Indicators of Quality Care and Services for Adults With Acute Ischemic Stroke in Different Types of Hospitals in Quebec (IndiQ-AVC) : Research Protocol
Conditions: Ischemic Stroke
Sponsor: Amelie Belanger

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Indicators of quality care and services for adults with acute ischemic stroke in different types of hospitals in 
Quebec (IndiQ-AVC):  research protocol 
 
Amélie Bélanger 1-2 RN MSc., Line Beaudet 3-4, RN PhD, Julie Houle 1-2 RN PhD 
Affiliations : 
1. Université du Québec à Trois-Rivières, Sciences infirmières, Trois-Rivières, QC, CAN 
2. Centre intégré universitaire de santé et services sociaux de la Mauricie et du Centre-du-Québec (CIUSSS MCQ), 
Trois-Rivières, QC, CAN 
3. Université de Montréal, Sciences infirmières, Montréal, QC, CAN 
4. Centre hospitalier de l’Université de Montréal, Centre de recherche, Montréal, QC, CAN 
 
 
Corresponding author: Amélie Bélanger, RN, MSc. PhD (c) 
Assistant professor 
Department of Nursing, Université du Québec à Trois-Rivières 
3351, boul. des Forges, Trois-Rivières (Québec) G9A 5H7  
Email: Amelie.belanger1@uqtr.ca 
 
 

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Table of contents 
1. 
Introduction ........................................................................................................................................... 6 
2. 
Objectives, questions and research hypotheses ................................................................................. 11 
3. 
Methodology ....................................................................................................................................... 11 
3.1 
Type of study ........................................................................................................................................... 11 
3.2 
Target population .................................................................................................................................... 12 
3.3 
Sample ..................................................................................................................................................... 12 
3.3.1 
Sampling methods ........................................................................................................................... 12 
3.3.2 
Sample size ...................................................................................................................................... 13 
3.4 
Tools and data collection ......................................................................................................................... 13 
3.4.1 
Data collection on patients’ characteristics .................................................................................... 13 
3.4.2 
Data collection on clinical and organizational quality indicators .................................................... 14 
3.4.3 
Data collection on hospitals’ characteristics ................................................................................... 14 
3.5 
Projected statistical analyses................................................................................................................... 15 
4. 
Consent process .................................................................................................................................. 16 
5. 
Project progress ................................................................................................................................... 16 
6. 
Ethical and regulatory considerations ................................................................................................. 16 
6.1 
Tri-Council Policy Statement (TCPS2) ...................................................................................................... 16 
6.2 
Ethics review ............................................................................................................................................ 16 
6.3 
Confidentiality ......................................................................................................................................... 17 
6.4 
User data retention and archiving ........................................................................................................... 17 
6.5 
Benefits .................................................................................................................................................... 17 
6.6 
Risks for patients ..................................................................................................................................... 17 
7. 
Source of funding ................................................................................................................................ 18 
8. 
Impacts of this research project .......................................................................................................... 18 
8.1 
Strengths.................................................................................................................................................. 19 
8.2 
Limitations ............................................................................................................................................... 19 
8.3 
Dissemination of results .......................................................................................................................... 20 
9. 
References ........................................................................................................................................... 20 
APPENDIX 1 .................................................................................................................................................. 25 
List of clinical and organizational indicators for optimal management of acute ischemic stroke management in 
adults ........................................................................................................................................................... 25 

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APPENDIX 2 .................................................................................................................................................. 33 
Detailed list of data to collect on patients’ characteristics and clinical and organizational quality indicators
 
33 
APPENDIX 3 .................................................................................................................................................. 44 
Collection sheet on hospital characteristics ................................................................................................ 44 
 
 
 

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Summary of research project 
Title of study 
Care and service quality indicators for adults with acute ischemic stroke in 
differently designated Quebec hospitals (IndiQ-AVC) 
Target hospitals  
1) Primary care hospital for stroke management 
2) Secondary care hospital for stroke management 
3) Tertiary care hospital for stroke management 
Objectives and research 
questions 
Objective 1: Describe performance of care and services based on   
measurement of clinical and organizational quality indicators of acute 
stroke care in differently designated Quebec hospitals (primary, secondary 
and tertiary). 
Research question 1: What is performance of care and services based on 
measurement of clinical and organizational quality indicators of acute 
stroke care in differently designated Quebec hospitals (primary, secondary 
and tertiary)? 
Objective 2: Identify the sociodemographic and clinical characteristics of 
patients that may influence results regarding measurement of clinical and 
organizational quality indicators of acute stroke care.  
Research question 2: What are the sociodemographic and clinical 
characteristics of patients that may influence results regarding 
measurement of clinical and organizational quality indicators of acute 
stroke care? 
Target population  
Adults with ischemic stroke 
All persons hospitalized for ischemic stroke within the 6 months preceding 
approval of the Research Ethics Board (REB). The study will be conducted 
based on their health records. 
Inclusion criteria 
Adults 18 years old or over with ischemic stroke requiring hospitalization in 
an acute care unit or special stroke unit 
Exclusion criteria 
Adults with hemorrhagic stroke 
Type of study 
Retrospective descriptive-correlational study 
Period covered by  
study 
6-month period preceding approval of the REB 
Sample size  
 
 
Given that about 660 patients are hospitalized for ischemic stroke each 
year in the three hospitals under study and the data will be collected over 
a period of 6 months, sample size is estimated to be about 130 health 
records.   
Because the minimal effect size is not known, an effect size of 50 % is used. 
A power calculation in G*Power on analyses of group averages indicates 

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this sample size is largely sufficient to have a power of 95 %, an alpha set 
at 0.05 and a minimal effect size of 0.5. The number of patient records 
retained will provide a sample representative of the hospitalized 
population in the three hospitals.   
Finally, a records evaluation test (n=6) will be performed in advance to 
estimate the time needed to examine each record and allow needed 
adjustments to be made to conduct research within the context of a 
doctoral study.  
Data collection 
Results measurement: 
• 
Retrospective data collection performed on patients’ health records 
included in the study (patients’ sociodemographic and clinical data, 
results of evaluation of clinical and organizational quality indicators)  
• 
Description of hospitals through data collected on their characteristics 
based on an analysis of the environment and context of the different 
centers. This data collection will be performed using a structured 
interview guide (targeted questions) to identify hospitals’ 
characteristics according to the clinical documentation and 
consultations with various clinicians, managers and doctors available in 
the centers under study.  
Data analysis 
Statistical analyses will be conducted using SPSS software to meet the 
study’s objectives. 
Objective 1: Retrospective descriptive analysis based on patients’ health 
records  
Objective 2: Univariate and multivariate analyses; type of analysis based on 
type of variable (linear and logistical) and according to distribution 
(parametric and nonparametric tests)  
Anticipated impacts 
• 
Broaden the state of knowledge regarding acute ischemic stroke by 
drawing a picture of stroke patient management in three differently 
designated Quebec hospitals;  
• 
Identify the sociodemographic and clinical determinants that may 
influence the results of certain indicators; 
• 
In the long term, this project may contribute to reduce the gap 
between current practices and guidelines regarding post-acute stroke 
management;    
• 
Optimize acute stroke care and services across Quebec through 
improved understanding of different hospital contexts.  
 
 

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1. Introduction 
In Canada, ischemic stroke is the fourth leading cause of death (Statistics Canada, 2020) and one of the main 
causes of severe disability in adults (Krueger et al., 2015). The literature clearly shows that rapid management, 
access to revascularization treatments and an offer of structured, well-coordinated care are necessary, even 
essential, for the physical, cognitive and psychological recovery of persons experiencing a stroke (Boulanger et al., 
2018). In Quebec, ischemic stroke is the most common cause of hospitalization (Institut national de santé publique 
du Québec [INSPQ], 2018). An increase of about 17,000 hospitalized patients was identified, notably, in the decade 
between 2003-2004 and 2013-2014, representing an increase of about 46 % accompanied by a parallel rise in the 
needs for care and services for these patients (INSPQ, 2018). 
To ensure equity and quality of care and services at the national level, Canadian and international guidelines are 
regularly published, disseminated and updated consistent with evolution of the state of knowledge regarding, 
notably, ischemic stroke. These guidelines are deployed on a continuum of stroke-related care and services 
involving six phases: 1) public awareness raising, 2) primary prevention, 3) hyperacute management, 4) acute 
management, 5) rehabilitation, and 6) return and maintenance in the community. This continuum guides the offer 
of care and services and contributes to optimal follow-up in persons with stroke or at risk of stroke and their 
caregivers concerning immediate recognition of signs of stroke, rapid restoration of blood flow to the brain with 
hyperacute revascularization treatments, and organization of care and services based on predefined care 
trajectories (Ministère de la Santé et des Services Sociaux [MSSS], 2017a). In ischemic stroke, the first aim of 
treatment is to restore blood flow to the brain as rapidly as possible in order to limit deficits and thus facilitate 
early rehabilitation supported by caregivers. For a number of years now, the administration of intravenous 
thrombolysis (IVT) to dissolve blood clots obstructing blood vessels has been the first treatment of choice for 
persons with ischemic stroke who meet eligibility criteria (Adams et al., 2007; Boulanger et al., 2018; Lindsay et 
al., 2005). In addition to type of stroke, the main eligibility criterion involves access to the treatment within 4.5 
hours from onset of symptoms, which unfortunately restricts its administration (Boulanger et al., 2018; Wardlaw 
et al., 2014). Studies conducted in Canada report certain issues regarding IVT. Notably, in Québec, in 2016, the 
Institut national d’excellence en santé et services sociaux (INESSS) revealed that 23 % of all candidates in the 
province considered eligible for thrombolysis IV had received the treatment (INESSS, 2016). With the advance in 
treatments since 2015, thrombectomy, which involves removing clots blocking an artery with specialized devices, 
has become an additional recognized, privileged practice for treating ischemic stroke caused by obstruction of the 
large vessels (Goyal et al., 2016; Menon et al., 2016; Vidale et Agostoni, 2017). In Quebec, this type of treatment 
is available in tertiary hospital centers, i.e., specialized centers offering neurointervention. However, according to 

