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Stroke Network of Southeastern Ontario News and Events for Health Professionals Vol.8 October 2012

Southeastern Ontario (SEO) - Regional Stroke Steering Committee Priorities

The following are key messages associated with each of four ranked priorities of the Regional Stroke Steering Committee for system change across the stroke care continuum. The priority setting process included a review of stroke care evaluation data interpreted with input from stakeholders on local strengths and gaps in care. Priority #1: To lead the development of a regional plan to implement provincial rehabilitation expert panel best practice recommendations for stroke care. This plan is to include recommendations for a) funding reallocation based on a regional economic analysis and b) addressing human resource shortages in rehabilitation services.

Key Message #1: Early and ongoing access to intensive rehabilitation will improve patient flow and outcomes for all. The Ministry of Health and Long Term Care established an Expert Panel on the Impact of Rehabilitation on ED/ALC rates and recommended the following best practices as priorities in 2011:

Early access to rehabilitation: acute stroke units providing an

early intensive team approach; standardized triage tools and

admission to rehab 7 days/week

Intensification of rehabilitation: 3 hours a day up to 7 days a

week

Intensive outpatient and community rehabilitation services

In 2013-4, the MOHLTC will introduce Quality Based Funding for

stroke care that will incent best practices.

Immediate challenges in stroke rehabilitation across SEO:

Fewer patients hospitalized with a stroke access inpatient rehab (SE rate of 29.4% versus a

provincial rate of 31% and provincial “achievable benchmark” of 42.3%)

Patients wait longer for inpatient rehab (median wait time of 13 days versus a provincial

median of 10 days and a provincial “achievable benchmark” of 7 days)

One in three days in SEO acute hospitals is spent waiting for an alternate level of care (ALC).

The proportion of ALC days to total length of stay (LOS) in SEO is 34% versus 32.5%

provincially with an “achievable benchmark” as low as 14%.

Fewer patients discharged from acute care access outpatient rehab (SE rate of 4.6% versus

a provincial average of 5.9% and benchmark of 12%)

Current successes in rehabilitation system change:

Enhanced Community Rehabilitation has been provided since 2009 through a CCAC “Discharge Link” Service with a 15.6 day decrease in hospital length of stay. To build on recovery made in hospital, stroke survivors benefit from access to community-based rehabilitation services.

The opportunity for change in SEO:

In alignment with the Restorative Care Roadmap of the SE LHIN, the RSSC seeks support from stakeholders in developing a regional rehabilitation plan that will create evidence-based timely

access to intensive rehabilitation across the care continuum (inpatient, outpatient and community based services) in order to:

a) Improve functional outcomes, community reintegration and quality of life for stroke

survivors and b) Reduce ALC rates thereby improving patient flow through the hospital and ED, reducing

health costs.

Health system change requires rehabilitation access.

Our Mission: To continuously improve stroke prevention, care, recovery and reintegration.

Our Vision:

Fewer strokes. Better outcomes.

In This Issue

1 Regional Stroke

Steering Committee Priorities; Key Message #1 Early and ongoing access to intensive rehabilitation

2 Key Message #2

Sustained funding for Community Support Groups

3 Key Message #3

Vascular health in partnership with primary care.

4 Key Message #4

Acute Stroke Units

5 Best Practice Stroke

Prevention and TIA Management

6 Quinte Health Care

Acute Stroke Update

7 Stroke Education for

Health Care Providers

8 Stroke Education

Resources

9 Rehabilitation across

the Continuum of Care

10 Community

Reintegration: Stroke Survivor & Caregiver Support Groups; the Discharge Link; Best Practice in LTC

12 2011-13 Regional

Stroke Best Practice Workplan

Access to timely, intensive post-stroke

rehabilitation decreases

mortality rates, improves quality of

life, and reduces the need for LTC

as more people are able to return home

and stay home.

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Priority #2: Support the Stroke Network Community Re-integration Leadership Team to investigate and secure funding for stroke survivor and caregiver support groups.

Key Message #2: Effective community re-integration requires sustained funding for community support groups.

Re-engagement with the community is a key

component to successful recovery for the survivors of

stroke, their family and friends. Sudden and

profound changes in life circumstances present

challenges for both the survivor and caregivers long

after the initial hospital stay.

Adjustment to living with disability is emotionally

intensive. Grief, anger and depression are commonly

expressed by both stroke survivors and caregivers. It

is critical that professional facilitators with expertise

in psychosocial counselling be available as part of a

strategy to support self-management, reduce

isolation and prevent and manage depression.

Without such support to manage complex needs, both

stroke survivors and caregivers are at increased risk of

hospitalization.

Many caregivers report their own health to be “fair” to

“poor” and when providing 24/7 care and support to a

loved one; social function and personal relationships can deteriorate and contact with the

outside world often slips away placing caregivers at risk for dependence on the

healthcare system. If a caregiver is hospitalized, the stroke survivor may of necessity

enter the system as well.

Access to and participation in stroke survivor and caregiver support groups facilitated

by a professional with expertise in psychosocial counselling has demonstrated a

reduction in the caregiver burden and improved support for both the stroke survivor and

the caregiver. This in turn, can result in improved health, fewer situational crises; fewer

Emergency Room visits and a reduction in hospital and Long Term Care facility

admissions.

Current successes within SEO:

Stroke survivor and caregiver support groups exist in Belleville, Kingston, Brockville and

Perth. Regional funding has been secured through the SE LHIN for a limited timeframe with

an evaluation requirement. Partnerships with local community support services have been a

critical component to this success.

