Ottawa (May 23, 2013) – New recommendations released today for physicians, nurses and allied health professionals highlight the need to educate the public to call 9-1-1 or a local emergency number if they are experiencing or witnessing a stroke. According to the recommendations only two-thirds of Canadians experiencing stroke and seeking acute care arrive at the emergency department by ambulance – those not calling emergency medical services (EMS) are putting themselves at risk of not accessing the expertise and treatment they need fast enough.

“This is troubling and means that one-third of all stroke patients are not able to benefit from potential emergency protocols that would route them to appropriate stroke facilities,” says Dr Leanne Casaubon, co-chair of the guideline writing group. “If someone is experiencing stroke the fastest and safest way to get the right help is to call 9-1-1.”

The first few hours after symptom onset are critical. Clot busting treatment for stroke needs to be given as soon as possible, and not later than four and a half hours. Calling 9-1-1 or a local emergency number is an essential first step that helps minimize delay in starting treatment. The 9-1-1 dispatcher is able to capture important information from the caller; paramedics at the scene assess the patient and call ahead to the receiving hospital. On arrival in the emergency department, the patient is examined and taken directly to the CT scanner. This is all done with the aim of starting the intravenous clot-busting drug within 60 minutes of arrival in the emergency department. The sooner the treatment is delivered the greater the likelihood of a good outcome.

“Emergency medical services play a critical role before a suspected stroke patient reaches hospital,” says Dr Casaubon. “The goal is to ‘recognize and mobilize’ and ensure that patients who require time-sensitive therapies are directed to specialized stroke centres.”

Many stroke patients will require admission to hospital.  As part of acute management, the recommendations also highlight the need to start stroke rehabilitation treatment as soon as possible, and develop a plan for ongoing care when the patient leaves the acute-care hospital.

The new recommendations which were released as updates to the Hyperacute and Acute Stroke Care chapters of the Canadian Best Practice Recommendations for Stroke Care also stress the need for coordination of patient care among all hospital departments and services and the strength of organized stroke teams. Strong evidence points to the link between better outcomes for patients cared for on an organized stroke unit with a dedicated interprofessional stroke team. Where stroke units are not available, every effort should be made to implement a model where all stroke patients are cared for on the same hospital unit with staff trained in stroke.

The updated Canadian Best Practice Recommendations for Stroke Care chaptersareposted at www.strokebestpractices.ca and will be widely disseminated in the Canadian health-care community. The recommendations provide evidence-based guidelines for the prevention and management of stroke and are updated on a rotating cycle every two years.

These updates are the first to be disseminated since the Heart and Stroke Foundation assumed responsibility for the management and development of the Canadian Best Practice Recommendations for Stroke Care as the Canadian Stroke Network prepares to sunset in August 2014.

“The transition of the Canadian Best Practice Recommendations for Stroke Care is one important example of the Heart and Stroke Foundation’s continued and expanding commitment to stroke research, prevention, treatment and survivor support in Canada,” says Bobbe Wood, President, Heart and Stroke Foundation.

The Canadian Best Practice Recommendations for Stroke Care is a joint initiative of the Canadian Stroke Network and the Heart and Stroke Foundation.

There are about 50,000 strokes in Canada every year and 315,000 people living with the after-effects of stroke. Stroke is a leading cause of adult disability and a leading cause of death. Learn more by visiting www.heartandstroke.ca.

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The Heart and Stroke Foundation, a volunteer-based health charity, leads in eliminating heart disease and stroke, reducing their impact through the advancement of research and its application, the promotion of healthy living and advocacy. Healthy lives free of heart disease and stroke. Together we will make it happen. Heartandstroke.ca

The Foundation is asking all Canadians to Make Health Last by taking action today to give themselves, their friends and families longer, healthier, fuller lives. Take the Heart&Stroke risk assessment today at makehealthlast.ca

The Canadian Stroke Network (www.canadianstrokenetwork.ca) is a national research network headquartered at the University of Ottawa. It includes scientists, clinicians and health-policy experts committed to reducing the impact of stroke.

Media inquiries:

Stephanie Lawrence

slawrence@hsf.ca

613.569.4361 ex 351

“The occurrence of post-stroke depression and changes to cognition affect a large proportion of patients who have experienced stroke,” says Dalhousie University professor Dr. Gail Eskes, who chaired an expert national panel on Mood and Cognition in Patients Following Stroke. “Of equal concern is the large number of spouses and informal caregivers who experience depressive symptoms in the post-stroke recovery phase.”

