Secondary stroke prevention can reduce subsequent vascular events, mortality and accumulation of disability. Current rates of adherence to secondary stroke prevention indicators are unknown. Our aim was to evaluate secondary stroke prevention care in Ontario, Canada.

A retrospective cohort study using health administrative databases included all adults discharged alive following an ischemic stroke from April 2010 to March 2019. Indicators of secondary stroke prevention, including laboratory testing, physician visits and receipt of routine influenza vaccinations, were evaluated among survivors in the one year following a stroke event. The use of medication was also assessed among individuals over the age of 65 years and within subgroups of stroke survivors with diabetes and atrial fibrillation.

After exclusions, 54,712 individuals (mean age 68.4 years, 45.7% female) survived at least one year following their stroke event. In the 90 days following discharge from the hospital, most individuals (92.8%) were seen by a general practitioner, while 26.2% visited an emergency department. Within the year following discharge, 66.2% and 61.4% were tested for low-density lipoprotein and glycated hemoglobin, respectively, and 39.6% received an influenza vaccine. Among those over the age of 65 years, 85.5% were prescribed a lipid-lowering agent, and 88.7% were prescribed at least one antihypertensive medication. In those with diabetes, 70.3% were prescribed an antihyperglycemic medication, while 84.9% with atrial fibrillation were prescribed an anticoagulant.

Secondary stroke prevention, especially for important laboratory values, remains suboptimal, despite thorough best practice guidelines. Future studies should explore barriers to better secondary stroke care.

NICE guidelines recommend that patients started on antidepressants aged 18–25 years are reviewed 1 week after initiating treatment to check response. All other patients should be reviewed within 2 weeks. The audit aimed to evaluate if these guidelines are being met in Primary Care now that most mental health appointments have changed from face to face to telephone consultations post COVID-19.

Notes of 60 patients that had been started on an SSRI across the period of January 2022 – December 2022 at a North West based Primary Care practice were analysed. Time from initial consultation to medication review with a general practitioner (GP) and/or contact with a Mental Health Practitioner (MHP) within the practice were recorded. Consultation notes from MHPs were analysed for reference to tolerability of medication to assess if the patient's new treatment was discussed as part of support appointments.

Median time for initial follow-up of patients aged 18–25 years was 3 weeks demonstrating 8% compliance with NICE guidelines. Median time for initial follow-up for those >25 was 4 weeks, demonstrating 19% compliance with NICE guidelines. Of those that did not receive a follow-up with a GP within the suggested time frame, 20% met with a MHP for support with their condition and had side effects of new medication referenced in the notes. Within 4 weeks, 58% of patients had an appointment with a MHP where medication was mentioned. Median follow-up for anxiety disorders was 4.5 weeks compared to disorders of depression at 4 weeks. Patients new to the SSRI were followed up at a median of 3 weeks compared to 4 weeks for those that had completed a course previously.

Current follow-up of patients at the practice is not compliant with NICE guidelines. A practice meeting will be held to identify improvements to the patient follow-up process and look at the barriers patients face when arranging follow-up appointments. More than half of audited patients met with a MHP for support within 4 weeks of SSRI initiation. This highlights an opportunity to assess patients that are already meeting with practice staff when GPs have been unable to review them within the time frame. A pro-forma will be developed for MHP to utilise to specifically ask about medication. A repeat audit of both GP and MHP appointments will be completed in 6 months.

By July 2021, we will increase the percentage of full recording of physical health data for 90% of patients

-Completion of recording (green results) was measured using Tableau Software for a 10 week period from Jan- March 2021 (baseline), then monthly during the study

• • PDSA cycles were conducted between April and July 2021 with analysis and changes tested monthly as per PDSA methodology. This informed future interventions.

• • We involved staff in designing a flowchart/protocol of how to book patients into the well-being clinic and sought opinions on how recordings could be improved.

• • In March, prior to any changes being implemented, staff were reminded to complete recording of physical health data. This improved percentage of recordings up to 62% by 1 st April.

• • Following this, a training session about the well-being clinic was arranged for all EIS staff.

• • A further session was arranged for staff to devise a flowchart of how the process will operate and generate further ideas.

• • A reminder system was put in place with the team leader emailing care co-ordinators monthly.

• • By 1 st July, percentage of complete recordings were 73%.

• • We decided to continue with the project and to increase the frequency of reminders to fortnightly. This helped to improve the percentage of complete recordings to 90% by September 2021.