Immediate Challenge:

Secure sustained funding for professional facilitation is not yet available to any group. The

funding will be dependent on demonstrating benefits through ongoing formal evaluation.

The opportunity for change in SEO:

Sustained funding must be secured for all four local Stroke Survivor and Caregiver Support

groups. Ongoing community partnerships are critical in supporting these groups. A regional

approach to evaluation is needed to sustain funding.

Facilitated community reintegration = reduced reliance on hospital system.

For more information on Community Support Groups, see pages 10 & 11

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Community Resource Directories for each area of the region have been developed and are available to providers to facilitate linkages to applicable resources. To view the Community Resource Directories, please visit our website at: http://strokenetworkseo.ca/commstrokerecres

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DEPRESSION

About one-third to one-half of survivors suffer from depression during the first year after a stroke.

Post-stroke depression can occur right after stroke. Most often, it develops within 3 months, but can also occur up to 2 years after stroke.

Less than half of survivors with post-stroke depression are identified.

Caregivers are also at higher risk of depression

Depression needs attention; it affects a person’s outcomes and quality of life.

Depression screening tools can be used to identify those who may benefit from treatment.

Recommended screening tools include the BASDEC (Brief

Assessment Schedule Depression Cards), the HADS (Hospital Anxiety

and Depression Scale) and the PHQ-9 (Patient

Health Questionnaire). The BASDEC is particularly well suited for use post-stroke with those who have communication deficits.

Community Support groups,

facilitated by professionals with

expertise in psychosocial

concerns, foster self-management and

quality of life, reduce isolation and depression,

and help stroke survivors and their

caregivers to continue to live

at home.

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Priority #3: Collaborate with other networks to build capacity within primary care for

vascular health

Key Message #3: Vascular health requires regional collaboration in partnership with primary care.

Vascular disease affects blood vessels and

encompasses many conditions such as stroke,

diabetes, kidney disease and certain heart diseases

such as coronary artery disease.

The challenge: The SEO region has higher rates

than the province for vascular disease risk

factors such as obesity and hypertension as well as

high rates of smoking and alcohol use.

In anticipation of the need to work together more

effectively in collaboration with primary care a

Southeastern Ontario (SEO) Health Collaborative

was formed in 2011 that includes several regional

chronic disease and self-management networks with

representation from the South East Primary Health

Care Council.

To improve our understanding of how to support vascular disease risk reduction and to

inform regional and provincial actions, the Stroke Network of Southeastern Ontario

completed an environmental scan of all Family Health Teams and Community Health

Centres across SEO in 2011 and 2012.

The SEO Health Collaborative worked with primary care partners in 2012 to plan and

deliver primary care Think Tanks that, in combination with the environmental scan, will

inform a regional plan for action. Examples of common needs and opportunities

include: 1) enhanced information sharing between primary care organizations;

2) effective utilization of the electronic medical record; 3) integrated vascular health

programs within primary care and 4) strengthening community partnerships. The input

received is summarized in a report, Vascular Health in Southeastern Ontario: a Focus

on Primary Care

Related provincial and national initiatives: An Integrated Vascular Health Blueprint

for Ontario was released in August 2012 and includes a recommendation for Regional

Vascular Collaboratives in each LHIN. The Canadian Cardiovascular Harmonization of

National Guidelines Endeavour (C-CHANGE) is an integrated evidence-based clinical

guideline that supports vascular health in primary care.

The opportunity for change in SEO:

The stroke network looks to its partners to recognize and support the regional profile of the SEO Health Collaborative in working with the Primary Health Care Council to develop a regional action plan for facilitating the integration of evidence based practice in vascular

health into primary care.

Regional collaborative planning for vascular health = disease prevention and

reduced health system use.

Primary Care Think Tank participants discuss their vision for Global Vascular Risk Reduction and the needed programs, tools and resources to support this vision. Spring 2012.

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Hypertension: The Canadian

Hypertension Education Program Guidelines (2012)

emphasizes blood pressure be consistently below 140/90 and for people with diabetes consistently below 130/80 mmHg.

For acute stroke, there is guidance now from the Canadian Hypertension Education Program Guidelines (2012) for people eligible for thrombolytic therapy to treat blood pressure >185/110 mmHg and for those not eligible for thrombolytic therapy to treat blood pressure >220/120 mmHg.

Did you know that Atrial Fibrillation may be caused by hypertension?

For stroke prevention, people with atrial fibrillation or atrial flutter (paroxysmal, permanent or persistent) should be stratified for antithrombotic therapy using a risk tool such as CHADS2 and consideration for the risk for bleeding. The CHA2DS2-VASc tool can be considered particularly in those with intermediate risk for stroke. Most with intermediate and high risk for stroke will be considered for dabigatran, rivaroxaban or apixaban (pending approval in Canada) or Warfarin. There are many factors to consider with patients when deciding the choice of the different oral anticoagulant medications such as costs, health conditions, kidney and liver function, compliance and patient preference. Reference materials are available from: www.ccsguidelineprograms.ca/pocket_card/2012_Afib_PG/AtFib_PG_Flipbook/index.html

Vascular health

reduces the incidence of stroke, diabetes, kidney disease and

targeted heart conditions.

Standardized global risk reduction

guidelines, programs, tools and resources

are needed to make it easier for primary

care settings to help prevent and manage

disease.

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Priority #4: Set and monitor regional expectations for acute stroke unit care.

Key Message #4: Acute stroke unit care improves outcomes.

