that identifies required rehab services, intensity and duration of therapy and rehab therapy goals.
6.5 The team includes discharge planning in each client’s rehab plan by identifying transition issues specific to the client and family, caregiver training needs and organizing home visits by health care professionals to assess the home environment.
6.6 The team conducts at least one formal interprofessional meeting per week to monitor clients progress in achieving their rehab goals.
6.7 The team , clients, family and caregivers regularly update the written rehab plan on the progress made towards client goals and anticipated discharge timing and destination.
6.8 When client rehab goals are not met, the team documents the reasons and updates the rehab goals, discharge timing, and destination plans as appropriate.
7.0 The stroke team provides comprehensive, safe, and timely inpatient stroke rehabilitation.7.1 Clients admitted for inpatient stroke rehab services are managed on a
dedicated stroke unit.
7.2 When clients are not managed on a dedicated stroke unit, there is a process for clustering stroke clients.
7.3 When the team provides rehab stroke care on general rehab units or mixed units, protocols are used that are specific to the care & management of stroke clients.
7.4 Team members deliver the appropriate intensity & duration of clinically
STANDARDS FOR INPATIENT STROKE REHABILITATION SERVICES – DISTINCTION PROGRAM relevant therapies across the care continuum as prescribed in the individualized rehab plan.
7.5 The team delivers a minimum of one hour of direct therapy for each relevant core therapy, a minimum of 5 days/week, to each stroke rehab client.
7.6 The team promotes integrating the skills gained in therapy into the clients’ daily routine to increase their participation and activity.
7.7 The team follows established protocols and mechanisms for the safety of stroke clients during inpatient rehab.
7..8 The team implements & evaluates a falls prevention strategy specific to stroke clients to minimize the risk of falls in this population.
8.0 The stroke team provides comprehensive, safe, and timely inpatient stroke rehabilitation.
8.1 The team provides clients & their family/caregivers with information on lifestyle modifications to address cardiovascular risk factors for recurrent stroke during inpatient rehab.
8.2 The team assesses clients for the presence of HTN and appropriately manages elevated BP during inpatient rehab in all clients who have had a stroke.
8.3 The team assesses clients for the presence of elevated lipid levels & appropriately manages elevated lipid levels in all clients who have had a stroke.
8.4 The team prescribes all adult clients with ischemic stroke or TIA with antiplatelet therapy for secondary prevention of recurrent stroke unless there are contraindications or an indication for anticoagulation.
8.5 The team assesses and manages diabetes in clients admitted to rehab in accordance with the current Canadian Diabetes Association recommendations for the management of diabetes.
8.6 The team treats adult clients with stroke and A fib with warfarin unless contraindicated.
8.7 The team addresses compliance with the anticoagulation regimen with all stroke clients and their families/caregivers in their follow up with clients.
8.8 The team follows mechanisms for referrals and follow up for clients who are admitted to inpatient rehab with carotid stenosis requiring possible surgical intervention.
HELPING CLIENTS AND FAMILIES LIVE WITH STROKE9.0 The stroke rehabilitation team assesses and manages potential sequelae of stroke in an accurate and safe manner. 9.1 The team screens the clients’ swallowing ability suing a simple valid reliable
testing protocol as part of their initial rehab assessment.
STANDARDS FOR INPATIENT STROKE REHABILITATION SERVICES – DISTINCTION PROGRAM 9.2 The team refers clients with features indicating dysphagia or pulmonary
aspiration for a full clinical assessment of their swallowing ability by a SLP or appropriately trained specialist who should advise on swallowing ability and consistency of diet & fluids.
9.3 The team refers clients who are at risk of malnutrition including those with dysphagia to a dietitian for assessment and ongoing management.
9.4 The team determines whether the client has a history of depression or risk factors for depression at the time of the first rehab assessment.
9.5 The team screens clients with stroke for depression at all transition points and whenever clinical presentation indicates.
9.6 The team refers clients identified as high risk for depression during screening to a psychiatrist, psychologist, or SW for further assessment, diagnosis and development of a treatment plan.
