Highlights
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Primary stroke centers (PSCs) have fewer resources than comprehensive stroke centers (CSCs), which leads to variable workflow.
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There is variation in the collection of data across Canada, which leads to incomplete and inaccurate data.
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There is a gap in stroke knowledge at PSCs, which leads to hesitancy in treating patients.
Introduction
Health systems across Canada have recognized the need for structured acute stroke systems of care to ensure timely access to stroke treatment. The development of acute stroke systems of care ensures that suspected stroke patients are directed by ambulance services to designated stroke centers that are capable of treatment with thrombolysis 1–Reference Menon, Buck and Singh3 and treatment with endovascular thrombectomy (EVT). Reference Goyal, Almekhlafi and Dippel4 Both treatments are highly time dependent, Reference Saver5–Reference Saver, Goyal and van der Lugt7 which makes timely access to hospitals with adequate capability and expertise to provide treatment especially critical. Establishment of primary stroke centers that are capable of thrombolysis treatment and comprehensive stroke centers that are capable of EVT Reference Menon, Buck and Singh3 (primary stroke centers [PSCs] and comprehensive stroke [CSCs], respectively) are key to designing stroke systems of care.
Despite the creation of designated stroke hospitals, disparity in acute ischemic stroke (AIS) treatment between rural and urban areas stands as a pervasive issue, Reference Leira, Hess, Torner and Adams8 reflecting broader challenges in healthcare accessibility and delivery. Urban centers typically benefit from more robust healthcare infrastructure, including specialized stroke centers, advanced imaging capabilities and readily available medical expertise and trainees. In contrast, rural regions often face limited resources, including fewer healthcare facilities, sparse access to specialized care, longer travel distances to reach medical facilities and the need to urgently transfer patients to receive higher level of treatment such as EVT. Reference Leira, Hess, Torner and Adams8,Reference Kamal, Jeerakathil and Stang9 This study aims to better understand the differences in the clinical workflow processes for acute stroke treatment across PSCs and CSCs. The objectives for the study are as follows: 1) to understand the similarities and differences in the stroke treatment process workflow, 2) to investigate how variations between PSCs and CSCs impact their incorporation of best practices and 3) to explore how data is collected and prioritized during acute stroke treatment and how it impacts clinical decision-making.
Methods
This study employed a qualitative approach utilizing semi-structured interviews to explore the thrombolysis treatment process for AIS in urban and rural hospital settings at designated stroke centers across Canada. The methodology was designed to gather rich insights from healthcare professionals directly involved in stroke care, encompassing their perspectives, experiences and perceptions regarding stroke treatment.
Ethical considerations
Prior to data collection, ethical approval was obtained from the Dalhousie University Research Ethics Board, ensuring adherence to ethical guidelines and principles throughout the research process. The study protocol, with the REB file number 2023-6753, was approved by the Board.
Data collection
Data was collected from September 15, 2023, to November 3, 2023. Participants were contacted via email and provided with a consent letter outlining the study’s objectives, procedures and confidentiality measures. Semi-structured interviews were scheduled, and then upon obtaining informed consent verbally, the interviews were conducted virtually using the Microsoft Teams. Interviews were conducted in private with only one of the authors (AF) and an individual participant present.
A standardized interview guide was developed, consisting of 18 questions to delve into a spectrum of topics ranging from workflow processes to treatment practices to pretreatment preparations. An overview of the interview topics is provided in Table 1.
Table 1. 18 Semi-structured interview topics
NIHSS = National Institute of Health Stroke Scale.
Each participant underwent the same structured interview process, fostering consistency and comparability across responses. Prior to the data collection, mock interviews were conducted to refine the interview guide and ensure the clarity and relevance of the questions.
Participant identities were coded to ensure their confidentiality, and permission was received to directly quote the participants’ responses during the interview sessions throughout this study. Additionally, participants were assured of their right to withdraw from the study at any point without repercussion. There was no compensation provided to any participants.
