A new University of Waterloo-led study has identified workflow barriers that contribute to treatment delays, helping health-care providers improve outcomes for patients across the stroke care pathway.
The research brought together experts from Waterloo's management science and engineering department with members of the research and stroke teams at Waterloo Regional Health Network (WRHN) to examine why door-to-needle time, the interval between a patient's arrival at hospital and administration of clot-busting medication, can be longer than recommended targets.
Researchers analyzed 218 acute stroke cases over a three-year period in Waterloo Region and found that treatment delays were most often associated with communication gaps, consultation requirements, emergency department crowding, staffing challenges and imaging workflow constraints.
"Stroke care is often described with the phrase 'time is brain' because brain tissue is lost with every minute treatment is delayed," says Rahenda Khodeir, a doctoral researcher in the management science and engineering department and member of the Waterloo Analytics and Optimization Lab (WANOPT). "Our goal was to understand not only where delays occur, but why they occur and how health-care organizations can address them."
Stroke is a growing health challenge in Canada, driven in part by an aging population. According to 2022 data from the Heart and Stroke Foundation, more than 89,000 strokes occur in Canada each year, and rapid treatment is critical for patients experiencing an acute ischemic stroke caused by a blood clot blocking blood flow to the brain.
"This project allowed us to look at stroke care from multiple perspectives," says Dr. Fatma Gzara, professor of management science and engineering and co-director of WANOPT. "Historical patient data helps us identify patterns, while observations and staff feedback reveal how care is delivered in real clinical environments."
The findings showed that delays rarely stem from a single issue. Instead, they emerge from a series of unplanned steps that accumulate along the care pathway, from pre-arrival communication to imaging, specialist consultation and treatment administration.
"Our findings demonstrate that stroke pathways are functioning, but they are not consistently fast enough to meet performance targets," Khodeir says. "Improving care will require coordinated system-level changes rather than isolated interventions."
The researchers developed several recommendations for improvement. These include standardizing pre-alert processes, preserving direct EMS-to-CT patient transfers whenever possible, strengthening stroke-related training and decision-support resources for emergency physicians, improving staff coverage during nights and weekends and modernizing systems to reduce consultation delays.
The project demonstrates how researchers and health-care providers can work together to improve health-care delivery through operations research and systems engineering. By combining analytics, process improvement and frontline clinical expertise, the partnership identified practical opportunities to reduce treatment times and improve outcomes for stroke patients.
"The clinical teams across WRHN are exceptional, and their commitment to delivering high-quality stroke care is evident every day. This partnership and the results of the study will give us an opportunity to build on that strong foundation by identifying ways to better connect the pieces of the care journey, strengthen what is already working well, and ultimately make an excellent system even better for our patients" says Dr. Stephen Giilck, Joint Chief of Medicine for WRHN and Medical Director of the Waterloo Wellington Stroke Program.
The team is now expanding its research to examine all Code Stroke cases and the full continuum of stroke care, from pre-hospital response to recovery. Researchers hope the work will support predictive models that help hospitals identify and address delays before they occur.
The study was conducted by researchers in Waterloo's WANOPT Lab and the Department of Management Science and Engineering in partnership with clinical and operational teams at WRHN.