9.7 The team screens all clients with vascular risk factors, clinically evident stroke or TIA for cognitive impairment at all transition points using a validated tool.
9.8 The team refers clients who demonstrate cognitive impairments in the screening process to a health care professional with specific expertise for additional cognitive, perceptual and functional assessment to determine the severity of impairment and impact of deficits on function and safety in ADL’s and IADL’s and to implement appropriate remedial compensatory and adaptive intervention strategies.
10.0 The stroke rehabilitation team effectively reintegrates clients and families into the community after inpatient stroke rehabilitation.10.1 The team works with clients, families and caregivers to develop a transition &
follow up plan that includes referrals for additional or follow-up services, and an individually prescribed exercise program.
10.2 The team provides stroke clients, families and caregivers with information regarding ongoing recovery, signs or symptoms of declining health status, and contact information for follow-up with the team.
10.3 The team provides clients, families and caregivers with education and support to identify & adjust to changes in roles and lifestyles.
10.4 The team provides education that promotes self-efficacy through mastering self-management skills.
10.5 The team provides training to family and caregivers to safely care for clients after discharge.
10.6 The team provides clients, families and caregivers with a list of primary care physicians community – based rehab, home care services, psychological counseling, caregiver training, stroke client support groups and vocational
STANDARDS FOR INPATIENT STROKE REHABILITATION SERVICES – DISTINCTION PROGRAM counseling services in the community..
10.7 The team works with clients, families and caregivers to help them access primary care, home and community services, community-based rehab & psychological counseling services
10.8 The team coordinates referral for follow-up secondary prevention service required by clients before leaving inpatient stroke rehab.
10.9 Following transition or end of service, the team contacts clients and families to evaluate the effectiveness of the transition and uses the information to improve its transition and end-of-service planning.
MAINTAINING ACCESSIBLE AND EFFICIENT CLINICAL INFORMATION SYSTEMS11.0 The team establishes and uses a stroke clinical information system to monitor client care and management, and plan inpatient stroke rehabilitation services. 11.1 The team maintains a clinical information system that collects information for
each client, including stroke symptoms, treatments and intervention.
11.2 The team gathers and organizes information in the clinical information system across the continuum of stroke services.
11.3 The clinical information system is linked to decision support tools such as evidence based guidelines and screening tools.
11.4 The team uses the system to obtain information about clients risk factors, appropriate stroke management and intervention, and to schedule appointments for clients and families.
11.5 The team uses information from the clinical information system to create reports about stroke system performance and use of decision tools.
11.6 The team shares reports about stroke system performance and use of decision support tools within the rehab site and with clients, families, primary care providers and community based services.
11.7 The team has security, back-up and confidentiality systems in place for the stroke data to meet legislation for protecting privacy and integrity of information.
MONITORING QUALITY AND ACHIEVING POSITIVE OUTCOMES 12.0 The team uses data to monitor quality and achieve positive outcomes for inpatient stroke rehabilitation services. 12.1 The inpatient stroke rehab team accesses & reviews clinical and service
utilization data.
12.2 The team identifies & monitors standardized process & outcome performance measures for inpatient stroke rehab.
12.3 The team monitors client & family perspectives on the quality of inpatient stroke services.
12.4 The team compares its results on performance measures with other similar
STANDARDS FOR INPATIENT STROKE REHABILITATION SERVICES – DISTINCTION PROGRAM interventions, programs or organizations.
12.5 The team uses information it collects about the quality of services to identify successes and opportunities for improvement and makes improvements in a timely way.
12.6 The team shares evaluation results with staff, clients and families.
STANDARDS FOR ACUTE STROKE SERVICES – DISTINCTION PROGRAM Standard Note: PRIORITY
Current Status
Additional Notes
INVESTING IN COMPREHENSIVE ACUTE STROKE SERVICES1.0 The site collects and analyzes information about the need for acute stroke services. 1.1 The site annually collects information about stroke occurrence in the population it
serves.
1.2 When planning stroke services the site collects information about the prevalence of major risk factors for stroke in the population it serves.
. 1.3 The site collects demographic information about high-risk and hard-to-reach populations.