Recruitment strategy
The sampling strategy employed a combination of non-probability snowball sampling and purposive sampling techniques. Reference Koerber and McMichael10 An initial invitation was sent to participants based on their expertise and direct involvement in stroke care, ensuring a diverse representation of perspectives across different healthcare roles and settings. After completing the interviews, participants were asked if they would be willing to reach out to colleagues involved in the stroke treatment process who would be interested in being interviewed. There were no additional screenings for eligibility, as the pool of diverse participants and perspectives allowed for the most breadth of insight.
Qualitative analysis
The qualitative data collected through semi-structured interviews underwent a thematic analysis to explore and interpret the complexities of stroke care delivery in diverse healthcare settings across Canada. This methodological approach facilitated a nuanced understanding of healthcare professionals’ perspectives, experiences and challenges in administering treatment for AIS patients.
The steps involved in the thematic analysis were as follows:
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1. The interviews were transcribed using the Microsoft Teams live transcription feature to capture participants’ responses. The transcripts were manually reviewed and edited to ensure accuracy, allowing for thorough analysis.
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2. Each transcript was systematically analyzed line by line. AF applied descriptive labels or codes to segments of text representing key concepts or ideas. Coding was conducted inductively, allowing for the identification of emergent themes without predetermined categories.
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3. AF and AS compared and refined the codes, grouping them into overarching themes after coding several transcripts. These themes were iteratively developed and defined, ensuring they accurately represented the content of the data.
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4. The established thematic framework was applied to the remaining transcripts, with each segment of text coded according to the predefined themes. This systematic approach ensured consistency and reliability in the analysis process.
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5. The final stage involved interpreting the data within the context of the research objectives. AF and AS examined the relationships between themes, identified patterns and variations and compiled the results of key similarities and variations identified between the interviews.
Results
An initial invitation was sent to 27 clinicians, 9 of which agreed to participate in the interviews. From snowball sampling, 10 colleagues of the interviewees were contacted, and half of them agreed to an interview, which resulted in 5 additional clinicians being recruited. A total of 14 participants took part in the study, as the codes and themes identified had reached a saturation point and no new themes or subthemes were emerging. Reference Guest, Bunce and Johnson11
The sample population recruited comprised five doctors (three stroke neurologists in CSCs, one neurologist in a PSC and one emergency physician in a PSC), seven nurses (two nurses working in CSCs and five in PSCs) and two stroke coordinators (both representing PSCs) spread across seven hospitals (three CSCs and four PSCs) in five provinces in Canada. The interviews took between 60 and 90 min.
Through thematic analysis, five themes emerged, each encompassing a range of subthemes. These five themes were 1) resource variation and management, 2) standardization of tasks, 3) data collection, 4) tools integrated into workflow and 5) teamwork and experience. Additionally, a total of 13 subthemes were identified. A description of the themes with illustrations is provided in Figure 2.
An affinity diagram of stroke treatment processes is showcased in Figure 1, categorizing the findings into the five key themes and their subthemes. Resource management and variation encompasses resource availability and its impact on workflow, highlighting challenges in patient monitoring and information gathering due to resource constraints. Standardization of tasks explores consistency in pre-notification times and role responsibilities, revealing differences between settings in advance preparation time and task division disparities. Data collection delves into documentation modalities, data reporting practices and data completeness and accuracy issues. Integration of tools into workflow explores how existing tools are used by clinicians to aid them throughout the treatment process using physical materials and existing software. Finally, teamwork and experience address the importance of both interdisciplinary collaboration and training in stroke treatment and hospital culture toward providing thrombolytic treatment.
Figure 1. Affinity diagram of stroke treatment processes.
Figure 2. Theme descriptions.