New recommendations, posted at www.strokebestpractices.ca, will be widely disseminated in the Canadian health-care community. Recent reports on the quality of stroke services in Canada show inconsistent screening and monitoring of stroke patients for depression and cognitive changes, even in large urban centres. Treatment delays may lead to poor outcomes, prolonged recovery and desperation on the part of patients and families.

This update to the Canadian Best Practice Recommendations for Stroke Care marks a new emphasis on psychological care of family and caregivers in addition to stroke patients. Depression can happen at different points in the recovery process – from months to years after the stroke. Annual assessment is recommended for patients and caregivers, who should have access to specially trained providers with expertise in mental health, neuropsychology, psychiatry and occupational therapy.

“Stroke impacts on the whole family, not just the person who has suffered a stroke,” says neuropsychologist Dr. Elizabeth Gilchrist of Glenrose Hospital in Edmonton, who helped develop the new recommendations. “Just like the patient, families and caregivers are at heightened risk of depression after a loved-one has had such a health crisis.  With these new guidelines, there is not only recognition of the value of regularly monitoring the mood of patients but of the importance of doing so for the patient’s family and caregivers.”

Neurologist Dr. Eric Smith of the Calgary Stroke Program, a member of the expert panel says: “Depressive symptoms are very common and may inhibit full recovery from stroke, including return to work. Depression is not seen only in severe strokes. Many patients with milder strokes, even strokes that appear to have resolved completely, may be still affected by depression or cognitive problems that decrease quality of life.”

Recommendations also highlight the need to screen stroke patients for cognitive decline and dementia. Research shows that two-thirds of patients experience cognitive impairment (changes to the way they think) and as many as a third of patients develop dementia. Mortality rates among stroke patients with cognitive impairment are double those of other patients.

The Canadian Best Practice Recommendations for Stroke Care is a joint initiative of the Canadian Stroke Network and the Heart and Stroke Foundation.

There are about 50,000 strokes in Canada every year and 300,000 people living with the after-effects of stroke. Stroke is a leading cause of adult disability and a leading cause of death. Learn more by visiting www.strokebestpractices.ca.

• Click here to read the news release
• Click here to download the mood and cognition updates
• Click here to read the updated Mood and Cognition section online

HONOLULU, Hawaii – A significant portion of people with unexplained strokes has silent atrial fibrillation, researchers in 16 Canadian stroke centres discovered as part of the largest study and first randomized clinical trial of heart monitoring in stroke patients. Atrial fibrillation, an irregular heart rhythm, is known to cause some of the most disabling, deadliest, and most costly types of strokes, but it can be a silent risk factor that evades detection.

The three-year EMBRACE trial involving 572 patients was presented today at the International Stroke Conference by lead researcher Dr. David Gladstone of the University of Toronto Department of Medicine. He reported that with a new strategy of advanced heart monitoring, one in six people with an unexplained stroke or transient ischemic attack (TIA) were found to have silent atrial fibrillation that would have otherwise gone undiagnosed and untreated by standard methods.

“This study provides the strongest evidence to date to support intensive heart monitoring in patients with unexplained strokes or mini-strokes,” according to the American Stroke Association, which highlighted the Canadian research as a late-breaking research development at the meeting.

Atrial fibrillation is a risk factor for stroke because it can promote the formation of blood clots in the heart that can travel to the brain. It is important to detect because it can be effectively treated with certain anti-clotting medications, which cut the risk of clots and strokes by two-thirds or more.

Dr. Gladstone, based at Toronto’s Sunnybrook Research Institute and Sunnybrook Health Sciences Centre, said the Canadian Stroke Network-funded study has implications for improving stroke prevention.“The hope is that earlier detection and treatment of atrial fibrillation may lead to more strokes prevented and more lives saved.”

The challenge has been that atrial fibrillation is often hard to detect because the irregular heartbeat may last for just a few minutes at a time, after which the heart reverts back to its normal rhythm. Unless an individual is wearing a heart monitor at the time it occurs, the diagnosis is usually missed. In practice, stroke patients have traditionally received short-duration heart monitoring for 24 or 48 hours to screen for atrial fibrillation. However, advances in heart monitoring technology now make it possible for patients to be screened at home for much longer periods.

The trial studied patients who had a recent stroke or mini-stroke of unknown cause and in whom standard heart monitoring failed to detect atrial fibrillation. Participants were randomized into two groups: the first received an additional 24 hours of monitoring, and the second received continuous monitoring for 30 days at home using a new technology chest electrode belt that automatically detects episodes of atrial fibrillation.

In the study, prolonged monitoring picked up a new diagnosis of atrial fibrillation in 16 per cent of patients, compared to three per cent of those who only received an additional 24 hours of monitoring. The enhanced detection led to significantly more patients being prescribed stronger anti-clotting medications to prevent recurrent strokes.