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the data collected by the INESSS in 2013-2014, of the 3,134 persons admitted for stroke in 70 hospitals in Quebec, 
only 14.2 % presented in a tertiary center for symptoms of stroke (INESSS, 2014). This indicates that the majority 
of those with ischemic stroke must be transferred to access this advanced treatment. In 2017-2018, in Quebec, 
the rate of thrombectomy was 4.5 %, while the anticipated rate of potentially eligible patients rose to about 10 % 
(INESSS, 2019). Accordingly, different care trajectories are envisaged to promote accessibility to optimal 
treatments based on geographic location, eligibility criteria and available resources.  
To date, the international literature has highlighted hyperacute stroke management regarding accessibility of and 
equity of access to revascularization treatments, an issue even in Canada (Eswaradass et al., 2017). Although the 
hyperacute phase is important and therefore extensively documented, guidelines maintain that the acute phase 
including early rehabilitation is also paramount in the post-stroke care trajectory to foster the ongoing 
improvement of cognitive, language and functional capabilities (Boulanger et al., 2018; Teasell et al., 2019).  
The acute phase involves hospitalization in an acute care unit of a patient with ischemic stroke whose 
revascularization treatment may have been administered based on their clinical condition. It generally occurs 
within the seven days following the stroke, and its duration may vary consistent with the patient’s state of health 
and needs for care and services. Favorably involving admission to a special stroke unit depending on the 
designation of the patient’s hospital and its available resources, this phase also includes early rehabilitation and 
the implementation of an interdisciplinary intervention plan carried out by a team composed of different clinicians 
in collaboration with the patient and caregivers. Finally, this phase also involves referral based on the patient’s 
needs including inpatient or outpatient rehabilitation and secondary prevention to limit the risk of a recurrent 
attack (MSSS, 2017a). In Québec, in the last decade, only two studies of the acute phase evaluated patient 
management to discern if clinical practice regarding certain interventions complied with Canadian guidelines. In 
fact, a provincial field assessment conducted in 2013-2014 revealed that only 14 % of patients had been admitted 
to a stroke care unit and that screening for dysphagia using a standardized tool was registered in only 16 % of 
patient records (INESSS, 2016). Furthermore, in 2015-2016, a regional study conducted in a hospital in Centre-du 
-Québec revealed that screening for dysphagia using a standardized tool was performed in 65% of the cases 
analyzed and that screening for risk of falls was recorded for 29 % of these same cases (Bélanger and Cloutier, 
2021). Moreover, in addition to the introduction of thrombectomy in 2015 in Quebec, which called for the 
reorganization of certain care and services, modifications surrounding the governance of the health system 
subsequent to Bill 90 (which modified existing organizational structures for patient care) produced substantial 
changes in terms of accessibility and offer of care and services (MSSS, 2014). Since then, no study has evaluated 
acute stroke clinical practice in the province.  Furthermore, reports describe the clinical and organizational effects 

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of the Covid-19 pandemic since 2020, which potentially influence the decisions of managers, role of the clinical 
staff and involvement of families and caregivers during a stroke (Montaner et al., 2020; Rudilosso et al., 2020; 
Smith et al., 2020).  
To optimize practice and support managers and clinicians in hospitals, experts have formulated recommendations 
aimed at enhancing the offer of care and services. These recommendations are regularly updated as the science 
evolves and enable a personalized action plan to implement within each organization depending on its mission. 
In terms of acute stroke, they stress the development of interdisciplinary approaches to improve management of 
stroke patients by outlining individualized interventions and including caregivers in care and decision-making. 
These interventions involve the evaluation of physical, mental and cognitive state of health, patient management, 
support for caregivers, and follow-up on the improvement or deterioration of cognitive, language and motor 
functioning in order to promote recovery, prevent the potential complications of a recurrent attack or offer 
palliative care if necessary (Boulanger et al., 2018; MSSS, 2017b; Powers et al., 2018; Teasell et al., 2019). To this 
effect, the authors of guidelines, scientific studies and the gray literature also propose numerous quality indicators 
to measure the results of an action plan and make needed adjustments at the clinical and organizational levels 
(Boulanger et al., 2018; MSSS, 2017b; Powers et al., 2018; Teasell et al., 2019). A quality indicator is defined as a 
reliable and valid measurement of a state of health, a practice or an organization of care (MSSS, 2012). Moreover, 
the current state of knowledge highlights certain discrepancies between the guidelines for achieving quality 
indicator targets associated with the time dependency of certain clinical medical interventions and practices 
related to the hyperacute management of patients with ischemic stroke in Quebec (INSPQ, 2019). Some such 
discrepancies are explained by, among other things, geographic and contextual issues based on types of patient 
management centers.   
In Quebec, temporary designations have been issued for primary, secondary and tertiary care hospitals meeting 
the criteria established by the MSSS (MSSS, 2013). A primary care hospital can diagnose a stroke and offer 
revascularization treatments such as thrombolysis IV or telethrombolysis IV. A secondary care hospital can offer 
thrombolysis IV at any time and houses a stroke care unit with a rehabilitation team composed of different 
clinicians. In keeping with the criteria established by the ministry, these types of center should also provide follow-
up with a secondary prevention clinic. Finally, a tertiary care hospital offers specialized neurovascular treatments 
including thrombectomy or neurosurgery (INESSS, 2016, 2019).  
Researches, however, have highlighted disparities regarding types of hospitals managing stroke patients.  One 
study in particular revealed that hospitals’ profiles had a significant impact on patients’ clinical results, mainly 

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because the availability of stroke units and number of patients admitted increased the exposure of clinicians and 
the medical team to stroke cases (Park et al., 2019). It also showed that hospitals with a higher level of care 
processes demonstrated improved performance of stroke healthcare based on measurement of quality indicators 
and therefore generated more favorable clinical results in patients, for example, a lower mortality rate (Yu-Chi et 
al., 2016). Moreover, a 10-year longitudinal study in the United States pointed to a persistent significant difference 
between rural and urban environments, the reason being rural patients’ less privileged access to hyperacute 
revascularization treatments and a higher 90-day mortality rate (Wilcock et al., 2020). This difference was also 
observed in Canada through a higher 30-day post-stroke mortality rate in hospitals in rural areas compared with 
those in urban centers. However, the province of Quebec was not included in this study in which 89 % of the 
hospitals lacked tomography services and 79 % had no intensive care unit (Fleet et al., 2018). In Quebec, super-
specialized (tertiary care) hospital centers are located in large cities, and hospitals in remote areas are less likely 
to have a stroke unit (INESSS, 2019). However the current state of knowledge does not allow for an overall picture 
of the issues surrounding acute stroke care in Quebec.  
Other studies have focused on the clinical profiles of stroke patients as possible factors contributing to differences 
in measurement of quality indicators irrespective of the center where these patients are hospitalized. Notably, 
the severity of the stroke evaluated by the National Institute Health Stroke Scale (NIHSS), the state of 
consciousness, aphasia at admission and duration and type of symptoms at admission were associated with 
different time intervals for getting a CT scan or receiving hyperacute thrombolysis (Ungerer et al., 2020). However 
the current literature does not associate patients’ clinical profile with the achievement of targets of certain acute 
stroke quality indicators. What’s more, it points to sociodemographic characteristics such as age, sex and ethnicity 
as possible influences on the achievement of quality indicator targets and optimal patient management. 
Moreover, it appears that women receive fewer hyperacute revascularization treatments than men (Colello et al., 
2018; Falsetti et al., 2017; Mainz et al., 2020; Strong et al., 2020) and that they generally take longer to present at 
the stroke unit compared with men, mainly because they wait longer to consult (Falsetti et al., 2017; Mainz et al., 
2020). Reasons appear to be more advanced age and the higher proportion of women living alone when the stroke 
occurs (Mainz et al., 2020). Regarding the hyperacute phase, several other studies discuss the impact of age during 
revascularization treatments including the decisional process involved in administering a thrombectomy to 
patients above 80 years old and the post-treatment clinical results of these patients (Al-Mufti et al., 2021). Now, 
to our knowledge, no study has evaluated the impact of age on the achievement of targets regarding acute stroke 
quality indicators in Quebec. The national data of the Institut national de santé publique (INSPQ) show that the 
prevalence of ischemic stroke increases sharply with age in groups 50 years old and over (INSPQ, 2018). In addition 