An Acute Stroke Unit is a specialized, geographically

defined hospital unit dedicated to the management of stroke patients. Stroke unit care is provided by an expert interprofessional stroke team educated in

best practice stroke care. This includes early access to a highly skilled interprofessional stroke rehabilitation team.

Strong evidence indicates that stroke unit care:

o reduces death and disability in all stroke

patients by as much as 30%;

o results in shorter lengths of hospital stay

o is cost effective and;

o reduces the likelihood of requiring long term

care.

All those with stroke, even the more severe, will benefit from the early access to the

intensive rehabilitation service that is one of the key defining features of an acute

stroke unit. For example, many stroke survivors experience difficulty swallowing which, if

not identified through swallowing screening, can lead to aspiration pneumonia increasing

the likelihood of death threefold. To mitigate these risks, acute stroke units provide

swallowing screening. Consistent best practices enabled by standardized patient care

order sets are implemented in stroke units to reduce post-stroke complications and

improve outcomes. Temperature regulation, management of incontinence, secondary

stroke prevention, early mobilisation and active participation in daily functional activities

are other examples of the benefits of an early intensive team approach to care.

In 2013-4, the MOHLTC will introduce Quality Based Funding for stroke care that will

incent best practices

The challenge: Only 47% of hospitalized stroke survivors in our region were treated in an

acute stroke unit in 2010-11. The opportunity for change in SEO:

The SEO region’s goal is to increase the rate of stroke unit utilization to 76% by 2016.

(This is also the goal of the Ontario Stroke Network for the entire province.) This will require a collaborative organized regional approach among acute care hospitals to cluster stroke patients at designated sites.

Acute Stroke Units = the best start for improved stroke patient outcomes and reduced costs

(From left) Physiotherapist Heather Jenkins, Stroke Resource Nurse Corrie Hall and Occupational Therapist Sandra Liu study a diagnostic image in the KGH acute stroke unit.

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Kingston General Hospital has a well-

established process for ensuring that stroke survivors access stroke unit care with utilization rates of between 75% and 85%. This improvement has been a key to KGH’s application for a Stroke Distinction Award through Accreditation Canada.

The accreditation survey will take place November 22 and 23, 2012. Much work has been underway preparing for this exciting event. This has included a review and update of all hyperacute and acute stroke protocols and care plans, a review of the acute stroke accreditation indicators and standards, a project on dysphagia screening implementation and a review of patient and family education processes, Nine core stroke care indicators have been assessed against stroke distinction targets resulting in focused and successful quality improvements in many aspects of care.

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Dr Al Jin, stroke

neurologist, joined our Regional Stroke Team as Medical Leader in Sept 2012. Welcome Dr Jin!

Acute Stroke Units: Stroke unit care has some

of the strongest evidence for improving outcomes and decreasing mortality.

Pneumonia can double to

quadruple the chance of death within three months after a stroke. Raising the head of a patient’s bed to 45

o can save lives.

Fever after an acute stroke

is associated with a poor clinical outcome. For a temperature greater than 37.5C, start temperature- lowering measures and investigate possible infection source.

Did You Know…

Best Practice recommends that all

patients with stroke or TIA

should be cared for in a stroke unit as there is strong evidence that this

improves recovery outcomes, reduces both mortality and institutionalization

post-stroke.

The SE Stroke Report Card released in May 2012 indicated that our region had the lowest 30 day all-cause readmission rate at 5.6 readmits per 100

patients with KGH named as the top performer across the province at a rate of 3.7. This is a sign that the stroke care system is working. Acute stroke units,

good secondary prevention strategies and access to rehabilitation and community support all contribute to this success. Access to an expert interprofessional team in the acute phase of recovery with strong links to ongoing expert rehabilitation and community support are critical to improved outcomes.

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Best Practice Stroke Prevention and Management of TIA

The Prevention section of the Canadian Best Practice Recommendations for Stroke has been

updated. Highlights of the updates to stroke prevention recommendations for 2012 include:

the potential stroke risk of oral contraceptives and hormone replacement therapy, especially in patients who also smoke;

continued emphasis on the important role of blood pressure in stroke prevention and diligent monitoring and treatment to keep blood pressure levels well below 140 mm Hg systolic and 90 mm Hg diastolic;

alignment of diabetes and stroke recommendations with updated guidelines by the Canadian Diabetes Association;

revisions to the lipid management section to reflect ongoing analysis and interpretation of the SPARCL trial (see inset bottom right of this page);

the release of the findings from the ASA versus ASA + clopidogrel arm of the SPS3 study reinforcing recommendations advising against the use of dual-antiplatelet therapy;

significant revision to the anticoagulant therapy recommendations for patients with atrial fibrillation and stroke to reflect the release of the new classes of anticoagulants, based on the RE-LY (dabigatran), ROCKET (rivaroxaban) and ARISTOTLE (apixaban) trials (see also the “did you know” on page 3);

carotid interventions for asymptomatic patients incorporating the 10 year follow-up findings of the ACST trial;

new recommendations on screening, identification and management of patients with obstructive sleep apnea, diagnosed both pre and post stroke;

expansion of recommendations on smoking cessation assessment and management, including pharmacotherapy, in collaboration with the CAN-ADAPTE and C-CHANGE guideline groups; and,

development of a Taking Action for Stroke Prevention quick response guide and

pocket card for TIA or non-disabling stroke pictured below and available at www.strokebestpractices.ca

Best Practice in Action after a

recent TIA/Stroke QHC-Belleville General, Kingston

General, Brockville General and Perth

& Smiths Falls District Hospitals have

each established a comprehensive

process in the ED whereby patients

presenting with TIA are referred to a

Stroke Prevention Clinic for follow-up.

