Improving stroke care in Nova Scotia, Canada: a population-based project spanning 14 years

Abstract

Stroke is a complex disorder that challenges healthcare systems. An audit of in-hospital stroke care in the province of Nova Scotia, Canada, in 2004-2005 indicated that many aspects of care delivery fell short of national best practice recommendations. Stroke care in Nova Scotia was reorganised using a combination of interventions to facilitate systems change and quality improvement. The focus was mainly on implementing evidence-based stroke unit care, augmenting thrombolytic therapy and enhancing dysphagia assessment. Key were the development of a provincial network to facilitate ongoing collaboration and structured information exchange, the creation of the stroke coordinator and stroke physician champion roles, and the implementation of a registry to capture information about adults hospitalised because of stroke or transient ischaemic attack. To evaluate the interventions, a longitudinal analysis compared the audit results with registry data for 2012, 2015 and 2019. The proportion of patients receiving multidisciplinary stroke unit care rose from 22.4% in 2005 to 74.0% in 2019. The proportion of patients who received alteplase increased steadily from 3.2% to 18.5%, and the median delay between hospital arrival and alteplase administration decreased from 102 min to 56 min, without an increase in intracranial haemorrhage. Dysphagia screening increased from 41.4% to 77.4%. More patients were transferred from acute care to a dedicated in-patient rehabilitation unit, and fewer were discharged to residential or long-term care. These enhancements did not prolong length-of-stay in acute care. The network was a critical success factor; competing priorities in the healthcare system were the main challenge to implementing change. A multidimensional, multiyear, improvement intervention yielded substantial and sustained improvements in the process and structure of stroke care in Nova Scotia.

Keywords: chronic disease management; complexity; continuous quality improvement; teamwork.

Figure 1

Charts showing the trajectory of improvement from preintervention levels in 2005 for: (A) Proportion of patients receiving stroke unit care; (B) Proportion of ischaemic patients who had a stroke receiving treatment with intravenous alteplase; (C) Median door-to-needle times for patients treated with intravenous alteplase; (D) The proportion of patients receiving alteplase within 1 hour of hospital arrival; and (E) Proportion of patients receiving a dysphagia screen in the emergency department.

Figure 2

Driver diagram illustrating approach to improving stroke care in Nova Scotia.

Figure 3

Implementation activities, 2005–2019. DHA, district health authority; PDSA, plan-do-study-act; SLP, speech-language pathology; TIA, transient ischaemic attack.