Study finds most people who have a stroke wait too long for treatment

The first major national Canadian study on the quality of care in Canada finds there is significant work to be done to improve prevention, treatment and recovery from stroke. The study, released by the Canadian Stroke Network, one of Canada’s Networks of Centres of Excellence, states that Canadians need to be better informed about the severity of stroke and what do to when experiencing stroke symptoms.

Two thirds of stroke patients failed to arrive at a hospital within the crucial 3½-hour window. This window is vital to have the best chance of recovery. Many patients arrived much later. Thirty-nine per cent of all stroke patients arrived at hospital more than 12 hours after symptom onset.

Hector Mackenzie is living proof of the importance of arriving quickly at a hospital. On Thursday, August 28, 2008 Mackenzie had a severe stroke. Thanks to his daughter, Anna, his wife, Kathy, who recognized the stroke symptoms, and a speedy medical team, Mackenzie walked out of the hospital a week and a half later.

The stroke caught Mackenzie completely by surprise. While helping his eldest daughter, Anna, move into a new apartment in Kingston, Mackenzie suddenly collapsed. Soon after he lost hearing in his left ear, vision in his left eye and was unable to move the whole left side of his body. Luckily for Mackenzie, his wife and daughter immediately recognized these stroke symptoms and called 9-1-1.

Mackenzie arrived at the hospital minutes later where he was taken by hospital staff at the Kingston General Hospital for a CT scan and an angiogram. Doctors discovered a blood clot on his carotid artery and treated him with tPA. “Everything that could go right, did go right,” says Mackenzie, who estimates his door-to-needle time was approximately an hour.

Merely days later Mackenzie was able to have a full detailed conversation with his doctor. The doctor informed Mackenzie that they saved most of his brain; his whole left side had initially been at risk. The fast-acting medical staff and tPA injections limited his brain damage to less than three per cent of the whole left side.

Within a month Mackenzie was back at work and life as usual. Unfortunately, not every stroke patient can tell the same story. The Quality of Stroke Care in Canada found only eight per cent of all ischemic stroke patients received tPA. Based on current tPA rates at some of Canada’s top stroke centres, the study revealed that this number has the potential to be triple the current rate.

The study also found that is severely underused. Telestroke allows doctors and stroke patients from rural Canadian cities to speak with experts across Canada through telecommunication technology. The study found less than one per cent of patients reported having a Telestroke consultation.

In areas of recovery, only 22 per cent of hospitals surveyed were affiliated with a secondary stroke prevention clinic. Once released from hospital, only 37 per cent of moderate to severe stroke cases are discharged to a rehabilitation facility.

“The study’s findings and recommendations are a ‘call to action’ to the Canadian stroke care community,” says Dr. Moira Kapral, a national steering committee member and Associate Professor, Faculty of Medicine and Department of Health, Policy Management and Evaluation at the University of Toronto. “There needs to be a greater emphasis on improving the public’s awareness about the early signs and symptoms of stroke and the importance of calling 9-1-1 and having an ambulance bring them to hospital immediately.”

Some of these “calls to action” for health-care providers are to ensure every hospital that provides tPA has a dedicated stroke unit, to take advantage of existing Telestroke technology, to work with patients to develop personalized rehabilitation plans, and to ensure the emergency room is set-up to achieve door-to-needle times of less than an hour for those eligible for tPA.

The study calls on the public to know and reduce their risk of stroke. To accomplish this, the report recommended to be aware of your blood pressure and ensure that it is controlled, reduce sodium intake, and maintain an active lifestyle.

To lower the time from symptom onset to arrival at hospital, the public should recognize the signs and symptoms of stroke: sudden weakness, trouble speaking, vision problems and severe headache. If any combinations of these symptoms appear, call 9-1-1 immediately to have an ambulance bring you to hospital. Calling an ambulance is essential because it allows the hospital to prepare for a stroke patient.

“The Quality of Stroke Care in Canada could not be timelier,” says Dr. Robert Côté, Chair of the study’s National Steering Committee and a Professor at McGill University. “The results of this study should be used to prioritize investments in stroke care and improve and monitor the quality of stroke care for all Canadians. Stroke is one of the leading causes of death and the main cause of neurological disability in Canada. The study will be of great value to our health system.”

The study represents data on 38,210 stroke patients from 295 hospitals nationwide. Data was collected over the period of a year from April 2008 until March 2009 at hospitals that admitted 20 or more stroke patients per year. Information collected included: time of stroke symptom onset, timeliness of emergency medical system access, treatments received in the emergency department, acute inpatient care and information related to patient discharge from the acute care hospital.

“We are extremely pleased with the results of the study because it illustrates what can be achieved in stroke care in Canada,” says Dr. Antoine Hakim, CEO and Scientific Director of the . “If Canada invests now in innovative and sustainable stroke care systems and programs—we will achieve real benefits such as saving more lives and reducing the impact of stroke.”