The Belleville Clinic receives referrals

from Trenton, Picton and North

Hastings and KGH receives referrals

for patients from Napanee. Many

patients who have had strokes and

spend time in hospital are also referred.

All clinics accept referrals from primary

care providers in their respective areas.

The clinics comprehensively review

diagnostic tests and stroke risk factors.

Close to 1400 new TIA patients are

seen each year in our region. Many of

those presenting to the clinics have

complex co-morbidities that require not

only a team approach within the clinic

but collaboration with primary health

care providers and specialists across

the region. The clinic physicians,

nurses and dietitians work together with

their patients to assist with risk

reduction strategies and lifestyle

changes such as smoking cessation.

SEO Stroke Prevention Clinic contacts:

Kingston General Hospital:

613-549-6666 x6320 Dr. Al Jin Paula Christie, Clinic CNS Karen Gray, Medical Secretary

Quinte Health Care, Belleville

613-969-7400 x2871 Dr. Curry Grant Michelle Slapkauskas, Clinic RN Christy Russett, Administrative Assistant

Brockville General Hospital

613-345-5645 x1410 Dr. Jay Bhatt Julie Lynch, Clinic RN Doris Morrison, Medical Secretary

Perth & Smiths Falls District Hospital

613-267-1500 x1138 Dr. Robert Del Grande Allison Fournier, Clinic RN Rose Bathurst, Medical Secretary

Did You Know…

Statin medication is

recommended for secondary prevention for TIA or Ischemic Stroke (SPARCL Trial). The target LDL cholesterol is: less than 2.0 mmol/L or 50% reduction from baseline. Did you know that it is

recommended to initiate or continue Statin medication in the early acute phase

post ischemic stroke while in hospital? For most patients this is strongly associated with improved survival. (Flint, A.C., Kamel, H.,

Navi, B.B., & Rao, V.A., et al., Stroke, 2011).

There is a validated tool

that can be used during the early assessment of acute ischemic stroke to help clinicians estimate outcomes including the risk of death at 30-days and 1-year. The new tool is called IScore (Predicting Ischemic

Stroke Outcome) and assists in decision-making about thrombolytic therapy (tPA) www.sorcan.ca/iscore A high IScore is associated with a lower probability of a good outcome post tPA. The tool is not a substitute for clinical judgment but can be used to estimate clinical response to tPA and might be particularly valuable for non-specialists.

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Quinte Acute Stroke Update 2012

Since the onset of QHC’s tPA/Telestroke initiative in Dec 2010, more patients have been seen

and assessed at the Belleville General Hospital for tPA than was anticipated. From Dec 2010

to the end of Sept 2012, 296 people in the Quinte region have received “Code Stroke” services

at the Belleville General Hospital (BGH) Emergency Department. Of those, 51 patients have

received tPA. “Code Stroke” is the name given to the collective interprofessional response to

the notification that a patient is coming into the hospital with stroke-like symptoms. The

majority of these patients have been redirected from other district hospital sites to BGH where

nurses, physicians and others immediately begin to assess and treat the patient.

Calling 911 at the earliest sign of stroke symptoms is critical because tPA is a time sensitive

treatment. Looking closely at local data and acknowledging how important it is to increase

awareness about the availability of the Code Stroke (tPA) program at BGH, the District Stroke

Centre staff and Physician Stroke Champion have targeted community communication to raise

the program’s profile through public speaking and media events.

“This initiative really is ‘feel good’ work”, says Christanne Lewis, District Stroke Coordinator for

Quinte. “When a Code Stroke is called while there is an immediate response, there is also a

feeling of optimism and hope. The Code Stroke team offers people of the Quinte region the

leading edge in stroke care beginning the moment the patient comes through the doors of the

hospital. We’ve seen some very positive outcomes to be sure, but more than that, this initiative

has allowed for a more focused effort, across the continuum to deliver the very best stroke

care to patients locally and to raise the profile of stroke so that the important work of

prevention and community reintegration can be prioritized.”

Some local media coverage in the last year in the Quinte region:

http://www.intelligencer.ca/ArticleDisplay.aspx?e=3299235

http://www.intelligencer.ca/2012/07/02/surviving--and-thriving--after-a-stroke http://www.intelligencer.ca/2012/07/02/new-awareness-saving-lives-doctor http://www.intelligencer.ca/2012/07/16/know-the-signs-of-a-stroke

Arriving in hospital on a Code Stroke? What Now?

When a patient (and family) arrive at Belleville General Hospital, they will often be greeted by

the Stroke Resource Nurse at QHC, Melissa Roblin who acts immediately to allay concerns

and answer questions. Melissa not only acts as a resource for best practice stroke care to the

staff at the hospital, but also to the patient and patient’s family. “From the moment, they come

through the door, you can tell that the family wants and needs reassurance and an informative,

supportive presence. That’s what Melissa offers the patients and families” says Christanne

Lewis, District Stroke Coordinator. Melissa’s role is unique in the hospital. She has no ‘home

unit’ instead working with the staff in the ED, the ICU, and the acute medicine unit at all QHC

hospitals as well as in the Rehab facility where stroke patients work tirelessly to make their

best recovery. Melissa supports staff by providing education on best practice care and acts as

a resource to patients and families to help them understand what has happened to them, what

happens during hospitalization, what to expect on discharge and to address a host of other

questions that arise when people feel unequipped to cope with the challenges of a new stroke.

