Inequalities in health across communities could be reduced with a new model for stroke care that is being studied. This model, presented at the Canadian Stroke Congress, shows how hospitals in rural areas can mimic the type of care that's often only available in larger centres.
In geographically diverse Canada, stroke care can seem like tale of two cities - or more like a city and a small town. The ideal is stroke unit care, where a multidisciplinary staff of doctors, nurses and therapists collaborate on treatment and the road to recovery. In Alberta, that type of care is only offered to 52 percent of patients, mainly in urban settings. The proportion is lower in many other provinces. Frequently, hospitals in smaller centres just don't have the same resources.
"There are challenges in these smaller centres, mainly because of a lack of sub-specialists, dedicated beds or early exposure to therapists," says Dr. Thomas Jeerakathil, stroke neurologist and co-chair for the Stroke Action Plan project, which is funded by the Cardiovascular Health & Stroke Strategic Clinical Network, Alberta Health Services. "What we're trying to do is replicate the experience of stroke unit care for rural and smaller urban areas."
The study received the Canadian Stroke Congress Co-Chairs Award for Impact.
The model described in the study starts with SUEC, which stands for Stroke Unit Equivalent Care. "You train staff to have additional expertise in stroke, have standardized orders and pathways, which are protocols that are followed, and increase rehabilitation staffing," says Dr. Jeerakathil.
In the smaller hospitals, stroke patients should all consistently be admitted to the same ward. The idea is that over time staff there will develop greater proficiencies in responding to these patients.
Another key element in the Alberta model is early supported discharge (ESD). Currently, only 14 to 19 percent of stroke patients receive intensive rehabilitation upon discharge. Dr. Jeerakathil suggests that ESD has the potential to expand intensive home-based rehab to another 30 percent of stroke patients.
With ESD, stroke patients who don't need in-patient nursing, and who aren't medically fragile, go home from hospital sooner once plans are in place for caregiver and other support. That might include frequent visits from a physiotherapist or occupational therapist at home to meet the patient's rehabilitation needs. ESD is used in Edmonton and Calgary as well as in larger centres in other provinces such as Ontario, and is being expanded to small urban areas as part of the project.
The third service-delivery method integrated into the model is community rehabilitation (CR). Sometimes, patients living with the residual effects of a stroke may fare well for a time then decline. CR looks to catch people like that, with followup for medical attention and monitoring, and perhaps a refresher course in rehab.
The SUEC model has been implemented at 14 rural centres, with ESD and CR in five of those. "We're seeing the results in terms of decreasing length of stay, the increasing number of patients with access to rehab and increased patient satisfaction," says Agnes Joyce, presenting author and manager of the Cardiovascular Health & Stroke Strategic Clinical Network.
Hot Topic in Stroke: Rural Care
"With strokes, as with other disease states, it's essential to minimize the urban-rural discrepancies we see sometimes in access to care," says Patrice Lindsay, director of stroke best practices and performance for the Heart and Stroke Foundation. "The Alberta project highlights how it's possible to raise the bar at smaller sites and align their care with best practices."
In Alberta, Dr. Jeerakathil also points to the benefits of telestroke as an effective way to deliver care to stroke patients anywhere. Telestroke uses telecommunication technology to link referring and consulting healthcare sites for real-time assessment and management. That provides stroke patients with extended access to a variety of treatments and services.
"Telestroke is underused," says Lindsay. "In a country the size of Canada, we have to be creative in finding ways to spread the best care to smaller communities, resulting in consistent services and ultimately the best outcomes."
The model developed in Alberta could be transferred to other provinces and have a dramatic impact on stroke care and outcomes across Canada.
Research Creates Survivors
Elwood Kirkpatrick, is a "grateful recipient of a great project" and one of the first patients at the ESD site launched in Red Deer, Alta. He wants everyone to know about early support discharge, which allowed him to return home sooner, where he then received one-on-one rehabilitation support. "It is quite a great service for citizens like me and others in this community."