1.4 The site uses information about urban and rural populations to analyze geographical barriers to stroke services.
ENGAGING A PREPARED AND PROACTIVE ACUTE STROKE SERVICES TEAM 2.0 The stroke team uses an interprofessional approach to coordinate and deliver hyperacute and acute stroke services.2.1 Team consists of physicians, nurses, PT’s, OT’s, SLP’s, SW, dietitians, and
pharmacists with expertise in stroke care to deliver hyperacute & acute stroke services to clients, families & caregivers.
2.2 The team has clearly defined roles and responsibilities for delivering stroke services to the client, family and caregiver.
2.3 Each team member has the necessary credentials or license from the appropriate professional college or association.
2.4 The team orients new staff & service providers about the unique aspects of acute stroke services.
2.5 The team receives ongoing professional development & training to deliver current evidence based hyper-acute and acute stroke services.
2.6 The team uses information from performance evaluations to improve acute stroke services, and identify support, training, or development needs for the team.
2.7 The team has adopted & implemented the Canadian Best Practice Recommendations for Stroke Care for the assessment and management of stroke clients.
3.0 The interprofessional team providing acute stroke services has support from leadership and resources to provide effectives services.3.1 The interdisciplinary team providing acute stroke services has a designated
coordinator.
3.2 The team works with staff, other service providers, and community partners to develop goals & objectives for acute stroke services that are aligned with the site’s strategic & operational plans.
3.3 Goals & objectives for stroke services are specific & measurable.
STANDARDS FOR ACUTE STROKE SERVICES – DISTINCTION PROGRAM 3.4 The team has resources to establish & support dedicated stroke units for acute
stroke services.
3.5 The layout of the physical space contributes to the effectiveness & safety of stroke services.
3.6 The team uses telehealth to increase access to stroke specialists.
3.7 When delivering acute stroke services, the team has access to equipment & supplies appropriate to the needs of the stroke clients & the population it serves.
4.0 The stroke team collaborates with other services, providers, and organizations to coordinate timely access to acute stroke services for stroke clients and the community. 4.1 The team identifies partnerships with surrounding acute care organizations &
EMS to coordinate and plan acute stroke services within the site’s boundaries & to provide access to appropriate stroke service for clients.
4.2 The team has a strategy to raise awareness in the community about the signs and symptoms of stroke and about the appropriate actions to take in the event of possible stroke to access acute stroke services.
4.3 The team establishes internal partnerships with the emergency department, neurology, critical care, internal medicine, diagnostic labs, and neurovascular surgery & imaging departments to coordinate & organize access to services.
PROVIDING SAFE AND APPROPRIATE HYPER-ACUTE AND ACUTE STROKE SERVICES5.0 The stroke team coordinates stroke services with EMS & the ED5.1 The team contributes to ongoing education for EMS providers about assessment
& management of suspected stroke clients at the pick-up site and during transport.
5.2 The team has protocols & MOU’s with EMS providers for direct transport to stroke centres, bypass of smaller centres, use of air ambulance services, and screening tools for suspected stroke clients.
5.3 The team has protocols with EMS providers to receive pre-notification of suspected acute stroke clients in transit.
5.4 EMS personnel, ED’s & stroke teams use agreed upon triage levels to assign clients with suspected stroke, and use these levels when communicating.
5.5 The ED & stroke team initiate stroke protocols when stroke pre-notification is received from EMS so stroke clients are received efficiently from EMS personnel when they arrive.
5.6 A designated stroke team member is notified when a suspected stroke client is in transit, or as soon as the client arrives at the ED.
5.7 The stroke team responds to ED requests for evaluation of a suspected stroke client to optimize opportunities for time-sensitive interventions.
STANDARDS FOR ACUTE STROKE SERVICES – DISTINCTION PROGRAM 5.8 The stroke team consults with other facilities providing stroke care to rapidly &
efficiently transfer stroke clients to or from another ED or acute inpatient setting to meet the emergent needs of stroke clients.
6.0 The stroke team provides immediate hyper-acute management for stroke clients.6.1 The ED triage staff or stroke team conducts triage on each client with suspected
stroke immediately upon arrival at the ED, regardless of how the client arrives.
