Health care specialists on the front line of stroke care include therapists, dietitians, social workers, nurses, pharmacists, physicians, speech language pathologists and client patient access services. Photograph by: Gord Waldner , The StarPhoenix
Two million neurons die each minute when someone has a stroke — and they don’t come back. While early medication and surgery can help limit the damage, it takes months, even years before many patients can relearn basic skills. For two decades, health care providers in Saskatoon have dreamt of having a specific unit dedicated to helping patients recover. Now, it’s finally becoming a reality. Here’s an introduction to the new team on the front line of stroke care.
It’s a few seconds past 9:30 a.m. as 14 health care staff start their meeting in a corner office on the sixth floor of Royal University Hospital.
Jodi Copeland, the acting clinical coordinator, frowns while discussing a 68-year-old woman whose lab work appears to be a mess.
“I think we’re going about this the wrong way,” she tells the team, and suggests fixing her sodium levels might help.
The team consists of physiotherapists, occupational therapists, clinical dietitians, social workers, nurses, pharmacists, physicians, speech language pathologists and client patient access services. They briefly check off the rest of the patients in Unit 4, then move to another room to see the patients in Unit 5.
The entire meeting has taken just four minutes — “bullet rounds” are called that for a reason.
These rounds used to happen only every Tuesday and Thursday, but are now held seven days a week. This lets the team catch missed tests, or recommendations from physiotherapists and nutritionists, days earlier than before.
The efficient, informative planning session seems unremarkable, but it’s part of a health care innovation 20 years in the making.
Changing the system
“Stroke is a bad disease,” Ruth Whelan stresses over and over again in an interview at the RUH neurology unit.
Whelan, the clinical nurse specialist for stroke services, went to the University of Saskatchewan for bachelor and master’s degrees in nursing. During her studies, she was placed in the neuroscience unit, and it was an immediate fit.
“It just clicked with me. I love it,” she said.
She taught for a while, before getting hired in the Department of Medicine to help with stroke research. On the side, she sketched out plans for what a dedicated stroke unit would look like. Then the health region hired her as a part time specialist. In her new gig she’s been able to delve into the research and learn more about best practices.
“I’ve been given time, which is all we really needed, was someone dedicated with time, who could start writing out a little bit more specific plans.”
Stroke patients have always come to this floor, but they weren’t concentrated in the same area, instead scattered among the 45 beds, said Dalene Newton, the health region’s director of adult medicine and complex care.
In the past, a therapist on the unit might count people with strokes, spinal cord injuries, multiple sclerosis or Parkinson’s disease as patients.
The best practice, however, is to keep stroke patients in one place and build a team around them, Newton said. This allows them to build up expertise and eventually decrease the length of patients’ hospital stays.
RUH is one of the last comprehensive hospitals in Canada to get a dedicated stroke unit, Newton said. Even five years ago, it was obvious the hospital needed to make the change, but it didn’t have the ability to gather and create a team.
One spark to making changes was the province’s acute stroke pathway, which aims to cut the waits — just minutes long — that can add up to critical delays in patients receiving emergency care. The unit became a priority during the 14- and 90-day challenges spearheaded by CEO Dan Florizone earlier this year. The SHR leadership and staff were ready for change, with years of grassroots preparation to draw on, Newton said.
The new 16-bed stroke unit opened June 1. The long term goal is for every stroke patient to stay there, but the unit doesn’t yet have an observation room. At the moment, it remains just down the hall.
How to treat a stroke
When a person has a stroke, one of two things are happening.
One kind of stroke involves a blood clot in an artery which blocks the flow of blood to an area of the brain, causing it to die.
Two treatments are then available. A clot-buster drug has been the standard of care for the past two decades, as long as it’s given within four and a half hours of the last time the patient felt well.
More recently, surgeons have been able send guide wires up through an artery in the groin to the brain and physically pull out the clot.
“It’s like a plumber with their snake going up, really,” Whelan said.
If the stroke involves a hemorrhage rather than a blockage, however, there’s not much doctors can do, other than to try to prevent further strokes by controlling blood pressure.
Whelan stresses, however, the most important factor in a patient’s outcome is rehabilitating and rewiring the brain to make up for the dead tissue.
“It’s so important for our patients to know that — ‘You know what, you don’t have a lot of great movement in that side,’ or ‘Yeah, you have some drooping,’ or ‘Yeah, your swallow isn’t working that great.’ But we have all these excellent therapists and excellent nurses, and that’s the key to getting better.”
The day after a stroke, therapists examine how the stroke has affected a patient, whether that means balance issues, dexterity or motor control. They can then teach ways to work around those deficits, such as using the tongue to feel for food if a person’s cheek has lost sensation.
Treatment means exercise, proper diet and medication, and talking through a patient’s anger.
“Stroke is interesting because not only is it physically debilitating, but it really is a huge time of grieving what you’ve lost,” Whelan said.
“Sometimes stroke has warning signs, those mini strokes. Lots of times patients come in and they were fine at home. They went to bed just fine and now today (their) life is totally different.”
Patients are not necessarily bound to spending their lives in a long term care home — Whelan encourages them to have hope for their recovery, even as she helps bathe and feed them.
It’s also just as important to her to offer compassionate, pain-free deaths, when the time comes.
It’s early days, but neurologist Dr. Gary Hunter says patients in the stroke unit are staying half as long in hospital as they used to.
“It’s been one of the most important developments in stroke care in the province in the last 10 years,” he said.
“We can see it’s made a huge difference for how we treat and manage these patients. We’re seeing they’re staying in hospital for a shorter period of time, they’re getting to the appropriate discharge destinations quicker, we’re seeing reduction in any sort of misses or near misses as far as how we’re delivering care.”
Meanwhile, Whelan says she has noticed an improvement in staff morale and communication. Nurses are also better informed and better able to keep patients and families up to date on their care plans; it’s exhausting for patients to keep repeating their stories to different care providers, she said.
On a patient’s third day in the unit, the team is already starting to plan future treatment, such as long term care or rehab, and figuring out how to prevent another stroke.
The team members have plans to further improve the unit. They want to be able to better transition patients to their next step, such as providing home care services every time they’re needed.
The health region aims to copy the stroke unit model for other conditions, such as spinal cord injuries, and make RUH the first hospital in Canada to implement a palliative care plan specifically for stroke patients.
“A stroke is a long journey,” Whelan said.