March 7, 2017
Story by Greg Harris; Photo by Paul Rotzinger
Shelley Castor was in a Red Deer bank last April when she started to feel dizzy and noticed her left hand and arm going limp. Her husband Ian sped to the hospital where nurses got Castor into a wheelchair and then began swarming around her in a trauma room.
“I knew right away I was having a stroke,” Castor recalls. “I kept saying over and over, ‘I have an 11-year-old daughter at home who needs her mother — I don’t want to die.’”
Thanks to neurologist Dr. Jennifer Bestard and the stroke team at Red Deer Regional Hospital Centre, Castor was treated with the clot-busting drug tPA (tissue Plasminogen Activator) in 23 minutes — not only saving her life but making a near full recovery possible.
Time is brain when it comes to treating stroke, an imperative at the heart of a provincewide quality improvement initiative that’s helping make Alberta’s 17 stroke treatment centres among the fastest in the world in giving patients tPA.
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 in 2012 to 36 minutes today.
“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 & 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 Dr. Hill, also a professor in the Department of Clinical Neurosciences at the University of Calgary’s Cumming School of Medicine and a member of the Hotchkiss Brain Institute.
An improvement of this magnitude 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.
During an ischemic stroke, in which blood supply to the brain is blocked, about two million brain cells die every minute and about 12 km of neural connections are lost.
All around the province, Albertans like Castor are getting speedy treatment for strokes, including Ian MacNeill of Airdrie; Florence Deschamps of Ma-Me-O Beach; Melissa Schiah of Fort Saskatchewan; and Richard Travis of Cochrane.
“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, 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.”
Covenant Health’s Grey Nuns Hospital currently holds the provincial record for the case with the fastest door-to-needle time, at six minutes.
“Improvements like this are life-changing for Albertans, and an example of the teamwork and innovative thinking that are helping to strengthen our health system to ensure all Albertans have the care they need when they need it,” says Sarah Hoffman, Minister of Health. “This is the kind of innovation and commitment to care that makes lives better for Albertans.”
“Successes like these have been driven by staff on the front lines who worked toward a common goal,” says Dr. Thomas Jeerakathil, an Edmonton-based stroke neurologist and QuICR co-lead for Quality Improvement. “There are few other areas in medicine where the concept of ‘teamwork’ is more important.”
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 coordinators, 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, who brings a systems engineering perspective to the task, 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.
“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 Dr. Kathryn Todd, 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 to improving the lives of stroke sufferers not only in Alberta, but around the world.”