The Quinte Stroke Team

Dr. F Curry Grant MD, MSc, FRCPC Internist/Cardiologist Stroke Prevention Clinic Physician

Christanne Lewis, BA, RN District Stroke Coordinator

Michelle Slapkauskas, RN, BScN Stroke Prevention Clinic Nurse

Melissa Roblin, RN, BScN, GNC(C) Stroke Resource Nurse

Christy Russett, Admin Assistant Stroke Prevention Clinic / District Stroke Centre

Dr. Andrew Samis, MD, BSc(Hon), MSc, MD, PhD, FCCP, FRCSC, FACS Physician Stroke Champion

Brandy Engelsdorfer participated in a provincial media campaign last June to highlight the release of the Stroke Report Card during stroke month. Brandy sustained a stroke last year and instructed her 5-year old daughter to call 911. She received tPA and rehabilitation at QHC-Belleville. She notes how grateful she is to have received this care saying “I get to see my kids grow up!” Pictured here are Melissa Roblin, Stroke Resource Nurse, Karen Voth, Recreation Therapist and Brandy. Photo by Susanne Anderson, Communications Department, Quinte Health Care. For the full story, see link below.

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Stroke Education for Health Care Providers

To register for education events, see the brochures and the on-line registration feature of our website at www.strokenetworkseo.ca/profedcalendar

September - October 2012

The Brain, The Body & You: Continuing Education

Dates: October 16, 23, 30 & November 8, 2012 Location: SLC Kingston Campus Target Audience: Nursing, Allied Health and PSW’s working in Acute, Rehabilitation, Complex Continuing Care, Community and LTC

Regional LTC & Community Collaborative: Overloaded, Continuing to Care for Ourselves

Date: October 25, 2012 Location: Italo-Canadian Club, Kingston General Hospital Target Audience: Health care providers in Community and LTC

November 2012

Leveraging Rehabilitation to Improve Patient Flow and Quality Outcomes in Southeastern Ontario using Stroke Care as a Model (see information top right) Date: November 28, 2012 Location: Days Inn, Kingston, Ontario Target Audience: Administrative and Clinical Leaders across Southeastern Ontario

Winter 2013- TBD

Dysphagia Management

Date: TBD Location: Perth and Smiths Falls DH Target Audience: Patient Care Teams

Rehab Triage with Alpha FIM

Date: TBD Location: Brockville General Hospital Target Audience: Acute & Rehab

February – March 2013

The Brain, The Body & You: Continuing Education

Dates: Winter 2013 TBD Location: SLC Brockville Campus Target Audience: Nursing, Allied Health & PSWs working in Acute, Rehab, Complex Continuing Care, Community and LTC

KFL&A: Stroke Best Practice Primary Care CME Update

Date: February 2013 Location: Kingston Target Audience: Primary Health Care Providers

Case Manager Education Interprofessional Best Practice Stroke Care

Dates: March 2013 - TBD 3 sessions - Belleville, Kingston & Brockville with video links Location: TBD Target Audience: CCAC Hospital & Community Case Managers

Shared Work Experience & Field Training Education Program

Collaborative Learning Networks Meeting Attendance Bursary

This professional education stroke fund is designed to facilitate the development of local, individual or group stroke-specific knowledge and skills and to further develop best practice stroke care and interprofessional networks. This fund includes 2 different educational support programs:

1. The Shared Work Experience Program supports one or more learners to spend time with a health care provider(s), working in stroke care.

2. The Field Training Program is designed to support an educational event for a group of health care providers working in stroke care to develop their knowledge and skill related to stroke care. To obtain the application form please visit the education section of our website www.strokenetworkseo.ca or contact the Regional Stroke Office.

A bursary of $75 is available to participating organizations to support staff attendance at Collaborative Network meetings in HPE, KFL&A or LL&G. To take advantage of this bursary complete the registration form at www.strokenetworkseo.ca or contact the Regional Stroke Office and submit the form prior to the meeting date.

The staff member selected to attend is: An enthusiastic learner; Committed to supporting the care team; Keenly interested in making a difference

for the resident/client and Skilled at motivating peers.

For more information contact Gwen Brown, Community & LTC Coordinator at browng2@kgh.kari.net

The Stroke Network of Southeastern Ontario has brought together a regional planning group that will inform how Rehabilitation can be leveraged to improve patient flow and quality outcomes.

Rehabilitation system gaps or “roadblocks” have been identified and a Regional Rehabilitation Forum is scheduled for November 28, 2012. This day will focus on identifying ways of addressing the “roadblocks” to best practice rehabilitation through system change. This work will help to inform the Restorative Care Roadmap of the SE LHIN and the care not only for those with stroke but for those with other chronic diseases.

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Obstructive Sleep Apnea

(OSA) may be a modifiable risk factor for stroke; treatment may improve outcomes post stroke and TIA. Many patients have been found to have OSA following a stroke or TIA. It is strongly recommended that patients who have had a stroke or TIA be screened for sleep apnea using a validated tool. Some suggested tools are: Berlin Sleep Scale: www.cpap-supply.com/Articles.asp?ID-178 STOP BANG Questionnaire: www.carolinashealthcare.org/documents/cmcnortheast/STOPforSleep[1].pdf

Sleep Apnea Clinical Score: www.thoracic.org/assemblies/srn/questionaires/sdq.php

Pre and post stroke and TIA preventative strategies may include: Avoidance of sedation Weight loss C-PAP Referral to sleep

specialist Dental appliances Avoid lying on back if

diagnosed with supine sleep apnea

For more information, visit www.strokebestpractices.ca (prevention section)