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to sex and age, cultural differences are seen to influence the achievement of certain targets during measurement 
of quality indicators for stroke including mortality within a year and the administration of antithrombotics and 
statins for secondary prevention at discharge Gardener et al., 2021). 
These observations enable an understanding of the importance of evaluating practices using quality indicators to 
reduce the gap between acute stroke guidelines and practice. Prior to the present study, we conducted a scoping 
review of the Arskey and O’Malley methodological framework (2005) to identify the clinical and organizational 
indicators attributable to the acute phase. A total of 26 articles were included in the review and over 300 indicators 
were identified based on the grey literature, guidelines and scientific studies. A summary of these indicators 
followed. A stroke care advisory committee including a patient partner validated the indicators identified in the 
literature. This approach allowed us to identify 29 priority indicators to measure in clinical practice during the 
acute phase of the stroke continuum in terms of relevance, validity and feasibility. These clinical (n=19) and 
organizational (n=10) quality indicators were classified based on dimensions of care performance, namely, 
accessibility of services (accessibility and equity of access), optimization of resources (efficiency and viability) and 
quality of care (safety, effectiveness, continuity and reactivity) (Bélanger et al., 2024). Nevertheless, despite this 
broad inventory of acute stroke indicators, the way they have been validated, tested and integrated at the 
organizational level and in clinical practice remains unclear (Jolley et al., 2017). 
Prior knowledge indicates that quality indicators have been generally measured using patients’ health records to 
obtain a picture of the state of practices. Retrospective data collection is a method frequently employed in 
research and epidemiology to describe the achievement of quality indicator targets to evaluate the management 
of a large number of patients with a shared pathology or clinical condition (Simpson et al., 2017). When guidelines 
are issued in line with a particular care trajectory such as the stroke continuum of care, it’s important for health 
records to show that all patients receive care and services in compliance with guidelines irrespective of their 
sociodemographic data, clinical profile or geographic location. Now, in Quebec, no study on the measurement of 
clinical and organizational indicators takes into account the context of the different patient care centers. Nor does 
the state of knowledge identify the sociodemographic and clinical determinants of patients that may influence 
the results of measurement of acute stroke quality indicators. 
The aim of the present study is to get to discover the current state of acute stroke practice by evaluating the 
performance of stroke care and services based on measurement of clinical and organizational quality indicators. 
The achievement of these indicators during hospitalization for acute stroke in differently designated Quebec 
hospitals will be evaluated using patients’ health records. This research project is consistent with the guidelines 

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of the Ministère de la Santé et des Services Sociaux (MSSS), which aims to improve the performance of the health 
system in terms of accessibility of services, quality of care and optimization of resources (MSSS, 2017b). 
2. Objectives, questions and research hypotheses   
The aim of this research project is to describe performance of care and services of acute stroke care in differently 
designated Quebec hospitals  
1. Identify the sociodemographic and clinical characteristics of patients that may influence the results 
regarding measurement of clinical and organizational quality indicators of acute stroke care.  
More specifically, this research project aims to answer the following questions: 
1. What is performance of care and services based on measurement of clinical and organizational quality 
indicators of acute stroke care in differently designated Quebec hospitals (primary, secondary and 
tertiary)? 
2. What are the sociodemographic and clinical characteristics of patients that may influence results 
regarding measurement of clinical and organizational quality indicators of acute stroke care? 
Research hypotheses 
1. Results highlight gaps between guidelines and practice following measurement of clinical and 
organizational quality indicators during acute management of patients with ischemic stroke.  
2. Gaps between guidelines and practice resulting from measurement of the clinical and organizational 
quality indicators of acute stroke care may present similarities or differences between types of hospital 
centers.  
3. Some of patients’ clinical and sociodemographic characteristics influence the achievement of the clinical 
and organizational quality indicators of acute stroke care. 
4. Patients’ sociodemographic and clinical characteristics identified as influencing the achievement of clinical 
and organizational quality indicators may vary depending on types of centers.  
3. Methodology 
3.1 Type of study 
To meet the objectives of the research questions, a retrospective descriptive-correlational study will be conducted 
based on methods of collecting and analyzing quantitative data. The decision to conduct a retrospective study 
was made for two reasons: first, the nature of the data collected from records allows us to describe the current 
state of clinical and organizational practices during the length of patients’ stay; and second, this type of study 

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allows for the inclusion of a sample of patients hospitalized during a fixed six-month period. Finally, the feasibility 
of a retrospective study was considered within the context of a doctoral project with limited resources, time and 
budget.  
In keeping with these considerations, the present study involves a multicentric investigation to take place in three 
differently designated Quebec hospitals in terms of stroke care. The choice of a multicentric study is based on 
using a larger sample of patients from different areas to obtain a broad overall view of clinical and organizational 
practice in stroke management in Quebec. In this study, the primary care center is a multi-vocational center 
including hospital care that is located in a remote area. The second participating center is a secondary care 
university hospital that plays an important role in the optimization of stroke care and services throughout its 
territory given its status as a regional center. The third hospital targeted by the study is a specialized tertiary care 
center which is nationally recognized for stroke treatment and performs the most thrombectomies in Quebec.  
Having different and welldefined missions, these centers maintain an interdependent relation through the offer 
of proposed care and services. Notably, the patients from the primary care center requiring a thrombectomy are 
generally transferred to the tertiary center participating in this study to receive treatment. Additionally, although 
the tertiary care hospital is a thrombectomy center, the patients transferred there must also be returned to the 
secondary care referral center quickly after treatment to begin rehabilitation as early as possible. Since the 
majority of guidelines apply in all types of centers irrespective of where the patient is managed, each center must 
self-compare regarding the achievement of quality indicators.  
3.2 Target population  
The target population consists of adults 18 years old and over with ischemic stroke who are hospitalized in an 
acute care unit or a specialized stroke care unit. The only exclusion criterion is a hemorrhagic stroke. 
3.3 Sample 
3.3.1 
Sampling methods  
A random sample composed of the health records of patients hospitalized during a fixed period who meet 
inclusion and exclusion criteria will be included in the study. The list of randomly selected records of patients 
admitted to hospital for ischemic stroke in each of the participating centers during the six months prior to the 
date of approval by the Research Ethics Board (REB) will be transmitted by the archives service to the principal 
investigator. Data collection based on health records relative to clinical and organizational quality indicators will 
be performed by the principal investigator and a research assistant if needed. Additionally, the principal 

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investigator will collect data on the characteristics of each hospital center by consulting the health professionals 
and managers available at the time of observation and data collection.  
3.3.2 
Sample size 
Calculation of number of records aims for a certain representativity of the target population at the time of data 
collection. Given that about 660 patients are hospitalized each year with ischemic stroke in the three centers 
under study - 400 in the tertiary center, 250 in the secondary center and 12 in the primary center - and the data 
were collected over a period of 6 months, the sample size is estimated to be some 130 health records, i.e., about 
75, 45 and 8 to 10 records respectively. A power calculation in G*Power on analyses of group averages indicates 
this sample size is largely sufficient to have a power of 95 %, an alpha set at 0.05 and a minimal size effect of 0.5. 
When the size effect is not known, a minimal size effect of 50 % is acceptable (Julien, 2019). However, a first phase 
test will be performed with the health records of patients (n =6) hospitalized prior to the date set for the start of 
data collection to evaluate the average time required to analyze a record. This phase test will be performed on 
three health records from the secondary center and three from the tertiary center. Finally, this phase will enable 
needed adjustments to be made regarding implementation of research within the context of a doctoral study. 
Additionally, the principal investigator will have access to resources to validate the statistical analysis plan for the 
study duration.  
3.4 Tools and data collection 
Data collection will begin once ethical approval is given (REB) and will be conducted using the health records of 
patients hospitalized during the 6 months preceding this approval. Archivists in each center in the study will 
provide randomly selected lists of the health records of patients meeting inclusion criteria. Data collected on each 
of the variables under study will be stored in a password-secured file. The complete list of clinical and 
organizational quality indicators in the scoping review is presented in Appendix 1. The data collection sheet on 
patients’ characteristics and clinical and organizational quality indicators is given in Appendix 2.   
3.4.1 
Data collection on patients’ characteristics  
Patients’ characteristics refer to certain sociodemographic data such as age, sex and ethnic or cultural origin as 
well as a patient’s clinical profile including stroke diagnosis, type of treatment (thrombolysis IV, thrombectomy), 
list of medications, presence of a previous stroke, stroke risk factors, comorbidities, severity of stroke (National 
Institutes of Health Stroke Scale [NIHSS]) and pre-stroke functional independence (modified Rankin score [mRs]) 

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(Gonzalez-Suarez et al., 2018; Langhorne et al., 2018; Mohammed et al., 2020; Muñoz Venturelli et al., 2019; 
Nathan et al., 2018; Nishimura et ral., 2019).  
3.4.2 
Data collection on clinical and organizational quality indicators 
Quality indicators will be measured using the health records of acute stroke patients. Those measured will be 
classified based on dimensions of performance of care (accessiblity of services [accessibility and equity of access], 
optimization of resources [efficiency and viability] and quality of care [safety, effectiveness, continuity and 
reactivity]).  
3.4.3 
Data collection on hospitals’ characteristics  
Data on hospitals’ characteristics will be collected using an environmental analysis method (environmental scan) 
together with a data collection guide to identify the characteristics of hospitals based on the current clinical 
documentation and consultations with various clinicians, managers and doctors available. Environmental analysis 
is used to gather information on events and their relation to the internal and external environment of an 
organization. The method’s main objective is to gather, evaluate and disseminate data for strategic purposes 
(Clagett, 1987). The data collection guide will be developed using hospital characteristics identified in certain 
studies retained in the 2024 scoping review (Bélanger et al., 2024) and will be rooted in the conceptual framework 
Consolidated Framework for Implementation Research (CFIR) to obtain a broad view of the characteristics defining 
the organizational, contextual and clinical composition of a hospital. The CFIR is a metatheory that allows us to 
deepen the implementation of innovative interventions within organizations. Its concepts underscore five spheres 
of influence including, in the present study, 1) characteristics of interventions (e.g., complexity, accessibility), 2) 
strength and quality of conclusive results), 3) external context (e.g., available resources, guidelines), 4) internal 
context (e.g., type and number of staff available, structural characteristics) and 5) process (e.g., engagement, 
planning, execution, reflection). The CFIR takes into account the different actors working with a target clientele 
and focuses attention on both clinical and organizational contexts and the many complex issues in the field of 
health (Damschroder et al., 2009). Data will be collected on characteristics including type of center (primary, 
secondary or tertiary); description of mission and respective role of each center in line with type of designation; 
geographic distribution;  number of persons served by the center; average number of stroke patients admitted 
each year; number of beds in the stroke care unit; type and number of medical staff available (nurses, nursing 
assistants, patient care assistants, occupational therapists, physiotherapists, speech therapists, nutritionists, 
kinesiologists, etc.); presence of multidisciplinary teams (conduct and frequency of meetings); ratio of patients to 
nurses, nursing assistants, clinicians and patient care assistants; average number of years of experience of nurses 