Theme 1: Resource variation and management
Table 2 summarizes the main similarities and differences that emerged from the interviews with respect to stroke treatment related to resource variation and management. The primary subthemes are the size of the stroke team, the availability of staff and the availability of needed supplies. Frequently reoccurring codes concerning the available resources were the required balance between other emergency department (ED) patients with stroke patients, capability of having the same stroke care providers throughout the process and limited access to care beds with cardiac monitoring.
Table 2. “Resource variation and management” theme and subthemes
PSC = primary stroke center; CSC = comprehensive stroke center.
One key difference described by the participants in PSCs and CSCs was the members of the stroke team, as PSCs have fewer resources than the CSCs. While participants in both PSCs and CSCs consistently mentioned paramedics, radiologists, CT technologists and an emergency nurse as members of the stroke team, PSCs often only had an emergency physician (with a neurologist accessible via telestroke) and potentially a second emergency nurse as additional stroke team members. In CSCs, the additional stroke team members listed included a neurologist, neurology fellow, neurology resident, a specialized stroke nurse and the interventional radiology team.
A variation discussed with the participants from PSCs concerning the stroke team size was that in three of the PSCs interviewed, the emergency physician and nurse(s) may be unable to follow the patient to diagnostic imaging. Due to the fewer resources, the staff may be required to stay in the ED to care for other patients:
The physician does not necessarily go down with the patient to the CT scanner because we are a single coverage department. So, if we leave the [emergency] department for 15–20 min, sometimes it is an issue. (Participant 7, PSC 1)
Additional challenges were discussed concerning the inability to follow the patient throughout the treatment process, since the emergency physicians in PSCs have to manage multiple patients at one time and they may be required to redirect their attention between multiple patients during a stroke code:
If the patient leaves [the emergency department for imaging], mentally the physicians are going “that is done for the moment, I am being asked to do something else” then they must reorient back when they arrive back in the department. (Participant 5, PSC 2)
An additional variation discussed concerned the diagnostic imaging interpretation process. In CSCs, the neurologist follows the patient through the entire stroke process, so they attend imaging and interpret the results primarily independently. However, six of the participants in three of the PSCs discussed how, because the physician often remains in the ED, the radiologist must interpret the imaging and communicate their findings to the physician. This creates an additional potential for delays if there is no communication system in place, as discussed:
It used to be that our radiologist would review the CT and CTA, then dictate a report, then the doctor would look [the report] up on their computer, but the doctor would not get a notification of the report, so that was leading to significant delays. Now the radiologist looks at the CT and they immediately call the emergency doctor with a verbal report before they even look at the CTA. So that has helped to cut down our times. (Participant 4, PSC 2)
Finally, five of the PSC participants discussed there can be additional considerations of whether there is staff available to monitor the patient when they are going to receive a thrombolytic. When thrombolytics are administered, two nurses must be present to help administer the thrombolytics and monitor the patient. Four CSC participants stated that there is at least one (typically two) nurse following the patient throughout the process, but PSC participants discussed that they would often need to ensure they had nurses available to help treat the patient:
An important part [of treatment] is how we are going to manage them: do we have the resources? Often, our nurse that is taking care of them has three other patients besides them. It takes a lot of resources for one person. (Participant 14, PSC 1)
Theme 2: Standardization of tasks
Table 3 highlights the main similarities and variations between PSCs and CSCs in terms of standardization of tasks. The subthemes concern the timing of tasks and role responsibilities. Frequently reoccurring codes were the amount of pre-notification time before the patient arrived, the tasks clinicians would complete during the imaging process and how tasks were assigned between each role.
Table 3. “Standardization of tasks” theme and subthemes
PSC = primary stroke center; CSC = comprehensive stroke center.
