OSN 2014-15 Accomplishments Document

ONTARIO STROKE NETWORK
FY 14/15 ACCOMPLISHMENTS
In 2014, the Ontario Stroke Network (OSN) Board of Directors undertook a mid-term review of the OSN Strategic
Plan. Through this review, OSN strategic directions were revised and advanced to the following:
Strategic Direction 1: Be a credible leader and effective advisor
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The ’go-to‘ health system advisor on stroke prevention and care
An effective partner for positive system change
A clear communicator in messaging on stroke care and the OSN brand
A model network and a model of integration
Strategic Direction 2: Drive excellence
• Adoption of best practice
• Best Practice Innovations
• Strategic research
• Continuous improvement
• Goals that address gaps
• Accountability
Strategic Direction 3: Pursue strategic partnerships for vascular and brain health
• Build on partnerships with vascular agencies for prevention
• Partner with brain agencies for care
Throughout fiscal year (FY) 14/15, OSN continued to make significant progress on its strategic directions and
annual provincial work plans. Highlights of this progress and related accomplishments follow:
Strategic Direction 1: Be a credible leader and effective advisor
Quality Based Procedures (QBP)
A major focus of OSN’s work in FY 1415 was to advance the development and implementation of stroke QBP’s. In
follow-up to the release of the HQO QBP Clinical Handbook for Stroke (Phase1) the OSN undertook the following
activities in support of QBP development, implementation, clinical engagement and knowledge translation:
 The OSN provided review and consolidation/integration of Clinical Handbook Phase 1 and 2. The Health
Quality Ontario (HQO) Phase 2 (Post-Acute Community Based Care for Stroke) expert panel was convened.
The panel is co-chaired by Dr. Mark Bayley, OSN Evaluation Champion. The Phase 2 Clinical Handbook (which
integrated the Phase 1 Handbook) was released Feb. 24, 2015.
 In October 2014, AlphaFIM® became a mandatory Canadian Institute for Health Information Discharge
Abstract Database (CIHI-DAD) data element. AlphaFIM® data collection will support the QBP
recommendation that patients with an AlphaFIM® score of 40-80 be discharged to inpatient
rehabilitation, and patients with scores greater than 80, to outpatient/community based-rehabilitation.
 Standards were developed for Rehabilitation Intensity data collection. Beginning April 2015,
Rehabilitation Intensity will be collected in the National Rehabilitation Reporting System (NRS). This will
support a stroke QBP recommendation that patients be engaged in at least three hours of direct taskspecific therapy per day, for minimum of six days per week. An education package has been developed
and training provided for clinicians and coders.
 The Ontario Stroke Network Forum was held January 9, 2015 with 89 participants. Participants reported;
“great information to take back and implement pieces in our own organization” and; the “IDEAS session was
outstanding.”
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OSN Strategy for Patient Oriented Research (SPOR) Ensuring QUality in the Implementation of Quality Based
Procedures (EQUIP) Pilot Project
The overarching goal of SPOR is to translate research results into improved health outcomes for Canadians.
Ontario has established an Ontario SPOR Support Unit (OSSU) which includes two demonstration projects
(Patients Canada and OSN) to advance SPOR objectives within Ontario. The focus of the OSN EQUIP
demonstration project is on stroke QBP implementation. Key FY 14/15 activities include:
 OSN-SPOR Project Advisory Group established
 Confirmed MOHLTC areas of interest:
 Focus on QBP Phase 1;
 Use of the Clinical Handbooks;
 Collaboration Activities;
 Change Management and Transitions;
 Outcomes/Impacts;
 Lessons learned/Best Practices
 Areas of research/evaluation focus include:
 Qualitative current state analysis of QBP implementation and patient/family engagement
o data collection commenced March 2015
 Development of an evaluation framework
 Development of a Milestones and Timelines impact report
 Development of best practice recommendations for stroke QBP pricing
 Qualitative/quantitative impact of Stroke Distinction on QBP implementation
o Methodology and timelines developed for qualitative component of Stroke Distinction
 Policy and systems milestone chart established. To be aligned with impact/outcomes (October, 2015)
Directed Research Projects
Evaluation of the Implementation of the Revised Acute Stroke Medical Redirect Paramedic Protocol (ASMRPP) in
Urban and Rural Settings:
Results of this completed research project were presentation to the MOHLTC Emergency Health Services Branch
Medical Advisory Committee and through Provincial Stroke Videoconference Rounds. Results shared with Dr. R.
