Alberta’s 17 stroke treatment centres are now among the fastest in the world in giving patients the clot-busting drug tPA (tissue Plasminogen Activator).
Thanks to a year-long quality improvement initiative, the average time it takes from a patient’s arrival at hospital to being diagnosed with stroke and injected with tPA (known as door-to-needle time) has been halved from about 70 minutes to 36 minutes.
An improvement of this degree and across such a large geographical area has not yet been reported elsewhere in the world. For example, a similar effort in the U.S. has seen average door-to-needle times in participating hospitals drop 20 per cent, from 74 minutes to 59 minutes.
Breaking the 60-minute benchmark
“For many years now, the accepted benchmark has been to treat patients within 60 minutes of their arrival at hospital,” says Dr. Michael Hill, a Calgary-based stroke neurologist and principal investigator in a quality improvement and research program, funded by Alberta Innovates, called QuICR (pronounced "quicker"), Quality Improvement and Clinical Research – Alberta Stroke Program.
“But we know that by doing better, we can improve outcomes for patients by preventing or limiting long-term disabilities. And when we can give stroke patients better chances to fully recover, we also eliminate potential downstream costs to the health system,” says Hill, also a professor in the departments of Clinical Neurosciences and Community Health Sciences Cumming School of Medicine (CSM) and a member of both the Hotchkiss Brain Institute and the Libin Cardiovascular Institute.
During an ischemic stroke, in which blood supply to the brain is blocked, about two million brain cells die every minute and about 12 kilometres of neural connections are lost.
QuICR results in a provicewide improvement
“One of the remarkable things that has happened in Alberta in the past year is that improvements have been made by teams in every stroke centre — not just the large hospitals in Edmonton and Calgary,” says Noreen Kamal, PhD and project manager for QuICR. “Staff in Fort McMurray, Westlock, Red Deer and smaller facilities like Grey Nuns in Edmonton have all rallied together and figured out how to significantly reduce their door-to-needle times — in some cases with limited resources at their disposal.”
A patient who has had a stroke relies on the efforts of a team, which includes paramedics, emergency department nurses, registration clerks, diagnostic imaging technicians, stroke co-ordinators, emergency department physicians, radiologists and neurologists. Behind-the-scenes support from hospital administrators and managers in the emergency and diagnostic imaging departments is also critical.
Kamal, an assistant professor with the Department of Clinical Neurosciences at the Cumming School and in the Department of Electrical and Computer Engineering at the Schulich School of Engineering, brings a systems engineering perspective to the task, and says precious minutes are saved when team members work in parallel rather than sequentially.
“A traditional clinical approach is to step through necessary tasks one at a time until a definitive diagnosis and treatment recommendation can be made,” she says. With QuICR, staff work concurrently when possible. A lab technician might draw blood while the patient has a CT scan, while elsewhere a history is being collected from a family member and the tPA is being prepared.
One Calgary patient shares his stroke story
Rick Travis was in spin class when he felt an odd sensation in this hands. He got off the bike, but after a couple of moments decided he was OK to finish the class. A short time later when he arrived home he knew something was terribly wrong, “I was on the computer and I noticed I couldn’t type sentences,” says the 62 year-old. “I called my wife, but I couldn’t form the words to tell her what was happening. She knew right away it was a stroke and called 911.”
Paramedics rushed Travis to the Foothills Medical Centre where he was placed in the care of the Acute Stroke Team including Michael Hill. Travis was given tPA 34 minutes after arriving at the hospital. “Dr. Hill kept saying don’t worry, you’ll be saying tongue twisters in no time, and I am.” He was back home the next day, and now, three months later he’s made a full recovery and is back in spin class.
Network credited for improvements taking root
“Improving the quality of stroke care provincewide has been made possible, in large part, through partnerships created and enhanced by AHS’ Cardiovascular Health and Stroke Strategic Clinical Network,” says Kathryn Todd, PhD, vice-president, research, Innovation and Analytics for AHS.
“Having a network of people dedicated to improving health outcomes in specific areas ensures quality improvements spread and take root. We are very proud of accomplishments made by the QuICR teams in improving door-to-needle times. It’s so very critical; with stroke, time is brain.”
“Congratulations to the QuICR team for the tremendous work they’re doing to improve outcomes for patients by reducing stroke treatment times in Alberta,” says Laura Kilcrease, Alberta Innovates CEO. “Alberta Innovates is proud to play an integral role in supporting the QuICR team. This type of innovative and outside-the-box thinking is critical and has achieved meaningful results by improving the lives of stroke sufferers not only in Alberta, but around the world.”