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Acute Stroke Pathway

The Acute Stroke Pathway focuses on key interventions in the first few hours after onset of stroke symptoms. Timely and appropriate assessment and treatment during this period can significantly assist patient recovery. Pathway protocols are informed by the Canadian Best Practice Recommendations for hyperacute stroke care.

System-wide implementation of pathway protocols is now complete.

Rationale for Changes to Protocols
Before pathway implementation, patients were transported emergently to a regional or tertiary hospital within 3.5 hours of the onset of stroke symptoms. This was to allow for administration of tissue-plasminogen activator (tPA) within 4.5 hours. Patients outside this window were not treated emergently. Often they were admitted to local hospitals without proper assessment or diagnosis. Suboptimal outcomes were costly for patients and the health system.

In the Acute Stroke Pathway, as per Canadian Stroke Best Practice Recommendations (2015), patients up to 6 hours from onset of stroke symptoms will be emergently transported to a stroke centre for advanced imaging (CTA). Patients who wake up with stroke symptoms may be similarly managed. Regional stroke teams have an option to accept patients up to 12 hours from symptom onset at their discretion.

Under this protocol, most patients benefit from early comprehensive assessment and diagnosis, which sets the stage for better recovery and secondary prevention. Some patients will be eligible for hyperacute treatment.

Hyperacute Treatment
Administration of tPA is still associated with best outcomes within 4.5 hours. However, the availability of endovascular therapy provides another proven treatment option for patients with large vessel occlusions. Patients can be eligible for endovascular therapy up to 10 hours from the onset of symptoms.

Endovascular treatment involves mechanically removing the clot from the blocked artery. Saskatchewan neurosurgeons have participated in groundbreaking research on this procedure, which has been shown to markedly reduce death and disability from stroke. In 2015, 45 patients from across the province received endovascular treatment at Royal University Hospital. With implementation of pathway protocols, increased numbers of eligible patients can be identified and treated.

Hospitals with Stroke Services
Whether stroke alert is called by EMS personnel or in a local health centre, patients should be transported directly to a CT-enabled hospital where there is access to advanced imaging and assessment.

Location Hospital
Swift Current Cypress Regional Hospital
Moose Jaw Dr. F.H. Wigmore Regional Hospital
Estevan St. Joseph's Hospital
Yorkton Yorkton Regional Health Centre
Prince Albert Victoria Hospital
North Battleford Battlefords Union Hospital
Lloydminster Lloydminster Hospital
Regina Regina General Hospital designated tertiary centre
Saskatoon Royal University Hospital designated tertiary centre

Information for Family Doctors: Managing TIA in primary care
Patients who present to a family doctor or NP reporting transient stroke symptoms may have experienced a transient ischemic attack (TIA). Patients with TIA may avoid disabling stroke if they receive urgent assessment and treatment.

Some patients are at great risk of subsequent stroke and should be managed with an urgent referral (within 24 hours) for advanced assessment. Others can be assessed over a longer period of time. Pathway tools assist primary care providers to assess patient risk and direct patients for appropriate follow-up. Refer to Canadian Stroke Best Practice Guidelines to guide your navigation of these patients.

Decision Tree: Edmonton Zone TIA/Non-Disabling Stroke Risk

Resources
For comprehensive resources on stroke best practices for health care providers, visit www.strokebestpractices.ca

Stroke Order Sets
Saskatchewan Acute Stroke Pathway Order Sets are based on order sets developed by the Canadian Stroke Network (1999-2014). Through this collaborative, comprehensive evidence-based Stroke Best Practice Guidelines were developed, including order sets for acute stroke management in the emergency department, administration of thrombolysis agents, and admission to a stroke unit. Original order sets, with references, are available at www.strokebestpractice.ca and on patientordersets.com (for subscribers).

Saskatchewan Acute Stroke Pathway order sets have been slightly adapted to reflect local preferences.

Regional Health Authorities that participate in the Acute Stroke Pathway may find it necessary to make minor adaptations to the Acute Stroke Pathway Order Sets, as outlined in the guideline for implementation of order sets. Other than the exceptions noted, orders are as per current evidence and national standards and should be fully implemented.

Acute Stroke Pathway Update – March 2016

Information for Patients

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