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and different clinicians; proportion of nurse technicians and nurse clinicians; number of neurointerventionists, 
neurovascular specialists, neurologists, internists and general practitioners; protocols and procedures in effect; 
frequency,  type and content of stroke training offered to different medical workers; internal and external 
resources (material resources, patients’ needs, organizational networking, policies, plans or programs in effect, 
etc.); and methods of communication for transmitting important information to the teams (Gonzalez-Suarez et 
al., 2018; Langhorne et al., 2018; Muñoz Venturelli et al., 2019; Nishimura et al., 2019). An environmental analysis 
will be conducted based on observations in the healthcare setting and on consultations with health professionals, 
different clinicians, doctors and managers available in the different centers. An analysis of protocols, procedures 
and other documents in effect will also be performed to obtain a detailed picture of each center. First, we will 
start by collecting needed information from managers and nurse-managers in each establishment by setting up a 
meeting in advance based on their availability. Second, in the event of missing information, we will arrange with 
managers to target persons who can supply the missing data. All meetings with clinicians and managers will be 
scheduled to ensure the availability of the persons concerned. This data collection will serve to paint a portrait of 
the healthcare centers under study.  
3.5 Projected statistical analyses  
In response to the first research question, descriptive analyses will be conducted based on measurement of the 
clinical and organizational quality indicators identified in the acute phase. Medians and interquartile ranges, 
means and standard deviations and proportions will be used to describe performance of care and services for 
each center under study and comprehensively for all three centers. Additionally, a contextual description of each 
center will be presented using data collected on the hospitals’ characteristics.  
Results of the first objective will highlight indicators that do or do not meet the guidelines for quality of care for 
persons with ischemic stroke and their caregivers. For indicators presenting extensive data, regression analyses 
will be performed to identify the determinants likely to influence results regarding these indicators.  
Dependent variables are clinical or organizational quality indicators, while independent variables correspond to 
the sociodemographic characteristics and clinical profile of patients with ischemic stroke. Type of regression 
analysis will vary consistent with the nature of the dependent variables (dichotomous or continuous) and their 
distribution (parametric or nonparametric tests).  
A univariate regression analysis will first allow us to associate determinants (independent variables) with results 
for the indicators (dependent variables). Variables with a statistically significant association will then be 
introduced into a linear or logistic regression model. Additionally, these regression analyses will include 

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confounding variables that may also influence results from the measurement of clinical and organizational quality 
indicators. To be statistically significant, results must obtain a value of p < 0.05 and have a confidence interval of 
95 %. All statistical analyses will be conducted using SPSS 28.0 software. Results will be presented 
comprehensively for the three centers; they may also be presented individually for the secondary and tertiary 
centers to see if the associations in them are similar or different. If the number of records in one of these hospitals 
is not enough for statistical power, the analysis will not be performed.   
4. Consent process  
This study will be carried out retrospectively by analyzing the health records of patients meeting the admissions 
criteria. This type of study is more in line with a practice assessment process where the patient’s consent is not 
considered necessary according to the 2018 Tri-Council Policy Statement (TRPS2). However, authorization by the 
Direction des services professionnels et de la pertinence clinique (DSPPC) following ethical approval of the 
research is needed to access patients’ health records.   
5. Project progress 
After the ethics certificate and a letter authorizing access to health records have been obtained from the Direction 
des services professionnels et de la pertinence clinique (DSPPC), the random list of 130 health records of patients 
admitted within the preceding 6 months can be transmitted to the principal investigator to initiate data collection. 
Random lists of health records meeting the criteria will be drawn up by an archivist in each of the centers. The 
data will be collected in all three hospital centers at once based on availability of records.  
6. Ethical and regulatory considerations  
6.1 Tri-Council Policy Statement (TCPS2) 
As defined, this protocol is intended to confirm that the principal investigator respects the principles of the Tri-
Council Policy Statement ensuring the security and confidentiality of the data collected in patients’ health records.   
6.2 Ethics review 
This research protocol and the documents in the appendices will be evaluated and approved by the Research 
Ethics Board. A convenience evaluation must be obtained and conducted for each center included in the 
multicentric study. The ethics certificate must be issued before the project is started. Additionally, this protocol 
must be evaluated and approved by the ethics committee of the UQTR, the university hosting the principal 
investigator, whose project will be implemented within the context of her doctoral studies.  

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6.3 Confidentiality 
Every effort will be made to ensure the anonymity of patient health records included in the research. None of the 
records will be photocopied, and data will be collected in an area designated for this purpose in each of the three 
centers. Records will be assigned a digital identification code in a password-secured file stored separately from 
the collected data. It will be possible to trace the identity of patients, but only the principal investigator and her 
research assistant can access the records. At no time will the names of patients in the records be divulged. The 
data extraction grid needed to perform statistical analyses will contain no identifiable information allowing 
patients to be traced. Data collection sheets will be stored in a locked filing cabinet in Local G2 110D located in 
the Centre hospitalier affilié universitaire régional (CHAUR) de Trois-Rivières. The data will be entered into a 
database in a password-protected Excel file on the password-protected research computer belonging to the 
principal investigator. No document identifying the participants will leave the investigational site.  
6.4 User data retention and archiving 
All documents associated with this project will be kept by the principal investigator. Electronic data will be 
deposited in a UQTR institutional data repository server, Borealis (Dataverse), which is available to institutions 
and research organizations in Canada only. Borealis ensures the long-term retention of data, access to the data, 
and the attribution of unique and permanent digital object identifiers (DOI). Two types of data will be deposited 
in this server: raw data (untreated data drawn directly from patients’ records) and treated data (raw data 
manipulated in preparation for transfer to SPSS for statistical analyses). Data are anonymous and contain no direct 
identifiers. Additionally, the hospital centers under study will be identified as primary, secondary or tertiary in the 
data dictionary accompanying the databases. To facilitate interoperability, data will be saved in an open-access 
Excel file (CSV). Data can be accessed by contacting the principal investigator. To ensure continuity of access, a 
second person may be charged with managing data deposit and granting access to data upon request.  
6.5 Benefits  
Anticipated benefits include contribution to the advancement of knowledge aimed at improving the acute care 
management of adults with ischemic stroke and their caregivers.  
6.6 Risks for patients 
There are no concerns regarding risks to patients. Every effort will be made to protect patients’ privacy and the 
confidentiality of the results obtained. The file containing records’ identifying numbers will be kept separate from 
the data collection file, thus ensuring that patients cannot be identified.   

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7. Source of funding 
Previous or pending grants 
A grant from the Fonds de soutien à la recherche de la Fondation régionale de Trois-Rivières (RSTR) in the amount 
of $12,000 was obtained in May 2021. This sum covered a portion of the expenses incurred during the scoping 
review prior to conducting this study and will allow us to engage a research assistant to help with data collection.  
The following internship grants and scholarships were also obtained. 
1) Scholarship  from Tremplin-Fonds de recherche du Québec-Santé (FRQS) to perform an internship at the 
Institut national d’excellence en santé et services sociaux (INESSS). Obtained in 2021/05. 
2)  Scholarship from MES-Universités-Bourses d’études doctorales-Concours 2020-2021. Obtained in 
2020/09 and 2021/09. 
3) Scholarship from university partners of the Réseau de recherche en interventions en sciences infirmières 
du Québec (RRISIQ). Obtained in 2020/10 and 2021/10. 
8. Impacts of this research project 
First, this research project will help broaden the state of knowledge regarding acute ischemic stroke by describing 
how these patients are managed in three differently-designated Quebec hospitals. Additionally, the results will 
allow for a clinical and organizational look at performance of care and services by highlighting concepts with the 
highest-performing results regarding measurement of indicators or, conversely, the lowest-performing. Indeed, 
this study is the first that measures quality indicators for acute stroke based on dimensions of performance of 
care in order to shed light on clinical and organizational practices relating to accessibility of services (accessibility 
and equity of access), optimization of resources (efficiency and viability) and quality of care (safety, effectiveness, 
continuity and reactivity). Furthermore, the results of measuring clinical and organizational quality indicators will 
highlight indicators calling for improvement and those for which variations have been observed.  
Second, the project will also identify the sociodemographic and clinical determinants potentially able to influence 
the results of certain indicators. This new knowledge will greatly help strengthen our understanding of the possible 
impact of certain determinants on patient management and would favor the development of an interdisciplinary 
intervention model better adapted to the needs of patients and caregivers in terms of improved physical, 
psychological and cognitive post-stroke recovery.   