Overall, the workflow of the stroke treatment process described was similar between PSCs and CSCs in terms of who is notified of the incoming stroke, methods clinicians used to complete their tasks and the treating physician’s considerations when treating a patient. The primary difference discussed between participants in three of the PSCs compared to participants in two of the CSCs is the consistency of pre-notification times that were seen as more consistent and earlier for PSCs than CSCs, likely due to CSCs being in urban areas with unpredictable factors affecting transport times:
Sometimes the ETA [estimated time of arrival] is off. Sometimes they say, “hey, we are 10 min out” and then they show up 3 s later. Or they are like, “I am 10 min out” and they show up 30 min later. (Participant 2, CSC 1)
The shorter pre-notification time discussed by three CSC participants impacts what tasks they can complete pre-arrival:
It [pre-notification] is usually 3 min of heads up. When you get the page, you just drop what you are doing, go down, and get ready. (Participant 12, CSC 2)
This contrasts with five participants from PSCs who discussed using pre-notification time to search the patient’s history to review their potential eligibility for treatment:
While they are on route, sometimes we get a patch 40 min out, so you have lots of time to look up history: if they had a recent stroke or recent bleed. You also can look up their drugs on the information system. (Participant 7, PSC 1)
The other subtheme within the standardization of tasks is role responsibilities, where the results showed variation between PSCs and CSCs. CSCs are often teaching hospitals, which provide residents and fellows to work alongside the attending neurologist. With a larger neurology team, four CSC participants discussed the ability to divide tasks within the team. In PSCs, six participants explained that most tasks in the treatment process are the emergency physician’s responsibility. Participant 9 in a CSC described an example of how their neurology team can divide tasks to retrieve required information in the process:
Maybe you are in the scanner and realize “Oh, I did not ask if they [the patient] are on any blood thinners,” I will tell the resident. “Can you quickly look in the system [to see] if they are on any medications that we should be aware of?” (Participant 9, CSC 3)
Theme 3: Data collection
Table 4 presents the main similarities and variations that emerged from the data collection theme. The subthemes were documentation modality, data completeness and consistency and data reporting. Frequently reoccurring codes included how high ED capacity affected the ability to capture data, how data was reported to provide feedback to the stroke teams and who were responsible for data collection.
Table 4. “Data collection” theme and subthemes
PSC = primary stroke center; CSC = comprehensive stroke center; NIHSS = National Institute of Health Stroke Scale.
Participants’ views on data collection in both CSCs and PSCs were that there were existing issues concerning how data was collected. Participants agreed that the key data they want to collect includes the last seen normal time, if onset of symptoms was witnessed, timestamps of in-hospital processes (time of arrival, imaging, thrombolytic treatment and EVT/transfer time) and National Institute of Health Stroke Scale (NIHSS) assessment times and scores. Participants discussed combining electronic data capture through electronic medical records as well as having paper forms they would document and review after treatment was completed. However, a similarity between participants in PSCs and CSCs was they discussed issues concerning data completeness and accuracy.
A noted challenge with data collection in CSCs was the reliability of documenting the treatment process. Four CSC participants discussed they often would have a nurse responsible for documentation during the stroke process, but it was not guaranteed and depended on whether a nurse was available. When asked about what the stroke team does if there is no nurse available to document the process, a participant responded as follows:
You do the best you can. Usually documentation suffers, because you are doing all the tasks you need to do, and then you document. But that happens when it is crazy busy. (Participant 1, CSC 3)
Additional challenges were discussed with documenting data accurately as the clinician is often unable to record concurrently with the treatment process. In CSCs, five participants discussed often having a nurse or resident dedicated to documenting, but if they must complete tasks during the process, they often delay documenting until they have downtime:
Our stroke nurses have a paper form that they will fill out often when we go to the Angio Suite. But the only time that gets done is at the end when there is downtime. (Participant 12, CSC 2)
Participants also discussed retrospective data collection, which is required for local registries and other quality assurance programs. In PSCs, five participants who conducted retrospective reviews discussed their method of data collection primarily through conducting manual chart reviews. There was a discussion of how the degree of data completeness was often clinician dependent:
Some physicians do write the (NIHSS) score on there (the patient chart), we have it on our stroke protocol sheets to write the score on, but I do not routinely see every physician writing it. (Participant 14, PSC 1)
I would say their notes are very well written, but to know which chart to go into is sometimes difficult, So, you have to look at a lot of things [documentation] before we can get a full picture. (Participant 8, PSC 2)
Finally, an issue discussed by four PSC participants was the lag time between stroke treatments and when the data was reported back to the stroke team. As the data from treatment is reported weeks or even months after treatment has happened, participants discussed that the lag time reduces the value of the data as a feedback mechanism:
We often do not get our data until six to nine months after it has been collected, which is not really useful when we are trying to tell the team “We need to work on this,” but they say, “that was nine months ago. We have changed since then.” (Participant 4, PSC 2)
Theme 4: Tools integrated into workflow
Table 5 shows the similarities and variations of tools integrated into clinical workflow. The main subthemes are software used and physical materials. The frequently reoccurring codes were how and when people would use software applications during workflow and the preparation of physical materials (such as order sets) before the patient arrived.