MacDonald, Medical Director, Quality and Research, Chair Quality Care Committee, ORNGE to inform discussions
regarding the role of ORNGE in the acute stroke paramedic protocol. Discussions revealed limitations to the role
of ORNGE in the acute stroke paramedic protocol due to time-sensitive treatment criteria and the time required
to activate the ORNGE service. Recommendations for next steps include; exploration of future provincial
opportunities such as acute Intra-Arterial treatment planning; and examination of local opportunities with ORNGE
be undertaken by NWO and NEO Stroke Networks.
Investigating Stroke Unit (SU) Care:
Preliminary survey findings were presented at the 2013 Canadian Stroke Congress and a final report submitted
December, 2014. Results showed a clear mortality benefit of SU care compared to General Wards (GW). Death
within one and two years of acute care discharge was considerably lower in SUs than in GWs, consistent with
findings of the 2013 Cochrane Review. SU care appears to be associated with improvements in (quality adjusted)
life expectancy compared to GW care without significant increases in total healthcare costs.
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Optimal TIA Management:
Results for inpatient TIA admissions suggest that patient-level characteristics rather than system-level factors have
a greater influence on decision to admit patients with minor stroke or Transient Ischemic Attack (TIA). These
results will contribute to the review of stroke prevention clinic model of care (led by Best Practice Subcommittee
FY 15/16). Provincial Stroke Rounds on June 3, 2015 will feature a presentation of this research by Dr. Moira
Kapral and Dr. Ruth Hall.
Other Research Activities/Projects
 OSN was invited to participate in a knowledge user advisory role on the Canadian Institutes of Health
Research (CIHR) project: Transformation of Indigenous Primary Healthcare Delivery (FORGE AHEAD) Initiative
with the goal of facilitating health care access and delivery to aboriginal communities.
 OSN is a co-investigator and knowledge user on a CIHR Planning and Dissemination Grant focused on Stroke
Rehabilitation and Multi-morbidity Think Tank.
 OSN is the Principal Knowledge User on a CIHR Knowledge to Action Operating Grant titled “Development and
Evaluation of iWalk: A Web-based Guide to Facilitate Evidence-informed Assessment of Walking after Stroke.”
 OSN is a partner in the development of a “National Vascular Health Network” which was successful in
achieving five-year CIHR funding (2013-2018). The OSN Best Practice Lead is the co-chair of the Knowledge
Translation Subcommittee.
 OSN was a collaborator on a Canadian Stroke Network grant awarded to Dr. Frank Silver for a “Telestroke
eConsult “project. Completed in June, 2014, this project resulted in the creation of a web-based application to
enable referring health care practitioners to more efficiently exchange patient health information.
Presentations and Publications
 Thirty-five (35) OSN and regional stroke network posters and ten (10) platform presentations were presented
at the 2014 Canadian Stroke Congress and one (1) oral and six (6) posters were presented at the 2015
International Stroke Congress (complete listing available upon request).
Education Activities
 The Professional Stroke Education Inventory was reviewed and updated.
 OSN co-chaired the 2014 Stroke Collaborative Planning Task Team. The 2014 Stroke Collaborative included a
comprehensive program and a highly successful event with more than 600 attendees (predominantly front
line clinicians). 98% strongly agreed or agreed that the conference was relevant to their practice/work.
 Six (6) CME accredited Provincial Stroke Rounds were held. Topics included carotid stenosis, impact of stroke
survivor and caregiver support groups on community reintegration, Cerebral Venous Thrombosis and
Intracerebral Hemorrhage. More than 1,000 participants attended, including nurses and family physicians.
 The OSN was a member of the planning committee for the successful 2014 Canadian Stroke Congress.
 The OSN contributed to National Best Practice Recommendations for Secondary Prevention and Acute Best
Practice Recommendations. The OSN also supported the development of the corresponding knowledge
transfer resources.
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Engagement and Knowledge Dissemination
 Partnered with the Alzheimer’s Society of Ontario to create a ‘Stroke and Dementia’ focused plan for Stroke
Month, 2014. The Stroke Month campaign was highly successful, with significant media attention and regional
campaign satisfaction.
 Created the Professional Stroke Education Inventory online, a repository of tools, resources and programs
that support health care professionals working in stroke care.
 Created 2013/14 Annual Report, distributed to stakeholders via print and online.
