title: The quality of treatment of hyperacute ischemic stroke in Canada: a retrospective chart audit.
abstract: BACKGROUND
  The use of thrombolysis in acute stroke is an important indicator of the quality of stroke care, because it requires health care providers to work collaboratively, rapidly and accurately to optimize patient outcomes. We sought to assess the quality of hyperacute stroke care in Canada using the rate of thrombolysis as the key indicator.
  
  
  METHODS
  We used national administrative data and a chart audit in a retrospective cohort design. We identified discharge diagnoses of stroke in the 10 Canadian provinces between 2008 and 2009. We drew a sample (over-weighted by population and hospital size) for a detailed chart review that was focused on identifying indicators of acute stroke care. We determined the proportions of thrombolysis use, complications and outcomes, adjusted for age and sex and stratified by type of hospital.
  
  
  RESULTS
  Our final audit sample included 9588 patient charts, representative of 88% of the 43 651 cases of stroke for which patients were admitted to hospital in Canada. A total of 5.4% (95% confidence interval [CI] 5.1-5.6) of patients with stroke and 6.1% (95% CI 5.8-6.4) of patients with ischemic stroke received thrombolysis. Comprehensive stroke centres used thrombolysis in about one-third of ischemic cases - double the rate seen in primary stroke centres. Often (35%-49% of the time), thrombolysis was not given owing to an interval of more than 4.5 hours between stroke onset and arrival at hospital.
  
  
  CONCLUSIONS
  The use of thrombolysis for acute stroke in Canada remains low and is limited by delays in both the arrival of patients to hospital and the in-hospital processes of neuroimaging and thrombolysis administration. Our data show the critical need for concerted national efforts to improve education regarding the treatment of acute stroke and speed up stroke management in the hospital setting.
authors.affiliation: The Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alta.
authors.forename: Aravind
authors.initials: A
authors.lastname: Ganesh
authors.affiliation: Centre Hospitalier affilié Universitaire de Québec, Hôpital de l'Enfant-Jésus, Québec City, Que.
authors.forename: Marie
authors.initials: M
authors.lastname: Camden
authors.affiliation: The Heart & Stroke Foundation of Canada, Ottawa, Ont.
authors.forename: Patrice
authors.initials: P
authors.lastname: Lindsay
authors.affiliation: Department of Medicine and the Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ont.
authors.forename: Moira K
authors.initials: MK
authors.lastname: Kapral
authors.affiliation: Department of Neurology, McGill University, Montréal, Que.
authors.forename: Robert
authors.initials: R
authors.lastname: Coté
authors.affiliation: Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ont.
authors.forename: Jiming
authors.initials: J
authors.lastname: Fang
authors.affiliation: Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ont.
authors.forename: Brandon
authors.initials: B
authors.lastname: Zagorski
authors.affiliation: The Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alta.
authors.forename: Michael Douglas
authors.initials: MD
authors.lastname: Hill