Table 5. “Tools integrated into workflow” theme and subthemes
PSC = primary stroke center; CSC = comprehensive stroke center.
Participants in both PSCs and CSCs had tools integrated into the workflow to aid their processes. The primary similarity discussed was that both types of centers had standard pre-prepared sets of physical materials including forms, medications and reference sheets. The physical materials discussed used during the treatment process varied in terms of being stored in either a dedicated stroke box, a dedicated trauma room or printed in advance of the patient’s arrival. However, the materials themselves were similarly described in that they contained order sets, treatment forms and the inclusion-exclusion criteria for treatment.
The biggest variation in terms of tools integrated into the workflow was four PSC clinicians interviewed discussed using software applications or physical forms for calculation and reference tools (such as the NIHSS assessment) more often than participants from CSCs (of which, one participant discussed regularly using software applications). Typically, the more experienced neurologists would not use software tools for reference because they had the required assessments memorized. The situations participants in CSCs would use software applications would be if they were using it to train residents or if they were treating a patient after regular hours:
I have the NIHSS in my head. Now, for residents, I ask them to use MD Calc, so they all use MD Calc. (Participant 9, CSC 3)
If I am tired and I cannot do the NIHSS, in my head, then I sometimes open and use the Neuro Toolkit app. (Participant 12, CSC 2)
Participants in PSCs discussed using the software more regularly in their practice for tools to aid in the workflow:
I do the NIHSS on MD Calc. And even when I know the score is going to be in a range that they are going to be eligible for thrombolytics, I do it so I can document on the chart what the score was. (Participant 7, PSC 1)
Theme 5: Teamwork and experience
Table 6 highlights the similarities and variations of teamwork and experience in stroke treatment. The subthemes include interdisciplinary collaboration, importance of training and hospital culture. Frequently occurring codes in this theme were the specific use of terminology between roles, the importance of a culture of improvement and methods to reduce repeating information.
Table 6. “Teamwork and experience” theme and subthemes
PSC = primary stroke center; CSC = comprehensive stroke center.
Participants frequently discussed the importance of closed-loop communication among the team. They discuss that even though different roles require different information, they develop standards so everyone can get information at the same time:
I won’t let the paramedics start the story until I have the nurse present, because otherwise they will have to repeat it. (Participant 12, CSC 2)
The importance of training and educating clinicians was emphasized by eight participants in both PSCs and CSCs. The main variation was PSC participants discussed more difficulties in keeping their teams trained in the stroke protocol:
One of our challenges is to make sure that people are aware of the protocols and have the training that they need and feel comfortable doing that [thrombolysis] delivery. (Participant 5, PSC 2)
An additional variation between PSCs and CSCs is clinicians’ confidence toward administering thrombolytic treatment. Five PSC clinician participants discussed having a more cautious approach when administering thrombolysis, while three clinician participants in CSCs felt more confident to treat with thrombolytics after gathering the essential information:
We are pretty cautious about it, and I think we always get concerned, like “should we give this to such a minor thing?” we are all worried about giving thrombolytics and causing bleeds. (Participant 7, PSC 1)
If the patient looks well enough, onset time was under four-and-a-half-hours ago, they were from home, they are not on blood thinners, and the scan looks like a stroke, I treat the patient. (Participant 9, CSC 2)
An additional aspect of the cautious approach toward administering thrombolytics applied to receiving consent to treat the patient. Four participants (three from PSCs, one from a CSC) discussed there can be longer discussions to receive consent to treat a stroke:
Some of our staff are still struggling with the consent piece. That is still sometimes, explained more than perhaps necessary. (Participant 5, PSC 2)
An overview of the process differences identified between PSCs and CSCs is showcased in Table 7.