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In the long term, this project may help reduce the gap between current practices and guidelines regarding post-
stroke patient management. Finally, because it is conducted in different types of Quebec hospital centers, this 
project will enable a better understanding of various contexts that is conductive to the optimization of acute 
stroke care and services across Quebec. Based on the project’s results, strategies of improvement through 
innovative interdisciplinary interventions could be developed that favor optimal management adapted to stroke 
patients’ needs.  
8.1 Strengths 
This first study on the measurement of acute stroke quality indicators in Quebec allows for an evaluation of 
performance of care and services based on various clinical and organizational aspects. Indeed, the study’s main 
strength is the measurement of diverse dimensions of performance of care that enables a picture of 
interdisciplinary practice for the entire acute phase of ischemic stroke. The implementation of the study in three 
different Quebec hospitals will also provide a better understanding of their distinct geographic and structural 
contexts. Inclusion of health records from three different centers also allows for better representativity of the 
population with stroke. As well, the rigorous method employed during implementation can be used by other 
organizations to obtain results specific to their own establishment. Finally, this retrospective study including a 
data collection close in time will enable an accurate picture of clinical and organizational management within the 
context of current healthcare.  
8.2 Limitations  
The study’s main limitation involves the level of data collection in the health records of different hospitals whose 
different and separate databases complicate the research. Additionally, retrospective research has certain 
limitations including the possibility of missing data during measurement of indicators or data that vary depending 
on the quality of notes in the records, factors the researcher cannot control for. What’s more, input errors may 
occur during data collection. To limit this type of error during data collection in health records, an automated 
coding system will be inserted in the file with a drop-down menu to enter textual data. A validation system will 
be integrated to issue an error message if aberrant data are recorded. As well, a data validation will be regularly 
performed to ensure the quality of the data collected by the research assistant. Although the number of indicators 
to measure ensures good representativity of acute patient management, priority indicators must be chosen to 
make data collection feasible within the context of a doctoral study. Additionally, certain hospital characteristics 
must be collected through observation and consultations with various available on-site stakeholders given the 
lack of written documentation on the subject in the different centers. Finally, the association between 

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determinants and results will not explain the cause of the different results, but will further identify the elements 
likely to influence the results obtained.  
8.3 Dissemination of results  
Results will be presented in a scientific article, as a poster presentation, during an oral communication at 
conferences and within different local and regional organizations with stakeholders delivering care and services 
to stroke patients and their caregivers. The confidentiality of patients whose records have been analyzed will be 
protected during dissemination of results. 
 
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Demaerschalk, B. M., Hoh, B., Jauch, E. C., Kidwell, C. S., Leslie-Mazwi, T. M., Ovbiagele, B., Scott, P. A., 
Sheth, K. N., Southerland, A. M., Summers, D. V. and Tirschwell, D. L. (2018). 2018 Guidelines for the Early 
Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the 
American 
Heart 
Association/American 
Stroke 
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Stroke, 
49(3), 
e46-e110. 
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Rudilosso, S., Laredo, C., Vera, V., Vargas, M., Renú, A., Llull, L., Obach, V., Amaro, S., Urra, X., Torres, F., Jiménez-
Fàbrega, F. X. and Chamorro, Á. (2020). Acute Stroke Care Is at Risk in the Era of COVID-19: Experience at 
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Comprehensive 
Stroke 
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in 
Barcelona 
 
Stroke 
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51(7), 
1991-1995. 
https://doi.org/10.1161/STROKEAHA.120.030329 
Simpson, A., Beaucage, C. and Viger, Y. B. (2017). Épidémiologie appliquée. Une initiation à la lecture critique en 
sciences de la santé (3ème e éd.). Chenelière Éducation. 
Smith, E. E., Mountain, A., Hill, M. D., Wein, T. H., Blacquiere, D., Casaubon, L. K., Linkewich, E., Foley, N., Gubitz, 
G., Simard, A. and Lindsay, M. P. (2020). Canadian Stroke Best Practice Guidance During the COVID-19 
Pandemic  The Canadian Journal Of Neurological Sciences. Le Journal Canadien Des Sciences 
Neurologiques, 47(4), 474-478. https://doi.org/10.1017/cjn.2020.74 
Statistics Canada. (2020). Table 102–0561 – Leading causes of death, total population, by age group and sex, 
Canada. CANSIM (death database) https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310039401 
Strong, B., Lisabeth, L. D. and Reeves, M. (2020). Sex differences in IV thrombolysis treatment for acute ischemic 
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meta-analysis 
Neurology, 
95(1), 
e11-e22. 
https://doi.org/10.1212/WNL.0000000000009733 
Teasell, R., Salbach, N. M., Acerra, N., Bastasi, D., Carter, S. L., Fung, J., Halabi, M.-L., Harris, J., Kim, E., Noland, A., 
Pooyania, S., Rochette, A., Stack, B. D., Symcox, E., Timpson, D., Varghese, S. and Verrilli, S. (2019). 
Recommandations canadiennes pour les pratiques optimales de soins de l'AVC. Réadaptation, 
rétablissement et participation communautaire après un AVC. Première partie : La réadaptation et le 
rétablissement après un AVC. Mise à jour de 2019. 1-128, article. https://www.heartandstroke.ca/-
/media/1-stroke-best-practices/rehabilitation-nov2019/french/2019-csbpr6-rehabrecovery-module-fr-
final-dec2019.ashx?rev=-1  
Ungerer, M., Begli, N. H., Heyse, M., Purrucker, J., Regula, J., Berberich, A., Ciolli, L., Nagel, S., Ringleb, P. and 
Gumbinger, C. (2020). Patient profiles contribute to differences in quality metrics of stroke centers 
Neurosciences (Riyadh, Saudi Arabia), 25(4), 292-300. https://doi.org/10.17712/nsj.2020.4.20190100 
Vidale, S. et Agostoni, E. (2017). Endovascular Treatment of Ischemic Stroke: An Updated Meta-Analysis of Efficacy 
and 
Safety 
 
Vascular 
& 
Endovascular 
Surgery, 
51(4), 
215-219. 
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Wardlaw, J. M., Murray, V., Berge, E. and del Zoppo, G. J. (2014). Thrombolysis for acute ischaemic stroke  
Cochrane Database of Systematic Reviews, (7). https://doi.org/10.1002/14651858.CD000213.pub3 
Wilcock, A. D., Zachrison, K. S., Schwamm, L. H., Uscher-Pines, L., Zubizarreta, J. R. and Mehrotra, A. (2020). Trends 
Among Rural and Urban Medicare Beneficiaries in Care Delivery and Outcomes for Acute Stroke and 
Transient 
Ischemic 
Attacks, 
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77(7), 
863-871. 
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Yu-Chi, T., Guann-Ming, C., Tung, Y.-C. and Chang, G.-M. (2016). The Relationships Among Regionalization, 
Processes, and Outcomes for Stroke Care: A Nationwide Population-based Study Medicine, 95(15), 1-8. 
https://doi.org/10.1097/MD.0000000000003327 
 
 

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APPENDIX 1  
List of clinical and organizational indicators for optimal management of 
acute ischemic stroke management in adults   
Accessibility of services 
Accessibility 
Indicator 1  
Proportion of patients with a wait time of 48 hours or less between emergency triage and first rehabilitation 
evaluation     
Numerator: Number of post-stroke patients with a wait time of 48 hours or less between emergency triage and 
first rehabilitation evaluation 
Denominator: Total number of patients with ischemic stroke 
Indicator 2 
Average and median time interval between hospital admission and initial evaluation for each professional involved 
in early acute rehabilitation (Record the average and median time interval for each professional: nurse, 
physiotherapist, occupational therapist, speech therapist, nutritionist, doctor.)   
Indicator 3 
Proportion of patients admitted to a stroke care unit within 4 hours or within 24 hours following arrival in triage 
(Record the average and median wait time between emergency triage and admission to a stroke care unit [Not 
applicable in a primary care center].). 
Numerator 1: Number of patients admitted to a stroke care unit within 4 hours 
Numerator 2: Number of patients admitted to a stroke care unit within 24 hours 
Denominator: Total number of patients hospitalized for ischemic stroke 
Indicator 4 
Average and median time interval between patient’s arrival in triage and initial screening of dysphagia by a 
medically trained health professional using a valid screening tool  
 
 

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Equity of access 
Indicator 5 
Percentage of remote communities with access to the Telehealth/Telestroke program which facilitates access to 
organized ischemic stroke care across the continuum of care, notably evaluation of needs and delivery of care 
related to post-stroke rehabilitation  
Numerator: Total number of remote communities served by the center and having access to the 
Telehealth/Telestroke program which facilitates access to organized stroke care across the continuum of care, 
notably evaluation of needs and delivery of care related to post-stroke rehabilitation 
Denominator: Total number of remote communities that could treat ischemic stroke 
Indicator 6 
Percentage increase of the Telehealth/Telestroke program’s coverage of remote communities to support 
organized stroke care across the continuum of care   
Optimization of resources 
Efficiency 
Indicator 7 
Proportion of hospitalized patients treated in a stroke care unit (Not applicable in a primary care center) 
Numerator: Number of hospitalized patients treated in a stroke care unit 
Denominator: Total number of hospitalized patients diagnosed with stroke 
Indicator 8 
Average length of stays: Average number of days waiting for transfer to an inpatient intensive functional 
rehabilitation unit (IFRU) from the time the patient is ready to begin rehabilitation until his or her 
admission/Average and median lengths of stay including emergency department (ED) and hospitalization/Average 
and median lengths of stay in intensive care/Average and median lengths of stay in stroke care unit (Determine 
ratio of number of days in stroke care unit compared with total number of days in hospital including stay in ED 
and not including stay in ED.) 
Indicator 9 