6.2 The stroke team and ED personnel have protocols to initiate rapid assessment & management of clients who present with symptoms suggestive of stroke or TIA.
6.3 The stroke team gathers information about VS, neuro status, time of symptom onset, deficits (e.g. cognitive, functional) and medications.
6.4 The stroke team or ED personnel follow established protocols for clients with suspected acute stroke to undergo brain imaging immediately upon arrival to hospital.
6.5 The acute stroke team or ED staff check the client’s blood glucose concentration as part of the initial blood work and repeats it if the initial values are abnormal.
6.6 The acute stroke team or ED staff evaluate stroke clients to determine their eligibility for treatment with t-PA using the current criteria in the Canadian Stroke Strategy’s Canadian Best Practice Recommendations for Stroke Care.
6.7 The acute stroke team or ED staff administers t-PA in accordance with the current American Stroke Association guidelines for t-PA mode of administration, dosage and infusion time.
6.8 The acute stroke team screens client’s swallowing ability using a simple valid & reliable bedside testing protocol as part of their initial assessment, and prior to initiating PO intake of meds, fluids or food.
6.9 The team refers clients with features indicating dysphagia or pulmonary aspiration for a full clinical assessment of their swallowing ability by a SLP or appropriately trained specialist to advise on swallowing ability & consistency of diet & fluids.
6.10 The acute stroke team administers at least 160 mg of ASA to all acute adult stroke clients after brain imaging has ruled out ICH.
6.11 The acute stroke team has rapid access to neurosurgery & vascular surgical services to collaborate on the assessment & management of clients with hemorrhagic stroke, intracerebral strokes, or other appropriate clinical indications.
6.12 The acute stroke team orders carotid imaging tests for clients with carotid territory TIA or ischemic stroke & follows up on results, even if the client is discharged directly from the ED.
6.13 The stroke teams refers clients who are discharged directly from the ED with a diagnosis of TIA or minor stroke to a stroke prevention clinic or physician with
STANDARDS FOR ACUTE STROKE SERVICES – DISTINCTION PROGRAM specific stroke expertise for further assessment & management.
6.14 The team effectively transfers information to inpatient stroke services about VS, time of onset, lab results(including blood work), neurological signs & fluctuations in status, diagnostic information (complete or in process), medications given in ED & interventions (e.g. t-PA) and family member accompanying the client.
7.0 The stroke team provides comprehensive inpatient acute stroke services.7.1 Clients admitted for an acute stroke or TIA are managed on a dedicated acute
stroke unit.
7.2 When clients are not managed on a dedicated stroke unit, there is a process for clustering clients.
7.3 The stroke team has a process to identify all stroke clients daily, including those on the stroke unit or stroke ward, new in-house admissions since previous rounds, and stroke that occur in patients already admitted within the organization.
7.4 The stroke team conducts a daily review of stroke clients to identify and update their case needs.
7.5 The stroke team assesses the client’s stroke rehabilitation needs within the first 48 hours after admission.
7.6 The stroke team continues to monitor clients’ blood glucose concentration as indicated by client status.
7.7 The team assesses stroke clients for their risk of developing venous thrombo-embolism, and implements appropriate management strategies.
7.8 The stroke team monitors client temperatures as part of routine vital signs and implements appropriate measures for increased temperatures.
7.9 The team mobilizes stroke clients as early and as frequently as possible and within 24 hours of stroke symptom onset unless contraindicated.
7.10 The team assesses stroke clients for urinary incontinence and retention, with or without overflow, fecal incontinence, and constipation and implements appropriate management strategies for these conditions.
7.11 The team assesses hydration status upon admission & implements appropriate intervention strategies to maintain adequate hydration for stroke clients.
7.12 The team screens for the nutritional status of stroke clients upon admission using a valid screening tool, and implements appropriate management strategies for clients with nutrition deficits.
7.13 The team implements and evaluates a falls prevention strategy specific to stroke clients to minimize the risk of falls in this population.