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The Brain Body and You

Register Early Modules Fill Up Fast! Sessions held Fall 2012 at St. Lawrence College, Kingston Campus and Winter 2013 St. Lawrence College, Brockville Campus Logon to access the registration form at http://strokenetworkseo.ca/profedcalendar

Book Your Educational Poster Boards Poster Topics: o Seating o Swallowing o Depression o Communication o Blood Pressure o NEW Cognition & Perception o NEW Stroke Prevention & Care o Coming soon: Leisure activity

You can register for one or more of these 4 hour FREE sessions. o Stroke Care Prevention to Life after Stroke &

Continence Care o Communication & Behaviour o Nutrition, Hydration & Feeding o Mobility Target Audience: Front-line staff (eg PSW, RPN, RN, Rehabilitation Assistants and Restorative Care Aides) who care for stroke survivors and other complex patient populations in the community, acute care, rehabilitation, complex continuing care, long term care and other related settings. Location: St. Lawrence College, Kingston Campus (Fall 2012) and Brockville (Winter 2013, location and date TBD)

Posters have been created to provide key knowledge points on various stroke-related topics. To view the posters, visit our website education page at www.strokenetworkseo.ca For information on how to book a Poster Education Board for your organization, please contact Gwen Brown at 613-549-6666 x6867 NEW Perception & Cognition

NEW Stroke Prevention & Care

Stroke Survivor Stories (Videos) Available online

Two Stroke Survivors have generously shared their experiences with their stroke.

1. Time is Brain: Emergency Stroke Recognition & Recovery: A Stroke Survivor's Reflection on Recovery following tPA. How prompt and effective best practice stroke care can make a difference. Hector MacKenzie

2. A Journey of Stroke Recovery: A Stroke Survivor's Reflections. How best practice stroke care can make a difference. Dan Brouillard

To access online go to www.strokenetworkseo.ca/profedvideos The Heart and Stroke Foundation has also produced a video called Speaking From Experience. This video includes several stories that can be viewed at http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.8032427/k.981/Video_Stories.htm#telling

Blood Pressure Education Toolkit, Managing Blood Pressure: It Takes a Team

This toolkit is designed to assist Personal Support Workers (PSW) and other health care team members to acquire the practical knowledge and skills to support blood pressure management and to build the capacity to work collaboratively with the health care team and resident/client to optimize blood pressure management. This program can be individualized depending on the needs of the learner and in accordance with the organizational/facility guidelines. The Learning Plan is divided into two modules each of which can be used independently of the other. Module #1: The Basics of Blood Pressure & Supporting the Patient Module #2: How to Take Blood Pressure. The toolkit may be used to support educators in a classroom setting or as self-learning modules. To access this tool kit visit www.strokenetworkseo.ca/profedatlas

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Community-based Rehabilitation:

Canadian Best Practice Recommendations for stroke care highlight the need for and benefits of intensive rehabilitation services post stroke. Improving patient flow is a priority across Ontario yet publicly funded home-based CCAC rehabilitation has tended to be limited to a consultation versus a treatment model. See http://www.strokebest practices.ca (click on rehab.) Hospital stays can be prolonged due to limited access to community rehabilitation, especially in rural areas. The provision of timely intensive stroke rehabilitation services upon transition to the community has a positive impact on health system utilization and stroke survivor outcomes.

AlphaFIM

® :

Quinte Health Care, Kingston General Hospital and now Lennox and Addington County General Hospital are using AlphaFIM

® data to support

rehab triage of stroke patients. For further information

on Rehabilitation in SEO, please contact Caryn Langstaff, Regional Stroke Rehabilitation Coordinator for Southeastern Ontario langstac@kgh.kari.net

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Rehabilitation across the Continuum of Care

In Ontario, rehabilitation has recently gained the attention of the Ministry of Health and Long Term Care (MOHLTC) being recognized as playing a pivotal role in assisting with the alternative level of care (ALC) issue faced by acute care hospitals. This attention has prompted the development of provincial and regional working groups to examine current processes and make recommendations for a stronger, more efficient health care system moving forward.

The Provincial Rehabilitation and Complex Continuing Care Expert Panel (Rehab/CCC Expert Panel) was formed as a subcommittee of the Provincial ER/ALC Expert Panel. The purpose of this subcommittee was to “fundamentally re-think the delivery of rehabilitation and complex care across the acute and post-acute continuum including community settings, hospitals, transitional and convalescent care settings and in long term care.”

The Ontario Stroke Network (OSN) and the Stroke Network of Southeastern Ontario are committed to promoting evidence-based best-practice principles in the care of people who experience a stroke. To that end, the OSN established a Stroke Reference Panel in order to provide stroke rehabilitation recommendations to the Rehab/CCC Expert Panel.

Evidence tells us that most stroke survivors will benefit from intensive rehabilitation services. Those with moderate to severe disability stand to benefit most.

The key best practices recommended by the MOH Panel on the impact of Rehabilitation on

ED/ALC rates include:

Early access to rehabilitation: acute stroke units providing an early intensive team

approach; standardized triage tools; admission to rehab 7 days/week o Mobilization within 24 hours of admission o Alpha FIM® Instrument completed on Day 3 for triage of rehab needs

Alpha FIM® score >80 = outpatient/community rehabilitation Alpha FIM® score 40-80 = inpatient rehabilitation Alpha FIM® score <40 = options for restorative care/ongoing assessment

o Onset to Inpatient Rehab Unit Admission: Ischemic strokes = Day 5 Hemorrhagic strokes = Day 7

o Rehabilitation has same priority level as acute care for access to LTC

Intensification of rehabilitation

o 7 day/week admission to inpatient rehabilitation o 7 day/week rehabilitation services o Minimum of 3 hours direct individualized therapy per day

Intensive outpatient and community based services

o Access to ambulatory and community-based rehabilitation o Outpatient or enhanced CCAC therapy visits: 2-3 visits/week for 8-12 weeks o Decrease admission of those with mild strokes (AlphaFIM® >80) through increased

access to early outpatient rehabilitation o Access to enhanced attendant care/supports in early discharge phase o Rehab provided as necessary using model of delivery that fits patient needs.

