Organization of Stroke Care Services

Stroke has a major impact in terms of mortality and morbidity, owing to its associated physical and psychological effects. In industrialized countries, stroke is the third leading cause of mortality in adults, after heart disease and cancer, and the leading cause of severe disability. According to available statistics, in 2005-2006, a total of 38,341 hospitalizations were attributable to acute stroke in Canada; in Quebec, 11,940 stroke hospitalizations occurred in 2008-2009.

The ministry asked the Agence d’évaluation des technologies et des modes d’intervention en santé (AETMIS) to provide a perspective on the best way to organize these services and to provide details on the structural entities, and their components, that should be part of the continuum of stroke care services. At the same time, the ministry established a working group of experts in the field with the mandate to support the implementation of the continuum, and AETMIS worked in collaboration with this group. It should be noted that on January 19, 2011, the Institut national d’excellence en santé et en services sociaux (INESSS) succeeded AETMIS.

Conclusions

At the end of this assessment, INESSS identified several points of consensus on the expected characteristics of the main structures that should provide services along the continuum of stroke care,and on the optimal pathways for patients or clients in the hyperacute, acute and post-acute phases. Relating these to the particular context of Quebec allowed for concrete proposals chiefly regarding the following points:

• hierarchical organization of acute care hospitals, with links for patient transfer;

• timely access to diagnostic imaging;

• development of stroke units in all secondary and tertiary acute care hospitals with the critical volume of patients required to maintain expertise;

• timely access to thrombolysis through the use of prehospital service pathways;

• clinical decision support and local administration of intravenous thrombolysis through telemedicine in primary acute care hospitals unequipped with stroke units in remote regions;

• early rehabilitation for all stroke patients, regardless of the type of hospital where they are admitted;

• participation of patients and their families/informal caregivers throughout the care process;

• planning of early supported discharge;

• equitable eligibility criteria for specialized rehabilitation services, whether offered in an institution, on an outpatient basis, or at home;

• access to local follow-up services offered by CSSS (Centres de santé et de services sociaux), including community reintegration support and non-specialized rehabilitation, after the specialized rehabilitation stage;

• timely access to secondary prevention clinics linked to hospital services and primary care;

• application of clinical practice guidelines by all healthcare professionals;

• periodic performance measurement, coupled with feedback to all stakeholders concerned.

The MSSS expert working group is continuing its work defining the organizational models and tools to support for Quebec, including such issues as the appropriateness and feasibility of on-call stroke triage teams, clinical triage instruments, organizational models for secondary prevention, clinical tools used in rehabilitation and telestroke.