Improving Access and Efficiency of Acute Ischemic Stroke Treatment Across Four Canadian Provinces: A Stepped-Wedge Trial

Noreen Kamal^1,2*Elena Cora³Simone Alim⁴Judah Goldstein⁵David Volders³Shadi Aljendi⁶Heather Williams⁷Patrick Fok⁵Etienne van der Linde⁸Trish Helm-Neima⁷Renee Cashin⁹Brian Metcalfe¹⁰Julie Savoie¹¹Wendy Simpkin¹²Cassie Chisholm⁹Michael D Hill¹³Bijoy K Menon¹³stephen Phillips¹⁴

• ¹Dalhousie University, Halifax, Canada
• ²Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, Nova Scotia, Canada
• ³Department of Diagnostic Radiology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
• ⁴Department of Mathematics and Statistics, Faculty of Science, Dalhousie University, Truro, Nova Scotia, Canada
• ⁵Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
• ⁶Faculty of Computer Science, University of New Brunswick, Fredericton, Canada
• ⁷Health PEI, Charlottetown, Canada
• ⁸Dr. GB Cross Memorial Hospital, NL Health Services, Clarenville, Canada
• ⁹NL Health Services, St. John's, Canada
• ¹⁰Medflight NL, St. John's, Canada
• ¹¹Vitalité Health Network, Moncton, New Brunswick, Canada
• ¹²Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
• ¹³Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
• ¹⁴Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada

Background: The translation of standard-of-care in acute ischemic stroke reperfusion interventions into practice is well established, but multifactorial obstacles exist in complete adoption, which has led to inequities in access and delivery of services. The objective of this study was to improve access and efficiency of ischemic stroke treatment across four Atlantic Canadian Provinces. Methods: A stepped-wedge cluster trial was conducted over 30 months with 3 clusters covering 34 sites. The trial was conducted across all 4 Atlantic Canadian provinces: Nova Scotia (NS), New Brunswick (NB), Prince Edward Island (PE), and Newfoundland and Labrador (NL). The design was quasi-randomized, with each cluster associated with one or more provinces: cluster 1 – NS; cluster 2 – NB and PE; and cluster 3 – NL. The patient population was all ischemic stroke patients across all 4 provinces. The intervention was a 6-month modified Quality Improvement Collaborative (mQIC), which was modified from the Breakthrough Series Collaborative to be half of the 1-year period and conducted virtually. The intervention consisted of assembling an interdisciplinary improvement team, 2 full-day workshops, webinars, and virtual site visits. Suggested changes included 6 process improvement strategies. Results: Over the trial period, 8594 ischemic stroke patients were included, out of which 1599 patients received acute reperfusion treatment. The proportion of patients that received treatment did not increase significantly with the intervention [0.4% increase for patients that received thrombolysis and/or EVT (p=0.68)]. Median door-to-needle time was reduced by 9.8 minutes with the intervention (p=0.006). Cluster 3 saw the greatest improvements in both access and efficiency. Conclusions: A mQIC intervention resulted in improvement of process measures like door-to-needle time. Quality improvement initiatives may need to be longer to allow full implementation and tailored for each health system to ensure that each system sees improvement. In-person activities might be critical to ensure fidelity of the intervention.