8.1 The team has identified which team members are responsible for providing
STANDARDS FOR ACUTE STROKE SERVICES – DISTINCTION PROGRAM inpatient education and education materials to clients, families and caregivers.
8.2 The team provides education and education materials to clients, families and caregivers about living with stroke & identifying & addressing potential changes in role and lifestyle.
8.3 The team provides education that promotes self-efficacy through mastering self-management skills.
8.4 The team provides training to family and caregivers to safely care for clients after discharge.
8.5 The education and resources provided by the team are appropriate to the client’s phase of care or recovery and client, family, and caregiver readiness and needs.
8.6 The team formally documents that client receive education prior to discharge. 8.7 The team provides emotional support and counseling to clients, families, and
caregivers to help them adjust and cope with the effects of stroke.
9.1 The team refers clients who have experienced a minor stroke or TIA to stroke
prevention clinics or MD’s with stroke expertise for ongoing assessment and secondary stroke prevention.
9.2 The team provides clients, family and caregivers with information on lifestyle modifications to address vascular risk factors for recurrent stroke.
9.3 The acute stroke team assesses clients for the presence of HTN & appropriately manages elevated BP in clients with stroke.
9.4 The team assesses clients for the presence of elevated lipid levels & appropriately manages elevated lipid levels.
9.5 The team has established protocols to assess & manage diabetes in clients admitted following a stroke.
9.6 The team prescribes adult clients with ischemic stroke or TIA with antiplatelet therapy for secondary prevention of recurrent stroke unless there are contraindications, or an indication for anticoagulation.
9.7 The team treats adult clients with stroke and Afib with warfarin unless contraindicated.
9.8 The team addresses compliance with the anticoagulation regimen with stroke clients, families, and caregivers in their follow up with clients.
9.9 The acute stroke team collaborates with neurosurgery and vascular surgical services to refer & follow up clients with carotid stenosis who are candidates for possible surgical intervention.
10.1 The team initiates discharge planning from time of admission.
STANDARDS FOR ACUTE STROKE SERVICES – DISTINCTION PROGRAM 10.2 The team uses formal referral criteria to identify stroke clients who are ready for
inpatient rehabilitation and makes a referral for inpatient services.
10.3 The team develops a transition & follow-up plan with input from the client, family and caregiver that includes information about ongoing recovery, signs or symptoms of declining health status, referrals for follow-up services, an individually prescribed exercise program & contact information for follow up with the team.
10.4 The team helps clients, families and caregivers access stroke self-management programs.
10.5 The team has a written list of community services & helps clients, families and caregivers access these services upon discharge.
10.6 The team effectively transfers information about diagnosis, tests, interventions, medications, referrals, psychosocial status, and family situation to the clients’ primary care providers.
10.7 When clients are referred to inpatient rehabilitation services the team effectively transfers information about pre-hospital history, history of onset, update on diagnosis, interventions completed, outstanding tests to be done, current medications and medication changes, family situation, psychosocial status, and referrals done or pending.
10.8 Where programs are available, the team assesses clients for early supported DC according to eligibility criteria.
11.1 The team maintains a clinical information system that collects information about
each stroke client, including stroke symptoms, treatments and interventions and client disposition across the continuum of care.
11.2 The team uses the clinical information system to gather and organize information across the continuum of stroke services.
11.3 The clinical information system is linked to decision support tools such as evidence based guidelines & screening tools for stroke.
11.4 The team uses the clinical information system to obtain information about client risk factors, appropriate stroke management and intervention and to schedule appointments for clients and families.
11.5 The team uses information from the clinical information system to create reports about stroke system performance and use of decision support tools.
11.6 The team shares reports about stroke system performance & use of decision support tools within the acute service site and with clients and families, primary care providers and community – based services.
STANDARDS FOR ACUTE STROKE SERVICES – DISTINCTION PROGRAM 11.7 The team has security back-up & confidentiality systems in place for the stroke
data to meet legislation for protecting privacy & integrity of information.
MONITORING QUALITY AND ACHIEVING POSITIVE OUTCOMES12.0 The acute stroke team uses data to monitor quality and achieve positive outcomes. 12.1 The team accesses and reviews clinical & service utilization data. 12.2 The team identifies & monitors standardized process & outcome performance
measures for acute stroke services.