Options include: CCAC, community based, hospital based ambulatory care

The potential economic impact on Ontario’s stroke system of applying these best practices has been studied by the Ontario Stroke Network. This economic evaluation demonstrates that, in addition to being patient-centred and improving patient outcomes, adherence to best practice can also have a positive impact on Ontario’s healthcare system by freeing up needed Emergency Department and acute bed days and improving patient flow through the rehabilitation system. This allows patients to receive needed rehabilitation services in the right place at the right time, making inpatient rehabilitation more readily available and reducing health system costs. The Ontario Stroke Network presented a detailed analysis of the potential economic impact of fully implementing the best practice recommendations of the Stroke Reference Panel. Results are included in a report released in August 2012 entitled The Impact of Moving to Stroke Rehabilitation Best Practices in Ontario.

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Rehabilitation is Critical…

The evidence indicates that if a person with stroke receives timely and intensive rehabilitation there will be decreased mortality, less need for LTC, more people will get home to stay and more

people will have improved quality of life.

Resource Matching and Referral…

The Local Health Integration Networks (LHINs) in Ontario are working together towards an electronic information and referral system. There are four pathways: Acute to Rehab; Acute to Complex Continuing Care; Acute to Long-Term Care; and Acute to CCAC in-home services. The referrals will be standardized across the province prior to becoming electronic. Once up and running, this Resource Matching & Referral Service (RM&R) system would match patient/clients to the earliest available services that best meet their individual needs. The overall goal is that of more streamlined, equitable and patient-centred care.

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Community Reintegration: Stroke Survivor & Caregiver Support Groups – An Update

A Brockville Support Group was initiated in the fall of 2011. The Community Reintegration Leadership Team, including representatives from Stroke Survivor and Caregiver Support Groups in Kingston, Brockville, Perth and Belleville, came together in 2011 to discuss the need for ongoing funding for the professional facilitation needed by all support groups. This need was presented to the Regional Stroke Steering Committee (RSSC) and subsequently identified as one of four regional priorities for stroke care. The Kingston Seniors received

one time funding support from the Local Health Integration Network (LHIN) for fiscal 2012-13. As well, a regional proposal was submitted in the summer of 2012 to the LHIN requesting funding to support professional facilitation for the groups in Perth, Brockville and Belleville. This funding request was successful. Community Primary Health Care received funding for the Perth & Smiths Falls and Brockville groups and Community Care for South Hastings

received funding for the Quinte group. Work is now underway to implement a standard approach to evaluating the effectiveness of the groups in order to demonstrate the benefit of sustained funding.

The Living with Stroke Program (LWS) has now been offered in three of the four southeast

areas (Kingston, Belleville & Perth). LWS was developed by the Heart & Stroke Foundation and consists of a six-week program that provides stroke survivors and caregivers with an opportunity to learn more about stroke, meet with peers and share experiences and knowledge. These programs have been well received by participants.

The Belleville and Brockville Support Groups, given the new funding, are in the process of hiring facilitation assistance.

See page 11 for more about the Kingston Support Group “Stroke Understood”.

Enhancing Community and LTC Stroke Rehabilitation Therapy Services for Stroke Survivors: the “Discharge Link”

Intensification of community therapy visits improves health system utilization and patient outcomes. Since February, 2009, over 600 stroke survivors across the Southeast have received timely, enhanced community-based rehabilitation from an interprofessional team for two months post-discharge from hospital. The mean number of community therapy visits in SEO now averages 12 per client versus the provincial benchmark at 6.8. Since implementation, Occupational Therapy and Physiotherapy visits have doubled and tripled respectively for patients discharged from inpatient rehabilitation. Frequency of service for Social Work has increased from 11% to 28% and for Speech-Language Pathology from 12% to 36%. Observed system improvements for those receiving enhanced rehabilitation include a decrease in hospital length of stay of 15.7 days (without negative impact on functional independence) and decreased one-year readmission rates. Average community rehabilitation wait times have significantly improved from 44 days, pre-implementation to current wait time of only 4.4 days.

0

10

20

30

40

50

60

70

80

FY 2006/07 FY 2007/08 FY 2008/09 FY 2009/10 FY 2010/11

Fiscal Year

Ave

rage

Len

gth

of

Stay

(d

ays)

Avg. ALC Rehab

Avg. Active Rehab

Avg. ALC LOS

Avg. Acute LOS

Program Impact FY2009/10 and beyond

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Exercise Guidelines:

The Guidelines for Community Based Exercise Programs for People with Stroke and accompanying brochure can be accessed on our website. In support of the Guidelines, a workshop was offered in March 2012 to community exercise providers in the southeast.

About Long Term Care:

Twenty-two percent of residents in LTC aged 65 or older have had a stroke and stroke is the third most common diagnosis in long-term care.

Community Support Services Scan:

A scan of the Community Support Service agencies in the southeast is currently underway to explore how we can best work together to ensure the best supports are in place for stroke survivors in the community.