 Created online Media Centre to house online releases, position statements and other items.
 Developed and distributed 26 OSN eBulletins. Since June 2013, subscribers have increased more than 500%.
 Targeted media release(s) developed and distributed.
 Social media strategy reviewed, updated and implemented. Social media posts have increased to four per day.
Followers on Twitter have increased more than 500% since June, 2013. Social media platforms have expanded
to include Twitter, Facebook, Google+, LinkedIn, Vimeo, Youtube and an up-to-date RSS feed.
 Institute for Clinical Evaluative Sciences (ICES) annual report highlights the Ontario Stroke Evaluation Program
as one of four high impact projects.
Strategic Direction 2: Drive Excellence
Telestroke
The OSN, Ontario Telehealth Network and the Ontario Telestroke Steering Committee (OTSC) continue to advance
planning for the provincial Telestroke program and key recommendations arising from the Telestroke program
review. Progress includes:
 Two new Telestroke sites (Bluewater Health Sarnia and Grey Bruce- Owen Sound) were launched in FY 14-15.
There are now 24 active Telestroke Referring sites in Ontario.
 Telestroke consultant capacity was increased with four additional stroke neurologists recruited. There are
now 14 Telestroke consultants.
 A memorandum of understanding to identify Telestroke responsibilities for OSN, Ontario Telemedicine
Network and CritiCall Ontario was developed and executed.
 The Ontario Telestroke Clinical Subgroup which provides expert advice, leadership and a coordinated
standardized approach for clinical and operational aspects of the acute phase provincial Telestroke has
identified the need for a Telestroke Toolkit. This Toolkit will focus on both clinical and operational activities in
support of Telestroke program implementation and will be completed in Q1 FY 15/16.
 Telestroke indicators were captured in the FY 12/13 Ontario Stroke Audit data collection and were included in
the 2014 Ontario Stroke Evaluation Report.
 OSN developed a media release regarding the achievement of a milestone for Ontario’s Telestroke program in
providing more than 1,000 thrombolysis (tPA) recommendations and fielding more than 4,300 physician calls.
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Best Practices Acute and Secondary Prevention Subcommittee
The OSN Best Practice Sub-committee (Secondary Prevention and Acute Care) establishes and oversees the
implementation of recommendations to improve quality of stroke care in secondary stroke prevention and acute
care. The Sub-committee informs the development of tools and processes to support knowledge translation of
best practices.
TIA/Minor Stroke
The standardized provincial TIA algorithm was finalized and endorsed by the Regional Medical Directors and the
BP Sub-committee. Development of a dissemination and evaluation plan is underway and targeted for completion
in May, 2015. Sub-committee members contributed to the Canadian Best Practices Secondary Prevention
recommendations Update released in December, 2014.
Continuous Improvement
A Provincial Integrated Work Plan Committee (PIWPC) was created to provide leadership in the development,
management and communication of provincial planning and project development. FY 14/15 priorities include:
 Early Supported Discharge (ESD) Task Team completed a backgrounder summarizing the evidence identifying
common core elements of ESD; forwarded a Briefing Note to the Phase 2 QBP Expert Panel Co-Chairs; and,
developed a sample business case template.
 Navigation Model to Support Patient Transitions to Community Task Team completed a literature review and
identified common elements and principles of navigation models (final report to be completed by March,
2015). Provincial Stroke Rounds are planned in Q1 FY 15/16 as well as an abstract submission to the 2015
Canadian Stroke Congress.
 An OSN Stroke Rehab Resource Centre was developed. This Centre will be updated as resources become
available. Knowledge users report the Resource Centre has been useful in engaging stakeholders in the
planning and implementation of stroke rehabilitation best practices.
 A pilot of the Resident Assessment Instrument (RAI) Stroke Care Plans was completed. Pilot results included:
 95.8% of post survey respondents indicated that stroke care plans enhanced their ability to care for
stroke residents to varying degrees;
 73% of respondents to the post pilot survey combined the content of the Stroke Care Plans with
existing care plans; and
 Stroke care plans have been integrated into all Extendicare Long-Term Care Homes in Ontario (34)
and all Jarlette Health Services Long-Term Care Homes in Central East LHIN (14). The Community and
Long Term Care Specialists continue efforts to facilitate integration of the stroke care plans into longterm care homes.