12.3 The team conducts research, clinical trials, and assessments of new interventions to find innovations in acute stroke services.
12.4 The team monitors client & family perspectives on the quality of stroke services. 12.5 The team compares its results on performance measures with other similar acute
stroke services or sites.
12.6 The team uses information it collects about the quality of services to identify successes and opportunities for improvement and makes improvements in a timely way.
12.7 The team shares evaluation results with staff, clients and families.
STROKE DISTINCTION ACCREDITATION STROKE DISTINCTION ACCREDITATION IS ALMOST HERE!IS ALMOST HERE!March 4March 4‐‐66
Join in stroke care leadership.
Recognize the signs of stroke:
Heart and Stroke Foundation
STROKE DISTINCTION ACCREDITATION STROKE DISTINCTION ACCREDITATION IS ALMOST HERE!IS ALMOST HERE!March 4March 4‐‐66
Join in stroke care leadership.
Vitals signs are vital after a stroke:
• Temperature should be ≤ 37.5°• BP should not be lowered for 48‐72BP should not be lowered for 48 72
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2 10
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2 11
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Version: September 17, 2012
Mackenzie Health District Stroke Centre
Mission
Relentlessly improve care to patients with, or at risk for, stroke to create healthier
communities.
Vision
Create a world class health experience that crosses the continuum of health and illness and
results in fewer strokes and better outcomes.
Values: Building on the values of the Ontario Stroke Network, we value:
Equity and Comprehensiveness: Our activities will be aligned with the health interests of all
members of our region. We will reach out to improve access to best practice stroke care and
respect the diversity of the population we serve.
Accountability and Integrity: We will demonstrate accountability and integrity in our role as a
District Stroke Centre.
Transparency and Engagement: We will foster and demonstrate a culture of responsive,
interactive and respectful communication and collaboration with our patients and their family
members, inter‐professional team and external partners.
Learning and Performance Improvement: We will contribute to and apply evidence and
knowledge, advance new ideas and take action to continuously improve stroke care.
Leadership and Innovation: We will look to the future, embrace change and innovation, and
through partnership build capacity within our region.
Version: September 17, 2012
Mackenzie Health District Stroke Centre
Guiding Principles
We provide best practice stroke care and seamless transition across the stroke continuum
We provide leadership and support to our community hospital partners in advancing stroke care in
our region
We provide patient and family centered care
We adhere to current Best Practices developed by the Canadian Stroke Network
We ensure the right patient is in the right bed at the right time
We place an emphasis on stroke prevention across the continuum
We commit to collaborate on system and regional population issues related to cardiovascular
wellness and care
Goals and Objectives Across the Continuum
SPC
We provide rapid access to assess & investigate the underlying cause
We initiate interventions based on best practices to address risk factors & the underlying cause if
identified
We provide education on lifestyle management, stroke prevention & warning signs
Hyper‐acute
We provide timely access to diagnostic testing – CT completed within 25 minutes
We provide t‐PA to all eligible patients within 60 minutes of arrival to Mackenzie Health
We refer all patients with TIA and minor disabling stroke, not requiring admission, to the Stroke
Prevention Clinic
Acute
We provide all patients with stroke access to evidence‐based stroke care
We provide initial inter‐professional assessment of all patients admitted with stroke within 48 hours
We prevent complications of stroke through the use of validated screening tools (Tor‐BSST; fall risk assessment; Braden Scale; depression screening; continence assessment)
We initiate secondary stroke prevention through education and support with lifestyle changes and administration of recommended secondary medications
We complete the Alpha FIM on all patients on day 3 – 5 in order to ensure appropriate sub‐acute stroke care
We follow evidence‐based clinical pathways
Rehabilitation
We provide all patients with stroke access to evidence‐based stroke care
Version: September 17, 2012
We provide initial inter‐professional assessment of all patients admitted with stroke within 48 hours
We prevent complications of stroke through the use of validated screening tools (Tor‐BSST; fall risk