Table 7. Process differences between PSCs and CSCs
PSC = primary stroke center; CSC = comprehensive stroke center.
Discussion
This qualitative study reveals clear differences between stroke treatment processes in Canadian PSCs and CSCs, highlighting disparities in different stroke centers across Canada. This study found that there are various causes that can lead to gaps in the care and treatment being provided to stroke patients who arrive first at a PSC compared to a CSC. Our study found that PSCs often have limited resources compared to CSCs, which have neurologists (often specializing in stroke), medical trainees and stroke nurses, whereas PSCs have emergency physicians and ED nurses, who have to manage all patients in the ED. Previous studies have shown stroke team management is strongly associated with improvement in stroke processes, Reference Kamal, Jeerakathil and Stang9,Reference Fonarow, Smith and Saver12 but PSCs often have smaller, less specialized stroke teams. Reference Bulmer, Volders and Kamal13,Reference Prabhakaran, Khorzad, Brown, Nannicelli, Khare and Holl14
The results of this study highlight the unique impacts on the flow of stroke treatment processes with fewer available staff. The literature has noted that in smaller centers, the emergency physician does not always accompany the patient to imaging Reference Bulmer, Volders and Kamal13–Reference Kennedy and Stout15 but have not discussed how it impacts the workflow compared to CSCs, primarily with regard to gathering information from Emergency Medical Services (EMS) throughout treatment, mentally balancing the needs of multiple patients at once and the additional coordination required between radiologists, CT technicians and emergency physicians.
To accommodate the resources and lack of specialized staff in PSCs, telestroke is regularly used across Canada to assist PSCs with the acute management of stroke patients in the ED. Reference Zerna, Jeerakathil and Hill16 While this provides access to stroke expertise, it adds additional work to their existing workflow that includes the management and care of other patients in the ED, and the emergency physician at PSCs also has to manage discussions with family and other tasks that are often done by a team of clinicians and trainees at the CSC. Reference Hill, Roshon, Bladen, Haley, McClelland and Suter17 However, well-implemented telestroke programs have been shown to reduce treatment times in rural areas significantly, and it is regarded as a critical component in improving stroke treatment in rural and remote areas. Reference Nguyen-Huynh, Klingman and Avins18,Reference French, Boddepalli and Govindarajan19 Studies have also shown the importance of standard metrics in contacting telestroke, as delayed telestroke alert times were associated with longer treatment times. Reference Jagolino-Cole, Bozorgui and Ankrom20
Our study also revealed that there is a significant variation in data collection between all the centers interviewed. There is no standardization around data collection prospectively, which makes retrospective quality reviews rife with incomplete and inaccurate data. This study revealed a significant opportunity with the acute stroke process to standardize data collection and look at ways to integrate a standard data collection tool into clinical practice. Research in health informatics reveals the need for standardized and accurate data collection to ensure successful quality improvement programs. Reference Shpak, Korwek and Nadasdy21,Reference Rose, Thombley and Noshad22 Furthermore, studies have associated the use of stroke registries with improved patient outcomes, highlighting the importance of consistent data collection practices and prompt data feedback. Reference Fonarow, Smith and Saver12,Reference Hills and Johnston23,Reference Hoque, Kumari, Hoque, Ruseckaite, Romero and Evans24
