This study is a single-center, prospective, uncontrolled before-and-after QI study, registered prospectively with the Open Science Framework to enhance transparency and minimize duplication [8]. The project follows the Institute for Healthcare Improvement Model for Improvement [9] and is reported in accordance with the SQUIRE (Standards for Quality Improvement Reporting Excellence) 2.0 guidelines [10]. The preimplementation (baseline) period is defined as fiscal year 2022 to 2023 (April 1, 2022, to March 31, 2023), and the postimplementation period covers 12 months following full implementation of the MOTIVE model, with data collected and analyzed at monthly intervals. Implementation will proceed in phased stages over 2 years, with iterative refinement guided by Plan-Do-Study-Act (PDSA) cycles.

Statistical process control methods will be used to evaluate temporal changes in outcomes. Such methods are widely used in health care QI to monitor processes over time and distinguish between common-cause and special-cause variations [11]. Observed changes will be interpreted in relation to PDSA cycles and relevant contextual factors rather than a single fixed intervention point. In this study, statistical process control methods are particularly suitable because the intervention is implemented iteratively and outcomes are expected to evolve over time.

The target population for this QI initiative includes all adult patients aged 18 years or older who were presented to the ED or admitted to nonstroke inpatient units with a diagnosis of TIA or acute ischemic stroke and a National Institutes of Health Stroke Scale (NIHSS) score of 5 or less [12]. An NIHSS score of ≤5 was used to define minor stroke. Although patients presenting with an NIHSS score greater than 5, those deemed by the medical team to have disabling deficits, or those who have undergone thrombolysis or thrombectomy are not eligible for MOTIVE assessment at initial presentation, eligibility will be reassessed once bed rest restrictions are lifted and neurological status has stabilized. Patients whose NIHSS score improves to 5 or less at reassessment will become eligible for MOTIVE-led assessment and discharge planning; those who remain above this threshold or continue to have disabling deficits will continue to follow the standard acute stroke care pathway.

Pre-existing cognitive impairment and limited social support (eg, living alone without an identified caregiver) will not be exclusion criteria [13] for the MOTIVE assessment or the evaluation cohort. Rather, these factors inform the interdisciplinary team’s determination of discharge readiness. Patients in whom such factors preclude safe same-day discharge will be managed via the standard inpatient pathway with MOTIVE-led interdisciplinary discharge planning and will remain in the analytic cohort to preserve analytic consistency and selection bias. To assess potential inequities in outcomes among vulnerable patients, a prespecified subgroup analysis will compare primary and balancing outcomes between patients with documented cognitive impairment or those who live alone and the remainder of the cohort.

The MOTIVE team is led by a stroke neurologist, who holds overall responsibility for medical decision-making and clinical oversight. The team integrates an advanced practice physiotherapist (APP) role into frontline stroke care, a position introduced by HSN in 2021 [14]. HSN was the first academic teaching hospital in Canada to establish an APP role in supporting acute stroke care. The APP role includes functional assessment of patients with suspected or confirmed stroke or TIA, collaborative triage with stroke neurologists and the interdisciplinary team to determine rehabilitation needs and disposition, leadership of QI initiatives, and implementation of evidence-based stroke care practices. This role represents a significant expansion beyond the traditional scope of physiotherapy and necessitates advanced clinical expertise in stroke, training in research and QI, and strong knowledge translation skills. The broader team includes a stroke nurse, occupational therapist, speech-language pathologist, and reactivation worker. The latter is a rehabilitation assistant (reactivation worker) who collaborates with the aforementioned disciplines to facilitate early mobilization and functional recovery of the patient.

The MOTIVE team will work collaboratively with the Medical Imaging Department at HSN to optimize access to time-sensitive diagnostics, enabling early discharge. Brain MRI is superior to head computed tomography in diagnostic sensitivity for identifying small ischemic lesions in patients presenting with TIA or minor stroke and can provide additional information to guide decisions regarding diagnosis, prognosis, and treatment. Currently, routine MRI wait times at HSN can extend up to 5 days, which significantly delays the definitive diagnosis and disposition of patients with suspected stroke or TIA. The team will work closely with the medical imaging department to establish “time-cohorted” scheduling whereby urgent MRI scans for MOTIVE patients are prioritized earlier in the day through intelligent reallocation of existing capacity without increasing overall system demand. This approach is anticipated to enable same-day imaging, eliminating the previous multiday wait and allowing stroke neurologists to review the results and confirm final management decisions immediately after the interdisciplinary evaluation is concluded. The team will maintain ongoing discussions with stakeholders, including outpatient therapy services (called outpatient neurological rehabilitation [ONR] at HSN), the Stroke Prevention Clinic (SPC) at HSN, Ontario Health at Home, and other community service providers (such as the poststroke transitional care program run by a community agency) to ensure rapid disposition planning, smooth handover of care, and continuation of evidence-based rehabilitation in the most appropriate setting, whether at home or a community-based program.

The intervention will be fully integrated into routine clinical workflows with the MOTIVE team deployed across the ED and all inpatient units where patients with stroke (except those in the stroke unit) are present. The team will assess 3 specific patient cohorts to ensure early and comprehensive interdisciplinary stroke assessment across all locations within HSN to close existing gaps.