 The OSN collaborated with Victorian Order of Nurses (VON) Seniors Maintaining Active Roles Together
(SMART) Program Phase 2, to provide stroke content expertise for the development and delivery of functional
fitness programs for clients with multiple chronic or conditions. Two webinar education sessions were held.
Survey results include greater than 69% felt the sessions contributed to preparing them to work with seniors
living with special needs, greater than 81% rated the sessions very good to excellent. Once available from
VON, modules will be posted on the OSN website.
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2014 Ontario Stroke Evaluation Report
The 2014 Ontario Stroke Evaluation Report includes an update on the 2010/11 Ontario Stroke Audit (OSA) using
FY 12/13 data (over 14,000 acute patient visits and inpatient stays) and provides a baseline for stroke QBP
performance indicators. The Report also updates acute stroke care performance and progress on OSN targets.
Ontario Acute Stroke Audit Findings – 2012-13
There have been many improvements in Ontario’s stroke system over the past 10 years including improvements
in acute care, and access to inpatient rehabilitation and prevention. Also, more stroke patients are receiving care
at designated stroke centres (56% compared to 44% in 2003) and statistically significant improvements in:
 Documenting stroke type, 92.0% are known
 Neuroimaging within 24 hours at 93.2% (exceeds most jurisdictions nationally and internationally)
 Carotid imaging (82.3%), and median time to intervention (15 days)
 Administration of tissue plasminogen activator (tPA) at 12.3%. 12.3% exceeds internationally reported
rates with exception of a province in Finland (16%)
 Accessing inpatient rehabilitation (32.6%)
 Stroke patients discharged from the ED and referred to a stroke prevention clinic (78.5%)
 Over the past three years (2010/11 to 2012/13) there has been a decline in:
o in-hospital, 30-day and one-year mortality (9.9%, 12.6% and 23.3%, respectively)
o 30-day all-cause readmission (7.4%) and 30-day readmission for stroke or TIA (4.3%)
o patients admitted to long-term care within one year of a stroke event (7.1%)
The 12/13 OSA was also used to analyze and validate the CIHI 340 data elements. Results were shared via
presentation and report to the MOHLTC and Regional Stroke Networks and presented as part of MOH-CIHI “data
blitz” and “road show.” Key findings of the comparison between OSA and CIHI 340 data were:
 Neuroimaging and tPA percent agreement greater than or equal to 85%
 Stroke Distinction accredited sites and stroke centres had higher levels of agreement for all variables
 Date and time elements for ’discharged with anti-thrombotic prescription problematic‘ in NACRS and
non-designated facilities in DAD
 Agreement between the DAD or NACRS and the OSA highly variable at individual hospital level
The definition of stroke unit care has been revised to ensure best practice stroke unit care is being provided.
 In 2012/13, 26% of Ontario stroke patients received care on a stroke unit (based on revised definition)
Summary of System Impacts
In comparison to the baseline year of 2003, significant and steady improvements in acute care outcomes and
positive trends in the rehabilitation sector are being seen with annual health system savings estimated to be $27
million. In comparison to 2003, findings include:
 almost 700 fewer deaths
 estimated 3960 fewer ED visits in 12/13
 estimated 4,400 acute care inpatient visits avoided annually
 total acute care inpatient length of stay decreased by one day
 Alternate Level of Care (ALC) length of stay decreased by one day
 time to carotid intervention among admitted patients reduced by 32 days
 wait times for admission to inpatient rehabilitation from acute care reduced by three days
 access to inpatient rehabilitation for severely disabled stroke patients increased 2% over the past
three years
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Ontario Stroke Report Cards
The 2014 Ontario Stroke Report Cards were released and for the first time included interpretative documents
capturing the collaborative work occurring between the Regional Networks and the Local Integrated Health
Networks (LHINs). These documents commented on accomplishments and areas for improvement related to
assessment and delivery of stroke best practices within the LHINs. The Report Cards graded the delivery of stroke
care for each of Ontario’s 14 LHINs since 2011 and remain a critical support to the Regional Stroke Networks in
driving improvements in access to best practices and patient/health system outcomes at the LHIN level. The
provincial report card showed statistically significant improvement in 16 of 19 indicators. Additionally, 14 of 17
benchmarks have also improved.
Regional Economic Assessments
Building on “The Impact of Moving to Stroke Rehabilitation Best Practices,” Regional Economic Assessments were
completed for 14 LHINs and distributed to Regional Stroke Networks for local contextualization, dissemination
and planning. These assessments have proved valuable in preparation for stroke QBP.