This research is relevant to an estimated three million people worldwide every year who suffer strokes of unknown cause. It will force experts to rethink the diagnostic and treatment approaches for such patients with so-called ‘cryptogenic’ strokes, which have remained a medical conundrum for years. The implication is that a half-million stroke patients each year may have untreated atrial fibrillation and not know it.

“These results are practice-changing,” says Dr. Antoine Hakim, CEO and Scientific Director of the Canadian Stroke Network. “This study really shows that the harder you look, the more atrial fibrillation you will find.”

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The Canadian Stroke Network (www.canadianstrokenetwork.ca) is a national research network headquartered at the University of Ottawa. It includes scientists, clinicians and health-policy experts committed to reducing the impact of stroke.

Contact: Cathy Campbell, Canadian Stroke Network, 613-852-2303 (cell) cathy@canadianstrokenetwork.ca (at the International Stroke Conference)

Nadia Norcia Radovini, Sunnybrook Health Sciences Centre, 416-671-9147(cell) nadia.radovini@sunnybrook.ca (to arrange patient interviews)

Download Release here.

Developed by the Global Stroke Community Advisory Panel (GSCAP), The Post Stroke Checklist (PSC) was developed by an international multi-disciplinary group of stroke experts, convened to focus on the need for improved long-term stroke management across the continuum of care. Professor Michael Brainin (Austria), GSCAP Chair, stated that “the need for practical tools to support clinicians in identifying long-term stroke complications and referring appropriately, with the goal of improving quality-of-life for stroke survivors, prompted the GSCAP to focus on PSC development as a priority.”

The PSC is a simple, easy-to-use checklist of 11 key questions that helps health care professionals identify post-stroke problems amenable to treatment and/or referral. The key questions focus on: 1) Secondary stroke prevention; 2) Activities of daily living; 3) Mobility; 4) Spasticity; 5) Pain; 6) Incontinence; 7) Communication; 8) Mood; 9) Cognition; 10) Life after stroke; 11) Relationship with family. The questions included in the checklist support productive clinician-patient dialogue and it is envisaged that the PSC will be administered during regular stroke follow-up at designated time intervals i.e. 3-months, 6-months, 12-months post stroke and annually thereafter.

Dr. Patrice Lindsay, director of Performance and standards at the Canadian Stroke Network says “the Post-Stroke Checklist aligns closely with our recently released updated stroke prevention recommendations, and reinforces our theme of ‘taking action’ in stroke care.”  Dr. Lindsay also points out that the PSC can be a valuable tool for patients and their families to use.  It will help them know what questions to ask about their care and be active participants in discussions with their healthcare team members.

Professors Christopher Chen (Singapore) and Anthony Ward (UK) carried out PSC feasibility and utility pilots during 2012. Professor Chen highlighted that “the pilots confirmed that the PSC is simple and easy to use with strong content validity, and demonstrated that the checklist supported the identification of a wide range of unmet stroke survivor needs.” He also noted that “clinicians and patients expressed high overall satisfaction with the PSC, that the checklist was generally well understood, and that the asking of appropriate questions was highly valued by stroke survivors and caregivers.”

Professor Stephen Davis (Australia), President of the World Stroke Organization (WSO), commented that “we need to continue to improve long-term care and support after stroke.  The WSO is keen to support the availability of tools that will improve stroke survivor follow-up and ensure that treatable complications are identified and referred for treatment.”   He continued that “the availability of the PSC is very good news for stroke survivors and commended the Canadian Stroke Network for making the PSC available as part of best practice recommendations.”

Assistant Professor Theodore Wein (McGill University, Canada) observed that “the PSC finally gives healthcare providers, caring for stroke survivors, a foundation and structure to support long-term follow-up and identify common post-stroke complications such that appropriate therapies may be implemented. The PSC fills a gap between current stroke guidelines and implementation in clinical practice.”

Click here to download the Post-stroke checklist.

Mark your calendars and don’t miss this opportunity to learn more about Telestroke and how it can work to improve stroke care across the continuum.

Event: 2013 Telestroke Summit
Date: May 10^th – 11^th, 2013
Location: Casino New Brunswick, Moncton, NB

Click here to download the brochure.

Learn more by watching the video and reading her blog. http://healthcouncilcanada.blogspot.ca/

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About the Health Council of Canada’s Understanding Clinical Practice Guidelines:
The Health Council of Canada developed this series of four videos to offer an introduction to clinical practice guidelines (CPG) in the Canadian context as well as a supplement, which provides a summary of the video content. The videos offer a variety of audiences a greater insight into what CPGs are, how they are used, disseminated, and implemented, and what impact they can have on patient outcomes and health care system performance.

