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An oral history of acute stroke care

Sherry Darling
Sherry Darling, a speech-language pathologist at the Krembil Neuroscience Centre, is one of several members of acute stroke care team at Toronto Western Hospital.(Photo: UHN)

Toronto Western Hospital's (TWH) efforts to attain Stroke Distinction took a big step forward this week when the hospital's stroke group hosted an on-site team of surveyors from Accreditation Canada.

While TWH already has a well-established reputation for clinical excellence and leadership in the delivery of acute stroke care, this special accolade is reserved for facilities that demonstrate a desire to advance the level of care for these patients.

This is achieved by demonstrating a commitment to innovation, high-quality service and positive outcomes for stroke patients while simultaneously delivering a comprehensive set of quality indicators that demonstrate an adherence to stroke care best practices.

The process of securing Stroke Distinction takes place over several months and is closely aligned with improving the patient experience, supporting our people and culture and promoting operational excellence, all of which are corporate priorities at UHN.

In an effort to better understand how this relates to frontline workers, UHN News sat down with several staff members who regularly care for stroke patients. Here, in their own words, staff members recount the different steps – from arrival at the emergency department to their transfer to a rehabilitation facility – that a patient with stroke symptoms goes through at TWH and how Stroke Distinction has helped improve the process.

Chapter 1: Arrival at TWH

Andrea Forde  

Andrea Forde, Emergency Department Nurse 

"EMS alert us that a potential stroke patient is en route to the Emergency Department. They provide brief details about the patient, such as age, time of onset, left side weakness, time last seen normal as well as an estimated time of arrival.

"The first thing I do is call the stroke nurse to give them advance warning. When the patient arrives we start an IV (intravenous therapy) and perform blood work. Then we assess the symptoms which can include slurred speech, numbness and dizziness, or weakness on one side of the body or other. If this is a stroke that needs to be treated, we want to get all that work done as quickly as possible.

"Once we suspect the patient is having a stroke, we send them to imaging to get a CT (computerized tomography) scan."

Chapter 2: Stroke team springs into action

Dr. Frank Silver  

Dr. Frank Silver, Medical Director, UHN Stroke program

"Usually I get a call from our stroke nurse, saying there is a patient with some basic description. It's nice to have that pre-notification so you can get dressed and get ready since we are often not at the hospital. Once it's established that it's a true code stroke – after our triage nurse discusses the case with our stroke nurse – we do what's called a fan out. The entire team has pagers and we all get a code stroke call.

"The next step is the nurses speak to the radiology technician in the Emergency Department and make sure the CT scanner is cleared. We meet the patient on the stretcher in the ED and take them directly to the CT table. The door to CT is generally 10 minutes. Nowadays, there is a wealth of electronic information available that makes us more efficient and allows us to have one person looking at the imaging, one person assessing the patient, and another person talking to the family.

"In the case of ischemic stroke, the faster you treat the better chance you have to help. Every minute that ticks by more brain cells die."

Chapter 3: Removing the clot

Dr. Timo Krings  

Dr. Timo Krings, Chief of Neuroradiology, UHN

"High quality imaging of the brain is key – we need to identify how much brain is already damaged beyond repair and how much brain is at risk ... We have the fastest and best CT scanners currently available at TWH that enable us to answer these crucial questions within minutes.

"When we know a patient is a candidate for an interventional procedure the entire team is alerted: technologist, fellow, nurse and staff.  We aim to get to the hospital in less than 20 minutes, which means we literally drop what we are doing, jump in the car and get to the TWH as fast as possible. Whoever arrives first in the operating room, the so called "angiosuite," starts to prepare the material needed for the complex procedure to remove the clot from the brain.

"The treatment to remove the clot is called mechanical thrombectomy. Shortly after the patient arrives we drape him or her in a sterile fashion, puncture the groin, insert a tube called a "catheter" in the blood vessel and track down the clot in the brain. Support from our anesthesiology team is present to ensure the stability of the patient during this procedure. 

"Thanks to the imaging equipment in the angiosuite, we can follow the catheter in real time inside the patient's body. By turning and twisting the catheter at the groin we can navigate through the patient's blood vessels. Once the clot is located we pull it out. Our fastest time, from groin puncture to recanalization, is seven minutes, but in difficult conditions, when the patient moves or has very tortuous vessels, it may take longer.

"This procedure, if done by an experienced interventional neuroradiologists, has decreased mortality dramatically, by more than 50 per cent. It's also increased independent living by double and significantly decreased the amount of time patients need to be in the hospital or a rehabilitation facility."

Chapter 4: Recovery and first steps

Charmaine Arulvarathan  

Charmaine Arulvarathan, Advanced Practice Nurse Educator, Neurovascular Inpatient Unit at TWH 

"In the initial hours after the stroke we are the next step before the patient either goes home or is sent to rehabilitation, or whatever other destination is required.

"Based on whatever new deficits the patient is coping with, we tailor a treatment plan. Speech difficulties, motor difficulties, sensory changes – including vision and hearing loss, and an inability to express themselves through language – are among the new deficits a patients could be facing at this time.

"Fortunately, we have a strong, diverse team who, beyond their professional designations, also bring an advanced knowledge of stroke care and education.  Our nurses are trained in a variety of special assessments to pick up the smallest changes in patients that may indicate a change in their neurological status."

Chapter 5: Finding a voice

Sherry Darling  

Sherry Darling, Speech-Language Pathologist

"Quite often people will have difficulties with swallowing after stroke.  It's quite common actually. Up to 80 per cent of stroke patients have some degree of difficulty swallowing, or what's called dysphagia.

"We a use a tool called the TOR-BSST (Toronto Bedside Swallowing Screening Test), which was developed at UHN by (Krembil Research Institute) researcher Dr. Rosemary Martino and is now used globally. It is easy to administer, nurses are trained on how to use it, and it helps provide a standard level of care."

"In an ideal situation I would work with a patient for a few days. Our goal is that by day three we have a plan for where the patient is going to go from here. Sometimes people are medically unstable or they might just need more time to adjust, but that is a target we have."

Chapter 6: Final thoughts: Why Stroke Distinction Matters

Charmaine Arulvarathan

"Stroke Distinction has been valuable because it's caused us to pause and look twice at what we do and evaluate whether that's the best way to do things. It's shone a light to expose gaps but to also highlight triumphs. …. Some of the major changes for nursing care that came out of accreditation are a renewed focus on patient and family education. It's definitely been very rewarding and informative for our team to learn new methods for developing our patients' self-management skills, for example."

Sherry Darling

"As a member of the allied health team, we have been very involved in a leadership capacity to help meet the standards and protocols. What this has really done is examine what we do already with a fine tooth comb and evaluate that and identify what we can do better."

Dr. Frank Silver

"We already thought we were at a place where we were as good as the level of stroke care can get, but this process has proven that we could push it to a completely different level. Stroke distinction has taken us from a system that was pretty good to one that is outstanding."

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