An ecological examination of stroke in Canada and Waterloo Region and best practice standards for care
Why Should We Care?
Working in the emergency department many of our patients come to us because of complications of chronic disease. In 2012, 1260 deaths were attributed to chronic disease in Waterloo Region (Region of Waterloo Public Health, 2017). The two most common chronic conditions were cardiovascular disease and cerebral vascular disease, with 154 deaths in the region related specifically contributed to stroke (Region of Waterloo Public Health, 2017) , stroke and cerebral vascular disease are the third leading cause of death in Canada (Public Health Agency of Canada, 2017).Our hospital is part of Waterloo Wellington’s Integrated stroke program with a focus on preventing strokes, treating acute strokes and providing rehabilitation. Waterloo Wellington is a provincial leader in stroke care including public education, acute stroke treatment and rehabilitation (Ontario Stroke Network, 2017). Working in the emergency department we not only treat acute strokes everyday, but also manage the complex medical needs of those patients living with the effects of stroke. Nationally in 2012 there were approximately 741,800 Canadians living with the effects of stroke (Government of Canada, 2016) and the cost of stroke is estimated to be approximately 2.8 billion dollars a year (Mittmann et al, 2012). The prevalence of, and cost associated with stroke care demonstrates the importance of understanding the primary determinants of stroke and in doing so develop an understanding of best practice for prevention and treatment of stroke.
Risk Factors and Stroke Prevention
There is a multitude of research available on the cause and risk factors associated with stroke. The Heart and Stroke Foundation of Canada states that key modifiable risk factors for stroke include, healthy diet, exercise, weight management, smoking cessation, lipid management and management of blood pressure (Wein & Gladstone, 2017). Hypertension is identified as being the single most controllable risk factor for stroke (Wein & Gladstone, 2017).
The Heart and Stroke Foundation of Canada uses a multisystem approach to address stroke prevention in Canada as demonstrated by the following model.
As many of the risk factors associated with stroke prevention target high risk groups, the use of social ecological theory in stroke prevention integrates individual behavioural changes with environmental enhancement in order to target the larges portions of the population at risk for stroke (Pearson, 2011). This “high-risk approach” is used by both the American Heart Association (Pearson, 2011), and the Hearth and Stroke Foundation of Canada to target those at risk for stroke (Wein & Gladstone, 2017). At the policy level risk for stroke is addressed through regulation of trans fats and sodium in foods, physical activity guidelines and national legislation and taxation of tobacco (Perason, 2011). An example of legislative action that has directly affected stroke is a decrease in hospital admission rates in Toronto for cardiovascular conditions (including stroke) after the banning of smoking in public places in 1999 (Naiman, Glazier, & Moineddin, 2010).
Institutional policy may dictate tobacco use in the workplace or encourage physical activity during the work day. These types of policies directly effect workplace environments; a key determinant of health according to the Government of Canada (Government of Canada, 2018). Interpersonal factors would include access to primary health care practitioners to test and treat for hypertension and hyperlipidemia, some of the most cost-effective methods for stroke prevention (Pearson, 2011). Access to health service is therefore an essential determinant in the prevention of stroke.
Stroke education is also a key determinant in the prevention and management of this devastating disease. Public policy targeted at education of stroke symptoms and media campaigns to identify the risk of stroke are used to ensure access for all to available stroke care programs in a timely manor due to improved outcomes for stroke patients based on the time in which they are seen by a healthcare professional (Government of Canada, 2016).
Stroke Practice Guidelines
Stroke prevention is not the only focus of managing this chronic disease. Once strokes occur treatment programs and risk factor modification are a key element in limiting the long-term disability associated with stroke. Every nine minutes in Canada a patient is treated in emergency departments for acute stroke or transient ischemic attack (or TIA) (Casaubon et al, 2015) and the Heart and Stroke Foundation of Canada Best Practice Advisory committee clearly outlines critical care guidelines for the treatment of stroke (Causbon et al, 2015). These guidelines include the management of TIA by primary care physicians, ambulance transportation of stroke patients to appropriate hospitals and emergency department rapid assessment and treatment of stroke (Causbon et al, 2015). The Ontario government also publishes best practice guidelines for stroke care in Ontario hospitals (Health Quality Ontario, 2016).
Our local regional centre is monitored by Ontario Stroke Network (OSN). OSN provides leadership to regional stroke centers, encouraging best practice standards are met and reporting on 20 key performance indicators for regional stroke care, from prevention, risk management, acute stroke care, rehabilitation, outcomes and mortality (Ontario Stroke Network, 2017). The emergency department in which I work is the local stroke center and we are one of the highest performs in Ontario in terms of acute stroke management (Ontario Stroke Network, 2017). Our regional stroke team adheres to best practice through a clearly mapped care plan for stroke patients at all stages of disease from prevention to rehabilitation (Waterloo Wellington Integrated Clinical Programs, n.d.).