Best Practice in Transition Management: We are participating on a provincial Registered Nurses’ Association of Ontario panel that is developing best practice guidelines focused on how to ensure the best possible transition for patients when they move between parts of the health care system (e.g. go from hospital to home or from home to long-term care or from community to hospital).

The Perth/Smiths Falls Support Group pictured here has developed a Peer Visiting Program where stroke

survivors visit patients in hospital who have just experienced a stroke. The Perth/Smiths Falls Support group now includes an exercise component in many of their monthly meetings.

Trend in Hospital Length of Stay Pre and Post Enhanced Community Rehabilitation Service Delivery

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Support Stroke Understood: a Peer Program Optimizing

Recovery Together

The Seniors Association and SUPPORT, the advisory committee for stroke services, were

successful in obtaining three funding sources to continue to offer the four groups for another

year. Funders include the SE-Local Health Integration Network and Green Shield Canada for

day-to-day operation and the Cataraqui Rotary Club for the Living with Stroke series. Kathleen

Pratt, RSW facilitates the groups.

The Seniors Association stroke services offers four stroke-related support groups: two survivor

groups, one care partner group, and one couples group. All four groups meet monthly.

Referrals continue to increase with 14 new survivors/caregivers between June 13 and August

14, 2012. Referrals are primarily initiated by hospital-based social workers and the Community

Care Access Centre. There has also been great success advertising in the community events

listings of the local paper. In June 2012, a letter to the editor of the Kingston Whig Standard

resulted in a number of self-referrals. Stroke services are advertised monthly in the Seniors

Association monthly newsletter, Vista.

The groups act as a lifeline for members by giving meaning to and support for their

rehabilitation. Groups provide a safe environment to vent frustrations, ask questions, and

share experiences and information. Despite individual challenges, meetings are well-attended.

Having the groups meet at The Seniors Centre has fostered involvement in recreational

programs, services such as foot care, and opportunities to volunteer. After each meeting,

some participants enjoy the chance to socialize over lunch in The Centre’s Rendezvous Café.

For more information about these services and the Seniors Association, visit

www.seniorskingston.ca or call 613.548.7810.

Best Practice Stroke Care in LTC Homes

A provincial project to develop and implement best practice stroke care plans in LTC Homes was initiated in January 2011. The project involves translating the best practice modules in

the Tips and Tools for Everyday Living resource into care plans. The care plans are then

integrated into the LTC Homes’ libraries so can be easily accessed and applied to bedside care. The implementation of RAI MDS assessment tool in all Ontario LTC Homes has provided the opportunity to link stroke best practice information with RAI MDS data elements and Resident Assessment Protocols (RAPs) A provincial pilot has now been completed that included a LTC Home in the southeast (Pine Meadow LTC Home in Northbrook).

RAI MDS

The RAI MDS is a mandated assessment tool that is used in community & Long Term Care (LTC) settings to collect information on client/resident care needs to facilitate care planning.

The RAI MDS is a data-rich instrument that assists care providers in assessing care outcomes, resource needs & changes in client or resident health status.

A provincial group comprised of LTC Home and stroke care representatives is currently working on an initiative to link stroke best practice information (Tips & Tools for Everyday Living) with RAI-MDS data elements. This will assist in the development of care plans that are linked to stroke best practices.

The KGH Stroke Collaborative Big Bike team prepares to get some exercise in the summer heat riding for Heart and Stroke.

The QHC District Stroke Centre

Big Bike team 2012

Did You Know…

The Stroke Network of Southeastern Ontario collaborates with the regional RNAO Best Practice Coordinator, Psychogeriatric Regional Consultants and the Pain & Symptom Management Team to offer ‘Learning Collaboratives’ in each

of the three local areas of southeast . These collaborative education sessions are responsive to the needs and requests of care providers, particularly those in LTC Homes and their community partners.

Offered as 3-hour interactive events 3 to 4 times per year, the Learning Collaboratives are provided at no cost to participants. As well, bursaries are available to employers to offset the costs of replacing those staff in attendance (see page 7 for more information about the bursaries).

“I come to the group for the stories. Just talking about stroke helps me feel like I’m part of the group. Humour is the cheapest medicine out there. I use it

every day!”

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Contact Us

Cally Martin

Stroke Network Director 613-549-6666 x3562 martinc@kgh.kari.net Dr Al Jin

Regional Stroke Medical Leader Sue Saulnier

Regional Stroke Education Coordinator 613-549-6666 x3622 saulnies@kgh.kari.net Gwen Brown

Regional Community & LTC Coordinator 613-549-6666 x6867 browng2@kgh.kari.net Caryn Langstaff

Regional Stroke Rehabilitation Coordinator 613-549-6666 x6841 langstac@kgh.kari.net Colleen Murphy

Regional Stroke Best Practice Coordinator 613-549-6666 x6306 murphyc2@kgh.kari.net Darlene Bowman

Stroke Specialist/Case Manager 613-549-6666 x2830 bowmand@kgh.kari.net Charlette Eves

Administrative Assistant 613-549-6666 x3853 evesc1@kgh.kari.net Christanne Lewis

District Stroke Coordinator Quinte Health Care 613-969-7400 x2874 clewis@qhc.on.ca Melissa Roblin

Clinical Resource Nurse Quinte Health Care 613-969-7400 x 2663 mroblin@qhc.on.ca Regional Stroke Office Stroke Network of SEO Doran 3, Room 310 Kingston General Hospital 76 Stuart St Kingston, ON K7L 2V7 Tel: 613-549-6666 x3853 Fax: 613-548-2454 www.strokenetworkseo.ca