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Proportion of acute stroke patients evaluated by a physiotherapist, occupational therapist, speech therapist, 
social worker, nutritionist, nurse or doctor (Proportion by type of health professional)  
Numerator: Number of acute stroke patients evaluated by a physiotherapist, occupational therapist, speech 
therapist, social worker, nutritionist, nurse or doctor during hospitalization for acute stroke 
Denominator: Total number of patients hospitalized for acute stroke 
Indicator 10 
Proportion of patients screened for dysphagia at admission and evaluated by a speech therapist, occupational 
therapist, nutritionist or other medically trained health professional 
Numerator: Number of patients screened for dysphagia at admission and evaluated by a speech therapist, 
occupational therapist, nutritionist or other medically trained health professional  
Denominator: Total number of patients screened for dysphagia at admission  
Quality of care 
Safety 
Indicator 11 
Proportion of post-stroke patients investigated for cardiac arrhythmia (electrocardiogram, heart monitor, 
telemetry, etc.)  
Numerator: Number of post-stroke patients investigated for cardiac arrhythmia 
Denominator: Total number of post-stroke patients 
Indicator 12 
Proportion of post-stroke patients screened for dysphagia within 4 hours following triage or within 24 hours 
following admission or prior to all oral intake of substances and liquids 
Numerator 1: Number of post stroke patients screened for dysphagia within 4 hours following triage 
Numerator 2: Number of post-stroke patients screened for dysphagia within 24 hours following admission 
Numerator 3: Number of post-stroke patients screened for dysphagia prior to all oral intake of substances and 
liquids 
Denominator: Total number of post-stroke patients 
Indicator 13 

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Proportion of post-stroke patients evaluated for pressure sore risk and regularly evaluated to prevent these sores 
using a valid tool (Braden Scale)  
Numerator: Number of post-stroke patients evaluated for pressure sore risk and regularly evaluated using a valid 
tool 
Denominator: Total number of post-stroke patients 
Indicator 14 
Proportion of post-stroke patients neurologically evaluated using a valid scale (e.g., Canadian Neurological Scale 
[CNS], National Institutes of Health Stroke Scale [NIHSS]) 
Numerator: Number of post-stroke patients neurologically evaluated using a valid scale 
Denominator: Total number of post-stroke patients 
Indicator 15 
Proportion of post-stroke patients screened or evaluated for risk of fall  
Numerator: Number of post-stroke patients screened or evaluated for risk of fall 
Denominator: Total number of post-stroke patients 
Indicator 16 
Proportion of post-stroke patients with complication of symptomatic intracranial hemorrhage following 
thrombolytic or endovascular therapy  
Numerator: Number of post-stroke patients with complication of symptomatic intracranial hemorrhage following 
thrombolytic or endovascular therapy  
Denominator: Total number of post-stroke patients given thrombolytic or endovascular therapy 
Indicator 17 
Proportion of post-stroke patients with one of the following complications during hospitalization: aspiration 
pneumonia, deep vein thrombosis, fever, pulmonary thromboembolism (PTE), shoulder subdislocation, urinary 
tract infection, contracture, malnourishment, depression/anxiety, gastrointestinal bleeding, convulsions (Result 
by type of complication)  
Numerator: Number of post-stroke patients with one or more of these post-stroke complications during 
hospitalization 

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Denominator: Total number of post-stroke patients 
Indicator 18 
Proportion of patients given a carotid Doppler test within 24 hours 
Numerator:  Number of post-stroke patients given a carotid Doppler test within 24 hours 
Denominator:  Total number of post-stroke patients 
Effectiveness 
Indicator 19 
Proportion of patients who die from stroke in hospital within 7 days and within 30 days following admission   
Numerator 1: Number of patients who die from stroke within 7 days following admission to hospital 
Numerator 2: Number of patients who die from stroke within 30 days following admission to hospital 
Denominator: Total number of ischemic stroke patients hospitalized or discharged from hospital 
 

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Indicator 20 
Proportion of patients with severe disability at discharge (mRS 0-3) (Calculate proportion of patients for each 
modified Rankin score, mRS of 1 to 5.) 
Numerator: Number of patients with a modified Rankin score (mRS) between 0 and 3 at discharge 
Denominator: Total number of patients with a modified Rankin score recorded at discharge 
Indicator 21 
Proportion of patients with increased shoulder pain based on pain intensity score evaluated with a valid tool using 
reference data during hospitalization   
Numerator: Number of post-stroke patients with increased shoulder pain based on pain intensity score evaluated 
with a valid tool  
Denominator: Number of post-stroke patients with shoulder pain 
Indicator 22 
Proportion of patients readmitted to short-term hospital care for a stroke-related issue after discharge (post 30 
days) 
Numerator: Number of patients readmitted to short-term hospital care for a stroke-related issue within 30 days 
after discharge  
Denominator: Total number of post-stroke patients re-hospitalized after discharge  
Continuity 
Indicator 23 
Proportion of post-stroke patients prescribed an anticoagulant, lipid-lowering medication, an antiplatelet, an 
antihypertensive, or a hypoglycemic at discharge (Result per medication) 
Numerator: Number of post-stroke patients prescribed an anticoagulant, lipid-lowering medication, an 
antiplatelet, an antihypertensive, or a hypoglycemic at discharge 
Denominator:  Total number of post-stroke patients prescribed one or more medications  
Indicator 24 

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Proportion of post-stroke patients with a record that includes a therapeutic nursing plan (TNP), an individualized 
intervention plan (IIP) or a care plan (CP) 
Numerator: Number of post-stroke patients with a record that includes a therapeutic nursing plan (TNP), an 
individualized intervention plan (IIP) or a care plan (CP)  
Denominator: Total number of post-stroke patients 
Indicator 25 
Transfer at discharge: Proportion of post-stroke patients transferred at discharge to inpatient rehabilitation, 
outpatient rehabilitation, return to residence, long-term care centre or palliative care (Result by patient’s place of 
transfer)   
 Numerator: Number of post-stroke patients transferred to inpatient rehabilitation, outpatient rehabilitation, 
return to residence, long-term care center or palliative care   
Denominator: Total number of post-stroke patients discharged from hospital 
Indicator 26 
Proportion of post-stroke patients referred at discharge to a secondary prevention program (Specify type of 
referral) 
Numerator: Number of post-stroke patients referred at discharge to a secondary prevention program 
Denominator: Total number of post-stroke patients discharged  
Reactivity 
Indicator 27 
Proportion of post-stroke patients and caregivers met by the team to discuss management of the patient and his 
or her needs following discharge  
Numerator: Number of post-stroke patients and caregivers met by the team to discuss management of the patient 
and his or her needs following discharge 
Denominator: Total number of post-stroke patients discharged  
Indicator 28 

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Proportion of post-stroke patients and caregivers instructed prior to discharge on the following stroke-related 
topics of interest: modifiable risk factors, warning signs and symptoms of stroke, how to activate medical 
emergency services, post-discharge services available, prescribed medications and community resources 
Numerator: Number of post-stroke patients and caregivers instructed prior to discharge on these topics of interest 
Denominator: Total number of post-stroke patients 
Indicator 29 
Proportion of post-stroke patients and caregivers who were invited to participate in advance planning of care or 
had a documented conversation with a health professional regarding resuscitation and level of care  
Numerator: Number of post-stroke patients who were invited to participate in advance planning of care or had a 
documented conversation with a health professional regarding resuscitation and level of care 
Denominator: Total number of post-stroke patients 
 
 
 

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APPENDIX 2 
Detailed list of data to collect on patients’ characteristics and clinical and 
organizational quality indicators 
 
A. Data collection information 
A1. Date of collection    DD/MM/YYYY   ____ /____ /_______           A2. Name. Collector: ______________________ 
A3. Patient ID         
 
B. Sociodemographic characteristics 
B1. Center  1-Tertiary    2-Secondary    3-Primary 
B2. Age at admission __________ years 
B3. Sex  
 1-Male         2-Female  
 3-Other: ________________ 
 99-Missing data 
B4. Ethnicity 
 1-White   
 2-South Asian (e.g, Indian from India, Pakistani, SriLankan, 
Chinese)  
 3-Black  
 4-Filipino  
 5-Arab  
 6-Latin American  
 7-Southeast Asian (e.g., Vietnamese, Cambodian, Laotian, 
Thai)  
 8-Mideastern (e.g., Iranian, Afghan) 
 9-Other: _____________________ 
B5. Home region 
 1-Mauricie 
 2-Centre du Québec 
 3-Estrie 
 4-Montreal 
 5-Laval 
 6-Lanaudière 
 7-Montérégie 
 8-Other: _____________________ 
 99-Missing data 

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 99-Missing data 
B6. Number of km between residence and hospital center: _______km 
 99-Missing data 
 