My experience in my current practice involves primarily acute stroke care. Adhering to best practice guidelines we ensure exceptional acute stroke care through the assessment and identification of acute stroke, initiating a hospital directed “Code Stroke” procedure to initiate prompt lab testing, imaging and medication administration. These practices adhere to best practice guidelines for the acute treatment of stroke (Causbon et al, 2015; Health Quality Ontario 2016; Waterloo Wellington Rehabilitative Care System, n.d.). Management of acute hypertension in the emergency department is how we directly affect stroke risk, this is in line with the Registered Nurses of Ontario (RNAO) best practice guidelines for managing hypertension (RNAO, 2015).
Links for Stroke Care Best Practice
By following best practice guidelines for treatment of stroke we can help to improve quality of life outcomes for our patients, decrease the financial burden of stroke and work with patients to prevent future complications or subsequent stroke. Below are listed key resources for healthcare staff looking to improve their knowledge related to best practice stroke care standards in Ontario.
· Heart and Stroke Canada Best Practice (Federal)
· Waterloo Wellington Stroke Pathway Care Mapping (Regional)
References
Casaubon, L. K., Boulanger, J., Blacquiere, D., Boucher, S., Brown, K., Goddard, T., … on behalf of the Heart and Stroke Foundation of Canada Canadian Stroke Best Practices Advisory Committee (2015). Canadian Stroke Best Practice Recommendations: Hyperacute Stroke Care Guidelines, Update 2015. International Journal of Stroke. 10(6), 924-940. https://doi.org/10.1111/ijs.12551
Government of Canada. (2016). Stroke in Canada. Retrieved from https://www.canada.ca/en/public-health/services/publications/diseases-conditions/stroke- in-canada.html
Government of Canada. (2018). Social determinants of health and health inequalities. Retrieved from https://www.canada.ca/en/public-health/services/health-promotion/population- health/what-determines-health.html?option
Health Quality Ontario. (2016). Ministry of Health and Long-Term Care. Quality-based procedures: clinical handbook for stroke (acute and postacute). Toronto: Health Quality Ontario. Retrieved from http://www.hqontario.ca/evidence/evidence-process/episodes-of- care#community-stroke
Mittmann., N., Seung, S.J., Hill, M.D., Phillips, S.J., Hachinski, V., Coté, R., … Sharma., M. (2012). Impact of disability status on ischemic stroke costs in Canada in the first year. The Canadian Journal of Neurological Sciences, 39(6). Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23041400
Naiman, A., Glazier, R. H., & Moineddin, R. (2010). Association of anti-smoking legislation with rates of hospital admission for cardiovascular and respiratory conditions. Canadian Medical Association Journal, 182(8). doi: https://doi.org/10.1503/cmaj.091130
Ontario Stroke Network. (2017). Ontario and LHIN 2015/16 Stroke Report Cards and Progress Reports. Retrieved from https://www.corhealthontario.ca/ICES-Stroke-Report-2017.pdf
Pearson, T. A. (2011). Public Policy Approaches to the Prevention of Heart Disease and Stroke. Circulation, 124(23). Retrieved from https://doi.org/10.1161/CIRCULATIONAHA.110.
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Public Health Agency of Canada. (2017). Stroke In Canada. Retrieved from https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases- conditions/stroke-vasculaires/stroke-vasculaires-canada-eng.pdf
Registered Nurses Association of Ontario. (2005). Nursing Best Practice Guideline; Nursing Management of Hypertension. Retrieved from http://rnao.ca/sites/rnao- ca/files/Nursing_Management_of_Hypertension.pdf
Region of Waterloo Public Health (2017). Chronic Disease Mortality, Waterloo Region and Ontario, 2010, 2011 and 2012. Retrieved from https://www.regionofwaterloo.ca/en/regional-government/resources/Reports-Plans-- Data/Public-Health-and-Emergency- Services/QSCHRONIC_DISEASE_MORTALITY.pdf
Waterloo Wellington Rehabilitative Care System, (n.d.). Stroke. Retrieved from http://regionalhealthprogramsww.com/HealthCareProviders/CarePathways/Stroke?deptI D=2
Wein, T. & Gladstone, D. (2017). Canadian Stroke Best Practice Recommendation
Prevention of Stroke 6th Edition. Heart and Stroke Foundation of Canada. Retrieved from http://www.strokebestpractices.ca/wp-content/uploads/2018/03/CSBPR2017-SPoS- Module-Master-FINAL-ENGLISH-without-Appendix-Four.pdf
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