Barriers and enablers to successful hyperacute ischemic stroke care

Parfrey, Patrick (2024) Barriers and enablers to successful hyperacute ischemic stroke care. Doctoral (PhD) thesis, Memorial University of Newfoundland.

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Abstract

Stroke is a leading cause of adult disability. Thrombolysis, and Endovascular Therapy (EVT) significantly reduce disability of ischemic stroke patients (85% of strokes). However, in Newfoundland and Labrador (NL), thrombolysis rates were low, and EVT only began in 2022. In addition, NL had a higher incidence of stroke, with worse outcomes than the rest of Canada. Due to the availability of data, this study used a mixed methods approach to investigate stroke care processes in the Eastern Health (EH) region of Newfoundland and Labrador (NL) and three other Canadian regions (Central zone Nova Scotia (NS), Southeastern Ontario (SEO) and Calgary zone Alberta) to identify policy recommendations to improve hyperacute stroke care. First, two time series analyses compared indicators between stroke centres between each region. In addition, case studies in each region were completed to provide a subjective view of their hyperacute ischemic stroke care. Using literal replication, the case studies recorded semi-structured interviews with stroke care professionals. For data triangulation, stroke care documents and archival data were requested. Through thematic analysis, the goal was to understand critical success factors to optimize efficient hyperacute ischemic stroke care. Finally, using cross-case synthesis, regions were compared using matrices to understand how they differ. The Health Science Centre (HSC) in EH showed impressive improvements from 2016/2017 to 2020/2021 with thrombolysis rates rising from 9.6% to 19.0%, nearing their target of 21.0%. In addition, HSC had similar indicators compared to the three Comprehensive Stroke Centres (CSCs) in the other regions. The four Primary Stroke Centres (PSCs) of EH have not shown the same improvement. However, SEO and Calgary reported Belleville and Red Deer as highly functioning PSCs due to their strong stroke champions, nursing leadership, and team culture. As the cases presented similar care models, I have concluded that EH PSC programs must standardize and map out processes supporting efficient treatment and improve early communication. Passionate leaders are also required to motivate teams and find time for change management and continuous quality improvement. The policy implications of the results suggest ways to improve hyperacute stroke care in NL: 1) Develop a provincial stroke program to standardize stroke care across the province, monitor performance, and collaborate with the air and ground ambulance system, 2) Expand EVT to a full-time service serving eligible patients across the province and expand the EVT treatment time window, and 3) Focus on continuous quality improvement with electronic collection of variables that measure the elements of the stroke care pathway, aiming to minimize delays in time to treatment.

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