C. Clinical characteristics 
C1. Stroke diagnosis 
 1-Left Sylvian 
 2-Right Sylvian 
 3-Other: __________________ 
 99-Missing data 
C2. Administration of thrombolysis IV (alteplase) 
 1-No                                     2-Yes 
 3-Not applicable               99-Missing data 
C3. Administration of thrombectomy 
 1-No                                     2Yes 
 3-Not applicable                 99-Missing data 
C4. History of stroke 
 1-No                                     2-Yes 
 99-Missing data 
C5. Other diagnoses 
______________________________________________ 
______________________________________________ 
C6. Pre-stroke medications (relevant with ischemic stroke) 
 1-Anticoagulant                                     2-Antihypertensive                            3-Cholesterol-lowering medication    
 4-Lipid-lowering medication                           5-Antiplatelet                                     6-Other: 
__________________ 
 7-Other: __________________           8-Other: __________________      99-Missing data 
C7. Covid-positive 
 1-No                                    2-Yes 
 99-Missing data 

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C8. First NIHSS evaluation (initial) 
 1-No                                     2-Yes 
 99-Missing data 
C9. Initial NIHSS result: ___________ 
C10. First modified Rankin assessment (initial mRS) 
 1-No                                    2-Yes 
 99-Missing data 
C11. Initial mRS result: ___________ 
 
D. Risk factors 
D1. Smoking  
 1-No                                     2-Yes 
 99-Missing data 
D2. Physical inactivity 
 1-Yes                                     2-No 
 99-Missing data 
D3. Obesity 
 1-No                                     2-Yes 
 99-Missing data 
D4. Poor nutrition 
 1-No                                     2-Yes 
 99-Missing data 
D5. Alcohol consumption 
 1-No                                     2-Yes 
 99-Missing data 
D6. Drug use 
 1-No                                     2-Yes 
 99-Missing data 
D7. Arterial hypertension  
 1-No                                     2-Yes 
 99-Missing data 
D8. Dyslipidemia 
 1-No                                     2-Yes 
 99-Missing data 
D9. Type 2 diabetes 
 1-No                                     2-Yes 
 99-Missing data 
D10. Carotid stenosis 
 1-No                                     2-Yes 
 99-Missing data 
 
D11. Sleep apnea 
 

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 1-No                                     2-Yes 
 99-Missing data 
 
E. Patient flow / Time intervals 
E1. Date and time of arrival at triage                          DD/MM/YYYY   ____ /____ /______   HH: MIN        ____ : ____ 
E2. Date and time of admission to a short-term unit (regardless of unit) 
DD/MM/YYYY   ____ /____ /_______ HH : MIN   ____ : ____ 
E3. Admission to stroke care unit 
 1-No                                     2-Yes                              3-Not applicable                      99-Missing data 
E4. Date and time of admission to stroke care unit 
DD/MM/YYYY   ____ /____ /_______ HH: MIN   ____ : ____ 
E5. Admission to intensive care unit 
 1-No                                     2-Yes                              3-Not applicable                      99-Missing data 
E6. Date and time of admission to intensive care unit 
DD/MM/YYYY   ____ /____ /_______ HH: MIN   ____ : ____ 
E7. Presence of nursing evaluation note in the record 
 1-No                                     2-Yes                                   99-Missing data 
E8. Date and time of first nursing evaluation note                               
DD/MM/YYYY   ____ /____ /_______ HH: MIN   ____ : ____ 
E9. Presence of physical therapy evaluation note in the record 
 1-No                                     2-Yes                                  99-Missing data 
E10. Date and time of first physical therapy evaluation note                               
DD/MM/YYYY   ____ /____ /_______ HH: MIN   ____ : ____ 
E11. Presence of occupational therapy evaluation note in the record 
 1-No                                     2-Yes                                   99-Missing data 
E12. Date and time of first occupational evaluation note                                     

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DD/MM/YYYY   ____ /____ /_______ HH: MIN        ____ : ____ 
E13. Presence of speech therapy evaluation note in the record 
 1-No                                     2-Yes                                   99-Missing data 
E14. Date and time of first speech therapy evaluation                                 
DD/MM/YYYY  ____ /____ /_______ HH: MIN        ____ : ____ 
E15. Presence of nutrition evaluation note in the record 
 1-No                                     2-Yes                                   99-Missing data 
E16. Date and time of first nutrition evaluation note                                     
DD/MM/YYYY   ____ /____ /_______ HH: MIN        ____ : ____ 
E17. Presence of social worker evaluation note in the record 
 1-No                                     2-Yes                                   99-Missing data 
E18. Date and time of first social worker evaluation                                              
DD/MM/YYYY  ____ /____ /_______ HH: MIN        ____ : ____ 
E19. Presence of doctor’s evaluation note in the record 
 1-No                                     2-Yes                                   99-Missing data 
E20. Date and time of first doctor’s evaluation                                               
DD/MM/YYYY   ____ /____ /_______ HH: MIN        ____ : ____ 
E21.Documented discussion of levels of patient’s care  
 1-No                                     2-Yes                                    99-Missing data 
E22. Dysphagia screening by a nurse or rehabilitation team member 
 1-No                                     2-Yes                                    99-Missing data 
E23. Date and time of dysphagia screening 
DD/MM/YYYY   ____ /____ /_______ HH: MIN        ____ : ____ 
E24. Date and time of first oral administration 
DD/MM/YYYY   ____ /____ /_______ HH: MIN        ____ : ____ 
E25. Presence of dysphagia 

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 1-No                                 2-Yes                          99-Missing data 
E26. Evaluation by a clinician in presence of dysphagia 
 1-No                                2-Yes                           3-Not applicable                     99-Missing data 
E27. Referral to IFRU by a doctor 
 1-No                               2-Yes                           3-Not applicable                    99-Missing data 
E28. Date and time of referral to IFRU 
DD/MM/YYYY   ____ /____ /_______ HH: MIN        ____ : ____ 
E29. Admission to IFRU 
 1-No                             2-Yes                             3-Not applicable                    99-Missing data 
E30. Date and time of admission to IFRU 
DD/MM/YYYY   ____ /____ /_______ HH: MIN        ____ : ____ 
E31. CT carotid angiogram  
 1-No                              2-Yes                           3-Not applicable                     99-Missing data 
E32. Date and time of CT carotid angiogram 
DD/MM/YYYY   ____ /____ /_______ HH: MIN        ____ : ____ 
 
F. Evaluations 
F1. Medical evaluation for cardiac arrhythmia 
 1-No                                     2-Yes                                 3-Not applicable                    99-Missing data 
F2. Presence of cardiac arrhythmia 
 1-No                                     2-Yes                                 3-Not applicable                   99-Missing data 
F3. Evaluation of pressure sore risk (Braden Scale) by the nurse 
 1-No                                     2-Yes                                 3-Not applicable                    99-Missing data 

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F4. Result of pressure sore evaluation (Braden Scale): _______________ 
F5. Re-evaluation of pressure sore risk (Braden Scale) by the nurse 
 1-No                                     2-Yes                                 3-Not applicable                   99-Missing data 
F6. Evaluation of risk of fall by a nurse 
 1-No                                     2-Yes                                 3-Not applicable                   99-Missing data 
F7. Neurological evaluation by a nurse using the Canadian Neurological Scale  
 1-No                                     2-Yes                                 3-Not applicable                    99-Missing data 
F8. Result of neurological evaluation on the CNS: ___________________________ 
F9. Neurological evaluation by the doctor using the NIHSS post revascularization treatment 
 1-No                                     2-Yes                                 3-Not applicable                    99-Missing data 
F10. Result of NIHSS post revascularization treatment: ____________________ 
F11. Neurological evaluation by a nurse using the Glasgow Coma Scale post revascularization treatment 
 1-No                                     2-Yes                                 3-Not applicable                   99-Missing data 
F12. Result of Glasgow Coma Scale post revascularization treatment: __________________ 
F13. Shoulder pain evaluation by the physiotherapist 
 1-No                                     2-Yes                                 3-Not applicable                   99-Missing data 
F14. Presence of shoulder pain 
 1-No                                     2-Yes                                 3-Not applicable                   99-Missing data 
F15. Result of first shoulder pain evaluation: ______________________ 
F16. Shoulder pain re-evaluation by physiotherapist 
 1-No                                     2-Yes                                 3-Not applicable                   99-Missing data 
F17. Result of second shoulder pain evaluation: _____________________ 
 
 
 
 
 

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G. Complications during hospitalization 
G1. Intracranial hemorrhage 
 1-No          2-Yes             99-Missing data 
G2. Urinary tract infection 
 1-No          2-Yes             99-Missing data 
G3. Aspiration pneumonia 
 1-No          2-Yes             99-Missing data 
G4. Other pneumonia (nosocomial, ventilator-associated, 
etc.)         Specify: ___________________ 
 1-No          2-Yes             99-Missing data 
G5. Malnourishment 
 1-No          2-Yes             99-Missing  
G6. Convulsions 
 1-No          2-Yes             99-Missing data 
G7. Deep vein thrombophlebitis 
 1-No          2-Yes             99-Missing data 
G8. Depression 
 1-No         2-Yes             99-Missing data 
G9. Temperature increase 
 1-No          2-Yes            99-Missing data 
G10. Anxiety 
 1-No          2-Yes             99-Missing data 
G11. Pulmonary embolism 
 1-No          2-Yes             99-Missing data 
G12. Gastrointestinal bleeding 
 1-No          2-Yes             99-Missing data 
G13. Shoulder subdislocation 
 1-No          2-Yes             99-Missing data 
G14. Contracture 
 1-No          2-Yes             99-Missing data 
 