Critically, there is a gap in the prerequisite knowledge about stroke treatment at PSCs in comparison to CSCs. PSC clinicians interviewed in this study often use software tools to help them. Additionally, PSC participants found staff were less experienced in the stroke protocol and challenges persisted from lack of awareness. Hesitancy to treat with thrombolytics persists at several PSCs interviewed, which suggests that patients who present to PSCs may have poorer access to treatment, given the staff’s level of training and confidence. The importance of training and education has been reported extensively in other studies with respect to improved treatment times and higher thrombolytic rates. Reference Bulmer, Volders and Kamal13,Reference Hennebry, Stoneman and Jones25–Reference Xian, Xu and Lytle27 This hesitancy also applies when getting consent from the patient to administer thrombolytics, as thrombolytic treatment is considered an urgent situation in which emergency consent procedures may be taken. Reference Boulanger, Lindsay and Gubitz28,Reference Skolarus, O’Brien, Meurer and Zikmund Fisher29 This signifies the importance of well-established protocols to ensure PSC clinicians can be confident when treating stroke.
Limitations and future directions
Some limitations need to be considered regarding the results of this study. First, while there was representation from five provinces and seven hospitals, recruiting additional participants in rural centers was challenging since snowball sampling more often led to recruiting participants in larger centers. Second, additional clinician roles, such as paramedics and radiologists, were not represented in the interviews. Finally, the representation of PSCs could be further subdivided based on their capabilities and resources; for example, some PSCs might have a neurology team or a stroke unit, and this will affect the capability of the PSC. Although the four PSCs represented in this study had different capabilities, we could not further divide the centers into more than PSC and CSC due to the sample size.
Future directions of this study should include a deeper analysis of the differences between PSCs and CSCs and compare stroke treatment variations in different countries. Even though studies analyzing stroke treatment processes have been conducted in different countries, further investigation should be done comparing the practices of centers in different countries. Reference Olson, Constable and Britz26,Reference Mazya, Silsby, Hospital, Padma Vasantha and Yea Hwong30 Exploring the different PSC settings based on location sizes and capabilities, such as having in-house neurology and a dedicated stroke unit, compared to PSCs that must rely on telestroke will further recognize potential variations in stroke treatment. Additionally, prospective data collection should be focused on for future studies since our study identified variations in data collection processes, reliability and accuracy. Finally, a wider spanning analysis of similarities and variations should include additional healthcare experts such as paramedics and radiologists since it can help understand the totality of the potential variations in stroke treatment across the system.
Conclusion
This study aimed to highlight the similarities and differences in acute stroke treatment across PSCs and CSCs in Canada. Key disparities included the lack of a dedicated stroke team to follow the patient through the treatment process, limited availability of staff and level of experience and training in stroke treatment. This study investigated the causes of gaps in treatment processes in PSCs and CSCs and how these gaps can be addressed through development and training in stroke protocols and leveraging existing technologies such as telestroke. Regardless of PSCs or CSCs, there was a challenge in complete and accurate data collection throughout the treatment process in centers interviewed, and data is often reported weeks or months after treatment has happened, creating an ineffective feedback mechanism for clinicians. A follow-up study will be conducted to identify the design requirements of a prototype software application that can aid in data collection during the clinical workflow of the acute stroke treatment process to better understand clinicians’ needs to effectively collect accurate data required during stroke treatment.
Author contributions
AF designed the study, conducted the study and wrote the manuscript. AF, RE and NK provided input into the study design and editorial input into the manuscript. NK holds the funds to conduct the study.
Funding statement
This research was funded through the NSERC (Natural Sciences and Engineering Research Council of Canada) Alliance grant ALLRP 580440–22.
Competing interests
The authors disclose no conflict of interest.
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