Video 1: What are CPGs

This video provides an introduction to CPGs: what they are, who can benefit from their use, and why patients and health care providers should take an interest in them.

Video 2: Challenges for CPGs


This video discusses the complexities that affect widespread usage of CPGs. National experts share their thoughts on the challenges that designers and users of CPGs face.

Video 3: Integration of CPGs at the system level

This video profiles Canadian organizations that have garnered recognition for their system-level approaches to CPGs. The groups highlighted include:

• The Canadian Taskforce on Preventive Health Care
• Canadian Stroke Strategy
• Cancer Care Ontario
• Registered Nurses’ Association of Ontario Best Practice Guidelines

Video 4: Opportunities and future considerations for CPGs

This video looks at where efforts are needed to realize the benefits of CPGs on improving patient outcomes and health care system performance in Canada. We discuss the future and next steps for CPGs with national experts.

Approximately, 25% of stroke survivors are people under the age of 65 and 10% are people under the age of 50 and in the prime of their working life .  Research indicates that return to work rates after stroke are as low as 7%.  Employment is one of the most important social roles that a person fulfills and not working has negative impacts on a person’s overall quality of life, health, finances, social isolation and self-efficacy.  Stroke survivors and health care professionals need resources to help them navigate the process of return to work after stroke.

In 2008, the Southwestern Ontario Stroke Network (SWOSN) hosted community forums across Southwestern Ontario with stroke survivors, their loved ones, and community service providers to determine barriers to living fully in the community after stroke.  One of the priorities identified in the forums and documented in the report Pathways for People with Stroke to Live Fully in the Community was the need for “return to work” services.

A working group of experts in vocational rehabilitation and stroke care, as well as stroke survivors, developed a toolkit of resources to educate and assist stroke survivors, family members, and their health care professionals to navigate the complex system of return to work.  These resources have been incorporated into the website www.swostroke.ca/return-to-work.

This informative website will provide stroke survivors, family members and healthcare providers with:

 assistance to navigate the process of return to work
 local and provincial resources that provide guidance, support and assistance
 an online self assessment guide to focus individual recovery efforts and provide information about ability or readiness to return to work.

Visit www.swostroke.ca/return-to-work today!

The theme of this fourth edition is Taking Action, and stresses the critical role and responsibility of healthcare providers at every stage of the continuum of care to ensure that best practice recommendations are implemented and adhered to.  Taking action is crucial within primary and secondary prevention of stroke and applies to systems of care, healthcare providers, patients and the broader community. Taking action can appear in the form of prevention of first and recurrent stroke through rapid access to specialized stroke prevention services, promotion of healthy lifestyles, aggressive risk factor management and screening of appropriate patients for smoking status, mood, cognition and sleep difficulties.

Keeping this theme in mind, some of the highlights of the new recommendations include:

• the potential stroke risk of oral contraceptives and hormone replacement therapy, especially in patients who also smoke;
• new recommendations on screening, identification and management of patients with obstructive sleep apnea, diagnosed both pre and post stroke;
• the release of the findings from the ASA versus ASA+ clopidogrel arm of the SPS3 study that reinforced recommendations advising against the use of dual-antiplatelet therapy; and,
• continued emphasis on thje important role of blood pressure for stroke, and diligent monitoring and treatment to keep blood pressure levels well below 140mm Hg systolic and 90mm Hg diastolic.

Included in the updated section on prevention of stroke are:

• the prevention of stroke recommendations;
• a quick reference guide to the chapter;
• patient order sets;
• slide decks, to facilitate teaching the guidelines; and,
• Canadian Cardiovascular Society atrial fibrillation pocket guides.

Prevention of stroke is only the beginning of new updates to the stroke best practices. Keep an eye out for more updates to be released soon. All new sections will be marked as updated content.

Prevention of Stroke Recommendations
Prevention of Stroke Quick Reference Guide
Patient Order Sets
Slide Decks

The surveys are available in three genres; prevention and transitions, hyper-acute and acute care and stroke rehabilitation. If you are able, please complete all three surveys. If not, complete the sruvey that best applies to you.

The surveys are available at the following links:

Prevention and transitions

Hyper acute and acute care

Stroke rehabilitation

Thank you for your participation.

Click here to view the new Prevention of Stroke Quick Reference Guide. To order a bilingual copy of the poster contact us at info@canadianstrokenetwork.ca. In your email be sure to tell us your address and the number of posters you require.