H. Discharge / Transfer 
H1. Death 
 1-No          2-Yes             99-Missing data 
H2. Date and time of death 
DD/MM/YYYY   ____ /____ /_______ HH: MIN        ____ : ____ 
H3. Short stay discharge 
 1-No                                     2-Yes                             3-Not applicable                    99-Missing data 
H4. Date and time of short stay discharge 
DD/MM/YYYY   ____ /____ /_______ HH:  MIN        ____ : ____ 
H5. Date and time of stroke unit discharge  

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DD/MM/YYYY   ____ /____ /_______ HH: MIN        ____ : ____ 
H6. Date and time of intensive care unit discharge  
DD/MM/YYYY   ____ /____ /_______ HH: MIN        ____ : ____ 
H7. Presence in the record of functional independence evaluation using modified Rankin Scale (mRS)  
 1-No                                2-Yes                            3-Not applicable                    99-Missing data 
H8. Clinician performing the functional independence evaluation using modified Rankin Scale (mRS) in the record 
 1-Nurse                                                          2-Neurologist                                   3-Occupational therapist                 
 4-Other: _______________________          99-Missing data 
H9. mRS result at discharge: _________________ 
H10. Anticoagulant prescribed at discharge 
 1-No                              2-Yes                               3-Not applicable                         99-Missing data 
H11. Lipid-lowering medication prescribed at discharge 
 1-No                              2-Yes                              3-Not applicable                         99-Missing data 
H12. Antiplatelet prescribed at discharge 
 1-No                             2-Yes                               3-Not applicable                         99-Missing data 
H13. Hypertensive prescribed at discharge 
 1-No                             2-Yes                               3-Not applicable                     99-Missing data 
H14. Hypoglycemic prescribed at discharge 
 1-No                             2-Yes                              3-Not applicable                      99-Missing data 
H15. Discussion with patient about targeted goals for discharge  
 1-No                            2-Yes                              3-Not applicable                      99-Missing data 
H16. Individualized intervention plan developed with patient and caregivers 
 1-No                            2-Yes                             3- Not applicable                      99-Missing data 
H17. Therapeutic nursing plan developed by nurse with patient and caregivers 
 1-No                            2-Yes                             3- Not applicable                      99-Missing data 
H18. Beneficiary assistant work plan developed by nurse 

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 1-No                            2-Yes                             3- Not applicable                      99-Missing data 
H19. Patient’s walking program developed by nurse or interdisciplinary team 
 1-No                            2-Yes                             3- Not applicable                      99-Missing data 
H20. Transfer at discharge 
 1-Return to place of residence                               2- Outpatient rehabilitation services      
 3- Inpatient rehabilitation                                       4- Long-term care center                                 
 5- Palliative care                                                    6-Not applicable                                                    
 7- Other: _____________________ 
H21. Referral regarding secondary prevention  
 1-No                            2-Yes                            3-Not applicable                        99-Missing data 
H22. Clinician who referred to secondary prevention services 
 1-Nurse                                          2-Neurologist                                   3-Other: ____________________      
 99-Missing data 
H23. Readmission within 30 days for stroke-related issue 
 1-No                            2-Yes                            3-Not applicable                        99-Missing data 
 
I. Discharge education 
I1. Information on modifiable risk factors 
 1-No                         2-yes                             3-Not applicable                            99-Missing data 
I2. Information on stroke symptoms 
 1-No                         2-Yes                             3-Not applicable                            99-Missing data 
I3. Information on the urgency of consulting in the presence of stroke symptoms 
 1-No                         2-Yes                             3-Not applicable                            99-Missing data 
I4. Information on post-stroke follow-up  
 1-No                         2-Yes                             3-Not applicable                            99-Missing data 
I5. Information on prescribed medications 
 1-No                        2-Yes                            3-Not applicable                             99-Missing data 
I6. Information on available community resources 

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 1-No                        2-Yes                             3-Not applicable                              99-Missing data 
I7. Professionals providing information to patient and caregivers 
 Nurse                                Physiotherapist                           Speech therapist                                     
 Neurologist                       Occupational therapist                 Nutritionist                    
 Autre : _______________________                                        99-Missing data 
 
 
 
1

 
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APPENDIX 3 
Collection sheet on hospital characteristics  
 
A. Hospital center 
A1. Collection data   DD/MM/YYYY   ____ /____ /_______  
A2. Center        
 
 
B. Geographic and demographic characteristics 
B1. Type of designation 
 1-Primary    2-Secondary    3-Tertiary 
B2. Description of center’s mission and role in relation to type of 
designation 
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________ 
B3. Geographic distribution (regions served) 
 Mauricie 
 Centre du Québec 
 Estrie 
 Montreal 
 Laval 
 Lanaudière 
 Montérégie 
 Other: _____________________ 
B4. Population served (approximate number of persons): _______________________ 
B5. Total annual average number of patients admitted: _______________________________ 
B6. Total annual average number of patients admitted with a diagnosis of ischemic stroke: 
__________________________ 
B7. Total number of short-term beds: _______________________________________ 

 
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B8. Total number of beds on stroke unit or reserved for stroke patients: ______________________ 
B9. Annual number of satisfactions and complaints related to patients’ stay in stroke unit: 
Satisfactions: _________________                     Complaints: _________________ 
B10. Annual number of incident/accident reports (e.g., medication errors, falls, etc.) related to patients’ stay in stroke 
unit: _________________________ 
B11. Annual number of restraint and seclusion measures related to patients’ stay in stroke unit: 
_________________________ 
B12. Number of continuous observations of a stroke unit patient by a patient care assistant (PCA), a security guard, or 
a member of the family or the establishment: _________________________ 
 
C. Characteristics of human resources 
C1. Type and number of clinicians available in 
neurovascular department/neurology (stroke) 
 Nurse technician: ______________________ 
 Nurse clinician: _______________________ 
Nurse specialist: ______________________ 
 Nursing assistant: ________________________ 
 Patient care assistant (PCA): ______________ 
 Occupational therapist: 
___________________________ 
 Physiotherapist: _________________________ 
 Speech therapist: ____________________________ 
 Nutritionist: _____________________________ 
C2.Interdisciplinary (multidisciplinary) meetings 
 No                                     2-Yes 
C3. Frequency of multidisciplinary meetings 
Frequency: ______________________________ 
C4. Progression of multidisciplinary meetings 
______________________________________________ 
______________________________________________ 
______________________________________________ 
______________________________________________ 
______________________________________________ 
______________________________________________ 

 
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 Kinesiologist: _____________________________ 
 Doctor: _________________________________ 
 Internist: ________________________________ 
 Neurologist : ______________________________ 
 Neurointerventionnist: _____________________ 
 Other: ___________________________________ 
______________________________________________ 
C5. Ratio patients/clinicians 
Ratio 
Day 
Evening 
Night 
Patients/Nurse  
 
 
 
Patients/Nursing assistant  
 
 
 
Patients/PCA  
 
 
 
Patients/Occupational therapist 
 
 
 
Patients/Physiotherapist  
 
 
 
Patients/Speech therapist 
 
 
 
C6. Mandatory overtime on stroke unit        No       Yes        Frequency: ____________________ 
C7. Rate of staff turnover on stroke unit: ____________________ 
C8. Rate of absenteeism on stroke unit: ____________________ 
C9. Average number of years of experience  
Clinicians 
Day 
Evening 
Night 
Nurse  
 
 
 
Nursing assistant  
 
 
 
Patient care assistant 
 
 
 
Occupational therapist  
 
 
 
Physiotherapist  
 
 
 
Speech therapist 
 
 
 
 
C10. Proportion of nurse technicians and of nurse clinicians (total number of nurses) 
Nurse technicians: ____________________ 

 
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Nurse clinicians: ______________________ 
 
D. Documentation and dissemination 
D1. Clinical and organizational documentation in effect (protocols, procedures, prescriptions, health records, etc.) 
______________________________________________   ______________________________________________ 
______________________________________________   ______________________________________________ 
______________________________________________   ______________________________________________ 
______________________________________________   ______________________________________________ 
______________________________________________   ______________________________________________ 
D2. Action plans or projects designed for continuous improvement of quality of care and services 
______________________________________________________________________________________________ 
______________________________________________________________________________________________ 
______________________________________________________________________________________________ 
D3. Frequency and type of content regarding training offered to different clinicians 
Frequency: ____________________________________ 
Content of training: 
______________________________________________   ______________________________________________ 
______________________________________________   ______________________________________________ 
______________________________________________   ______________________________________________ 
D4. Internal and external resources (material resources (organizational networking; policies, plans or programs in effect; 
service corridors and agreements, etc.)  
______________________________________________________________________________________________ 
______________________________________________________________________________________________ 

 
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______________________________________________________________________________________________ 
D5. Methods of communication for transmitting information to the teams 
______________________________________________________________________________________________ 
______________________________________________________________________________________________ 
 
E. Remote communities 
E1. Percentage of remote communities with access to the Telehealth/Telestroke program which facilitates access to 
organized ischemic stroke care across the care continuum, notably evaluation of needs and delivery of care related to 
post-stroke rehabilitation.  
Percentage: ___________ 
Comments:  
______________________________________________________________________________________________ 
______________________________________________________________________________________________ 
E2. Increase in percentage of Telehealth/Telestroke coverage of remote communities to support organized stroke care 
across the continuum of care in recent years  
Percentage: ___________(YYYY)               Percentage: ____________(2021-2022) 
Comments:  
______________________________________________________________________________________________ 
______________________________________________________________________________________________