The first cohort includes patients presenting to the ED with suspected TIA or minor stroke. Currently, these patients are typically admitted to a stroke unit for evaluation. The MOTIVE team will conduct a rapid interdisciplinary assessment directly in the ED, facilitating same-day discharge planning for suitable candidates.

The second cohort comprises patients admitted to acute nonstroke inpatient units due to bed shortages, systemic pressures, or stroke resulting from surgeries or other medical conditions during their stay (eg, admitted with cardiac conditions but sustaining a stroke as a complication). Clinical teams in these units often lack stroke-specific expertise, resulting in delays in specialist input and rehabilitation planning for patients. The team will assess all patients with stroke or TIA throughout the hospital (including general medical and surgical floors), ensuring equitable access to best practice stroke care and enabling earlier discharge when clinically appropriate.

The third cohort consists of postacute treatment patients who received intravenous thrombolysis or endovascular thrombectomy and were initially managed in the intensive care unit. Traditionally, these patients are transferred to a stroke unit for interdisciplinary assessment prior to discharge or repatriation. The MOTIVE team will complete a comprehensive assessment in the intensive care unit once patients are medically stable, allowing for direct discharge to home (with or without community support) or repatriation without an intermediate stroke unit stay, thereby reducing the overall LOS at HSN.

These coordinated processes will ensure that all patients with stroke and TIA receive timely expert care, facilitating earlier decision-making, efficient care transitions, and optimized resource use.

Data will be collected prospectively from administrative databases and electronic medical records by a research assistant and the QI team. All outcomes will be measured and analyzed at monthly intervals to support the longitudinal assessment of system performance over time. As this is a single-center, uncontrolled before-and-after study, baseline and postimplementation cohorts will be compared on key characteristics (age, sex, NIHSS, and stroke type) to assess case-mix comparability. Contextual factors that may influence outcomes (eg, seasonal variation and MRI access) will be tracked monthly, annotated on control charts, and considered when interpreting results. Residual confounding will be acknowledged as a limitation of this study.

The primary outcomes will be (1) the ED-to-inpatient admission rate, defined as the proportion of patients diagnosed with TIA or stroke in the ED who are subsequently admitted to an acute care bed and (2) the acute hospital LOS, calculated as the number of days from admission to discharge on the acute inpatient unit. The secondary outcome will be health care costs, estimated as the number of avoided inpatient bed-days multiplied by the HSN per diem cost.

Process measures will include (1) time from ED presentation to interdisciplinary team assessment, (2) MRI wait time, and (3) the proportion of eligible patients triaged within 24 hours. Balancing measures will include the following:

Together, these measures will be used to analyze whether early discharge planning adversely affects patient and caregiver experiences [15].

Patient and caregiver experience will be assessed using a 7-item questionnaire covering five domains mapped to the Donabedian framework [16]: (1) care transitions; (2) diagnostic processes and comfort; (3) patient involvement in decision-making; (4) clarity of information about the condition and medications; and (5) preparedness for discharge, including knowledge of follow-up care. The instrument will be developed by the multidisciplinary QI team through an iterative process, mapping the inpatient stroke journey from admission to discharge, guided by the Donabedian framework and existing literature on stroke-specific patient-reported experience measures [17]. Responses will be measured using a 5-point Likert scale ranging from strongly disagree to strongly agree. Prior to full deployment, the questionnaire will be pilot-tested for clarity and face validity with patients with stroke. It will be administered anonymously in electronic format at the point of discharge; in instances where patients are unable to complete the survey due to cognitive, speech, or physical impairments resulting from stroke, a substitute decision-maker or caregiver will complete it on their behalf. Performance will be evaluated using defect analysis, defined as neutral, disagree, or strongly disagree responses, and top-box analysis, defined as the proportion of respondents selecting strongly agree.

The HSN Research Ethics Board (file number 25-21) conducted a review of the MOTIVE Project and determined that it is exempt from research ethics board approval. This classification aligns with Article 2.5 of TCPS 2 (2022) [18], as the project is identified as a QI activity. This QI initiative will use data collected for clinical care and routine administrative purposes; therefore, individual patient consent will not be required. Patients will be informed about the use of their data for QI through standard hospital admission processes. All data will be extracted from the HSN electronic medical record and Discharge Abstract Database by authorized institutional personnel. Data will be stored on secure, hospital-managed servers protected by institutional firewalls and accessed only by the designated study team members. Analyses will be conducted on deidentified data, and the results will be reported in aggregate form. The patient experience questionnaire will be administered anonymously, and no identifiable information will be collected or transferred outside the institutional environment.

One of the aims of the MOTIVE QI project is to implement an earlier, coordinated discharge plan [23], thereby reducing the overall LOS. We calculated the required sample size for this single-arm QI project based on the baseline data extracted from the Discharge Abstract Database. Our 2022 baseline data, comprising 278 patients with ischemic stroke, revealed an average LOS of 11.2 days with an SD (σ) of 18.27 days. The steering committee’s initial goal was to achieve a 30% reduction from this baseline, targeting an average LOS of 7.84 days. It represents a minimum detectable change (Cohen d) of 3.36 days. We will use continuous real-time monitoring to identify barriers and will use PDSA cycles to align our target with the provincial benchmark of 5 days [6]. To detect this initial improvement, a sample size calculation [24] indicated that 183 patients were required, with a statistical power (β) of 80% and a significance level (α) of 5%.