Experience in Other Provinces:Nova Scotia Stroke System

Neala Gill, RN, BN, MACardiovascular Health Nova Scotia

Quebec Summit on StrokeOctober 7, 2008

Presentation Overview

• Background Information

• Factors Influencing Direction & Decision Making

• Funding Formula & Enhancements

• Enablers

Nova Scotia

• Population just under 1 million

• Services provided through 9 District Health Authorities with populations varying from 33,000 to 398,000

• Highest in-hospital stroke mortality in Canada, as reported by CIHI

Cardiovascular HealthNova Scotia

• Program of NS Department of Health• Provincial mandate – stroke and cardiac disease• Like other provincial programs, created to

– Improve care throughout NS– Develop/recommend care standards and service delivery

models, including funding recommendations– Assist District Health Authorities in implementation of

standards and service delivery models– Provide/coordinate related continuing education– Monitor & report outcomes

• Provincial quality improvement program

History in Brief

• Re-Organizing Stroke Care In NS - 2002• Gap Analysis - 2003• Stroke Services Inventory Report - 2004• SWH Stroke Demonstration Project - 2005-2007• Funding commitment – 2006• Provincial Stroke Audit - 2007• Professional Education Partnership - 2008• NS Stroke Care Guidelines – 2008

Factors Influencing Direction

• Stroke strategy document recommendations

• Best practice guidelines

• Findings of audit of all admissions for stroke in 1 fiscal year – RCSN

• Evidence of changes that would provide the biggest potential impact (Cochrane reviews)

• Available funding (announcement preceded planning)

Nova Scotia Stroke Audit:What Did We Find?

• 66% of hospitals care for < 34 patients / year

• Significant differences in case-mix, treatment, and outcomes, both between and within Districts

• Some districts do not have critical mass

• Diagnosis and other medical details poorly documented

Nova Scotia Stroke Audit:What Did We Find?

• Care falls far short of Canadian Best Practice Recommendations

• Stroke-unit care non-existent

• Thrombolysis rates low

• Wide variation in:– use of brain imaging & other medical tests– use of medications to prevent stroke recurrence

– access to rehabilitation treatment

Potential Effectiveness of Stroke Treatments inNova Scotia

Intervention * Benefit per 1000 treated

¶ Target pop. § N (%) avoided/yr

Stroke unit 56 1,600 (80%) 90 (8%)

Aspirin 12 1,900 (95%) 22 (2%)

t-PA 63 200 (10%) 13 (1%)*avoidance of death or dependency from Cochrane reviews¶ assuming 2,000 strokes per year in Nova Scotia§ assuming 55% patients dead/dependent at 1 yr untreated

Current TeamInvolvementTeam Member/Assessment QEII Others in

NSDietitian 57% 34%

Dysphagia 40% 24%

Nurse Practitioner 92% 0%

Occupational Therapy 69% 33%

Physiotherapy 69% 50%

Speech Language Pathologist 29% 16%

Social Worker 42% 26%

Decisions

• Investing in enhanced interdisciplinary stroke teams and clustering patients would likely have the greatest benefit

• Government commitment of $3 million is sufficient for– staffing enhancements to improve the acute &

rehabilitation care processes– Leadership/transition coordination– Secondary prevention – Specialty Nurse Practitioner

Decisions

• Partnerships in initiatives being developed under additional funding envelopes would be necessary to improve care across the continuum– restorative care initiatives– chronic disease management

• Focus is on enhancing existing capacity and reorganizing existing services

• Location of services based on critical mass to maintain high quality care– Adverse outcomes more frequent in facilities with < 100 strokes/year– 115 strokes/year = 6 bed stroke unit– Shared services required across some Districts

Process

• Reviewed and used evidence to develop formula for equitable funding across districts– Estimated current capacity from stroke audit– Set targets for percentage of patients to be seen by each

team member• Held consultation meetings – each District Health

Authorities, other stakeholders• Requested proposals from all District Health

Authorities– Local planning - representatives from across continuum &

multiple sites– Based on the plan and funding formula

Estimated # Beds

DHA # Stroke Admissions/Year, NS Stroke Audit

(2005/06)

Estimated # Stroke Beds/DHA

1 80 4 2 121 6 3 152 8 4 95 5 5 46 2 6 76 4 7 52 3 8 245 13 9 520 30

Staffing Requirements

Discipline

FTE per 7 Bed Unit

FTE per 8 Bed Unit

FTE per 13 Bed Unit

Specialty Nurse Practitioner

0.7 0.8 1.3

Nursing 9.8 11.2 18.2 Occupational Therapy

0.7 0.8 1.3

Physiotherapy 0.7 0.8 1.3 Social Work 0.35 0.4 0.65 Dietitian 0.6 0.7 1.0 Speech-Language Pathology

0.7 0.8 1.3

7 Centres

Additional Work

• Dissemination & implementation of Nova Scotia Stroke Care Guidelines

• Explore primary prevention & other partnerships• Facilitate forums for sharing of successes,

approaches and tools across Districts• Provide continuing education based on guidelines• Develop framework for monitoring & surveillance• Explore potential for use of Telestroke

Enablers• Data to show districts how they are currently doing

compared to best practice• Nova Scotia Stroke Care Guidelines• Broad stakeholder engagement• Demonstration project in 1 District• Department of Health program with a mandate to

facilitate & monitor improvements in stroke care• Sharing of resources and tools throughout province• Opportunities to share experiences• Local coordination and transition planning

Thank you

www.gov.ns.ca/health/cvhns

cvhns@cdha.nshealth.ca