Strategic Direction 3: Pursue Strategic Partnerships for Vascular and Brain Health
Hypertension Management Program
The Hypertension Management Program (HMP) is an evidence-based, interprofessional, collaborative program
developed to support patients in managing their hypertension and associated chronic conditions. There are
currently 38 HMP sites located across Ontario; 24 in primary care clinics and 14 in aboriginal health centers. FY
14/15 accomplishments include:
 Delivery of improved site support protocols/processes that promote clinical self-management, and
implementation of a new HMP delivery website, including on-line HMP tools.
 Established criteria for expansion of HMP to additional sites. Based on learnings from the program evaluation,
mandatory site inclusion criteria include having full eMR utilization with either Telus PSTM or OSCAR eMR.
 A call of interest was released resulting in expressions of interest from more than 55 clinics. Candidate
readiness assessments and feasibility reviews have been undertaken and planning is underway for
implementation of 16-20 additional HMP sites across Ontario.
 Full evaluation of OSN/HMP Privacy framework, Personal Health Information protections and clinical data
sharing processes was completed. Outcomes include;
 update hosting/data sharing agreements;
 removal of legacy patient consenting process;
 OSN organizational responsibilities confirmed as the Electronic Service Provider of the HMP;
 new privacy policies and procedures were created; and
 staff privacy training
 Recommendations stemming from FY 13/14 Program Evaluation were assessment and implementation.
 Creation of an HMP Advisory Group and operating framework (including commencement of semi-annual
meetings).
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Vascular Health Primary Care Working Group
The OSN Vascular Health Primary Care Workgroup (PCWG) was established to advance the goal of improving
quality and access to a continuum of vascular healthcare services. In FY 14/15, the OSN PCWG continued its work
on two priorities:
 Development of a Vascular Health Assessment and Support Tool (VHAST). The VHAST proposes to function in
Ontario MD funding-eligible EMRs with embedded capability for clinical data to be compared against best
practice guidelines. Activities have been progressing on this main priority including:
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A Proof of Concept electronic Vascular Flow Sheet was positively received by many stakeholders and
the feedback informed the next phase prototype development of the VHAST.
Regular meetings have occurred between the OSN’s PCWG and Canadian Cardiovascular Harmonized
National Guidelines Endeavour (C-CHANGE) Initiative leads regarding alignment with C-CHANGE
guidelines.
A Request for Proposal (RFP) for the VHAST prototype development was released in October, 2014,
and in December, 2014, InfoClin was identified as the vendor who will develop the VHAST prototype.
The VHAST prototype development project commenced January, 2015. Consultation with
stakeholders (including primary care providers) to gather requirements for the prototype is ongoing.
A demo version of a user-ready VHAST prototype is on track for early Fall, 2015 completion.
 A Task Group of the PCWG is creating a Vascular Health QI Toolkit. Completed activities include:
 A Vascular Health QI ‘Companion’ resource has been drafted along with a framework for
supplementary QI elements.
 Initial topics for the supplementary QI elements were identified (smoking cessation, hypertension
screening and management, aortic abdominal aneurysm screening and VHAST implementation)
 QI elements for Aortic Abdominal Aneurysm (AAA) and hypertension screening and management
have been drafted and stakeholder consultations are continuing to determine the QI elements
pertinent to primary care providers and to align with HQO’s Primary Care Performance Measurement
framework.
 The PCWG has met with various groups including ICES, the Canadian Diabetes Association and the Ontario
Brain Institute seeking collaboration, alignment and potential linking of future evaluation activities.
Additional OSN achievements related to the VHS include:
 Working with representatives from multiple LHINs/regions, to achieve:
 Commitment from multiple LHINs to continue ongoing work towards integrated vascular health care
within their regions.
 Advancement of the approach to regional development and implementation of integrated vascular
health care including; drafting frameworks; and consideration of roles and responsibilities.
 In collaboration with the HSF, a Before/After Vascular Patient Case Study was developed to help build
a collective understanding of integrated vascular health care.
 A Vascular Health; Fact Sheet was developed as an aid to defining this work.
 A Healthy Catering Checklist and Implementation Guide has been informed and developed by the VHC in
partnership with the HSF to support healthy food selection for events/meetings held throughout Ontario.
Dissemination of the Checklist and an Implementation Guide has occurred and health care partners are
encouraged to apply these tools within their own organizations.
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