• • We learnt that education and training amongst all staff was needed to improve the recording of physical health data.

• • Improved utilisation of the physical health well-being clinic helped to streamline physical health assessments and helped to reduce the workload of EIS staff (also promotes sustainability).

• • Involving staff in designing and implementing changes leads to better adherence in improving physical health recording.

• • More time was needed for the interventions to be implemented in our service (target reached later than original timeframe), but this should now be sustainable.

• • Reminder systems will need to continue to ensure that performance is maintained, with further training provided as required.

The North Carolina Legislature appropriated funds in 2016–2019 for the Healthy Food Small Retailer Program (HFSRP), providing small retailers located in food deserts with equipment to stock nutrient-dense foods and beverages. The study aimed to: (1) examine factors facilitating and constraining implementation of, and participation in, the HFSRP from the perspective of storeowners and (2) measure and evaluate the impact and effectiveness of investment in the HFSRP.

The current analysis uses both qualitative and quantitative assessments of storeowner perceptions and store outcomes, as well as two innovative measures of policy investment effectiveness. Qualitative semi-structured interviews and descriptive quantitative approaches, including monthly financial reports and activity forms, and end-of-programme evaluations were collected from participating HFSRP storeowners.

Eight corner stores in North Carolina that participated in the two cohorts (2016–2018; 2017–2019) of the HFSRP.

Owners of corner stores participating in the HFSRP.

All storeowners reported that the HFSRP benefitted their stores. In addition, the HFSRP had a positive impact on sales across each category of healthy food products. Storeowners reported that benefits would be enhanced with adjustments to programme administration and support. Specific suggestions included additional information regarding which healthy foods and beverages to stock; inventory management; handling of perishable produce; product display; modified reporting requirements and a more efficient process of delivering and maintaining equipment.

All storeowners reported several benefits of the HFSRP and would recommend that other storeowners participate. The barriers and challenges they reported inform potential approaches to ensuring success and sustainability of the HFSRP and similar initiatives underway in other jurisdictions.

It remains unclear whether ST-elevation myocardial infarction (STEMI) patients transported by ambulance over long distances are at risk for clinical adverse events. We sought to determine the frequency of clinical adverse events in a rural population of STEMI patients and to evaluate the impact of transport time on the occurrence of these events in the presence of basic life support paramedics.

We performed a health records review of 880 consecutive STEMI patients transported to a percutaneous coronary intervention centre. Patients had continuous electrocardiogram and vital sign monitoring during transport. A classification of clinically important and minor adverse events was established based on a literature search and expert consensus. A multivariate ordinal logistic regression model was used to study the association between transport time (0-14, 15-29, ≥30 minutes) and the occurrence of overall clinical adverse events.

Clinically important and minor events were experienced by 18.5% and 12.2% of STEMI patients, respectively. The most frequent clinically important events observed were severe hypotension (6.1%) and ventricular tachycardia/ventricular fibrillation (5.1%). Transport time was not associated with a higher risk of experiencing clinical adverse events (p=0.19), but advanced age was associated with adverse events (p=0.03). No deaths were recorded during prehospital transport.

In our study of rural STEMI patients, clinical adverse events were common (30.7%). However, transport time was not associated with the occurrence of adverse clinical events in these patients.

The Quebec Emergency Department Management Guide (QEDMG) is a unique document with 78 recommendations designed to improve the organization of emergency departments (EDs) in the province of Quebec. However, no study has examined how this guide is perceived or used by rural health care management.

We invited all directors of professional services (DPS), directors of nursing services (DNS), head nurses (HN), and emergency department directors (EDD) working in Quebec’s rural hospitals to complete an online survey (144 questions). Simple frequency analyses (percentage [%] and 95% confidence interval) were conducted to establish general familiarity and use of the QEDMG, as well as perceived usefulness and implementation of its recommendations.

Seventy-three percent (19/26) of Quebec’s rural EDs participated in the study. A total of 82% (62/76) of the targeted stakeholders participated. Sixty-one percent of respondents reported being “moderately or a lot” familiar with the QEDMG, whereas 77% reported “almost never or sometimes” refer to this guide. Physician management (DPS, EDD) were more likely than nursing management (DNS and especially HN) to report “not at all” or “little” familiarity on use of the guide. Finally, 98% of the QEDMG recommendations were considered useful.

Although the QEDMG is considered a useful guide for rural EDs, it is not optimally known or used in rural EDs, especially by physician management. Stakeholders should consider these findings before implementing the revised versions of the QEDMG.