Background and Purpose: Many rural patients experiencing complex strokes are transferred from small hospitals with limited stroke-specific resources (spoke) to larger hospitals (hub). The Wisconsin (WI) Coverdell Stroke Program (Coverdell) utilized the Get with the Guidelines®-Stroke registry to determine the frequency of this spoke-to-hub transfer occurrence in WI in 2020, which was found to be 24.6%. This suggested a need for interactive maps to visualize stroke systems of care (SSoC) linkages between hubs and spoke hospitals across Wisconsin. Methods: In 2021, Coverdell partnered with eight Stroke Coordinators across five WI public health regions. Stroke Coordinators identified hospital transfer connections in their region where transfers occurred 25% or more of the time. With this data, Coverdell developed maps to visualize transfer lines between hospitals with estimated driving distances and transport times via ambulance. User testing, promotion, and publishing to the WI Department of Health Services Chronic Disease website was completed in April 2022. Findings: As of July 1, 2022, our maps have had 389 page views and 272 unique page views. These counts exclude DHS Internet Protocol traffic. Our interactive maps visualize transfers across WI and allow users to select individual hospitals to investigate relationships. We discovered a paucity of certified hospitals and stroke transfers in rural and northern WI. Conclusion: These maps can assist hospitals and Emergency Medical Service providers to visually identify where stroke patients are transported to. In addition, they can help state stroke programs and partners to recognize gaps in SSoC. The maps are a resource for those working with high-risk stroke populations to understand resources available in their communities and wider geographic areas. They also provide a visual representation for policy makers of locations where stroke services may be inadequate.
Background & Objectives: Stroke is the fifth leading cause of death and the leading cause of disability in the U.S. Timely administration of IV alteplase, can lead to reduction in the severity of disability and improve patient outcomes. The American Heart Association and the American Stroke Association have focused community awareness efforts on the importance of calling 9-1-1 when stroke symptoms are present. Our objective is to determine if arrival mode, specifically arriving by Emergency Medical Services (EMS) vs. privately owned vehicle (POV), impacts timely administration of IV alteplase. Methods: Get With the Guidelines (GWTG) -Stroke is a quality improvement initiative to improve care by promoting adherence to scientific guidelines. A retrospective review was conducted of 10,948 stroke patients from 261 hospitals using GWTG-Stroke in the Midwest from 2013 through 2015. Arrival mode, as well as IV alteplase administration times were analyzed. Results: In 2013, the median arrival to IV alteplase administration (admin) time was 58 minutes (min) when arriving by EMS vs. 64 min when arriving by POV. In 2014, patients arriving by EMS had a median arrival to admin time of 54 min in comparison to 59 min when arriving by POV. In 2015, patients arriving by EMS had a median door to admin of IV alteplase time of 51 min, whereas patients arriving by POV arrival to IV alteplase median time was 58 min. Conclusions: Midwest Stroke patients arriving by EMS received treatment of IV alteplase more timely than those that arrived by POV. Throughout the three years of this study, an average of 64.6% of patients arriving by EMS received IV alteplase within 60 min of hospital arrival in comparison to 52% of patients when arriving by POV. This demonstrates the collaboration, communication, and systems of care work being done by hospitals and EMS. With less than 40% of patients arriving by EMS, this data also identifies the continued need for community education regarding the importance of calling 9-1-1.
Introduction: Telestroke can enhance the timeliness and overall quality of stroke care for rural populations geographically separated from higher level stroke centers. To help hospitals utilize this resource, the Wisconsin (WI) Coverdell Stroke Program (Coverdell) and American Heart Association® (AHA) partnered with 15 hospital systems for a Telestroke Taskforce (TF) which met monthly June 2021-February 2022. Methods: A TF Charter and Framework guided the work. Framework items included: decision to call, telestroke consult, treatment and transfer decision, feedback, and patent satisfaction. Challenges, successes, WI consensus criteria, WI document development, Get With The Guidelines® (GWTG), resource needs and availability were addressed for these items. A manual and two videos were developed. The first video is a four clinician panel across four hospital systems sharing perspectives on telestroke implementation. Second, a demonstration video of conducting the National Institutes of Health Stroke Scale (NIHSS) via telestroke was produced to assist those unfamiliar with the process. The WI Telestroke Toolkit, which includes the charter, framework and established resources, will be published to the Coverdell website in Fall 2022. Results: Five measures were assessed quarterly Q1 2021-Q1 2022 among WI hospitals entering into GWTG® • Proportion of stroke patients w/ telestroke consult - 16.9ppt increase • Thrombolytic administration rate - 0.2ppt increase • Mechanical endovascular rate - 0.6ppt increase • Median time to consult - 2 minute reduction • Door-in-door-out times - 1 minute reduction Conclusions: Measure improvement, given the timeframe, is likely due to an increased focus on telestroke associated with the TF. As the Toolkit is shared and utilized by hospitals, we are hopeful for continued improvement. The Toolkit will be updated annually. Future considerations are to formally evaluate TS recipient satisfaction.
Background and Purpose: Abstractors of stroke records are at various levels of expertise in their role. Many have not received formal training and lack total confidence in the reliability of data entry. The purpose of this study was to engage participants in a 4-hour educational session to determine changes in confidence in performing stroke data abstraction and methods of interpretation. Methods: Pre and post-session surveys that contained six identical questions were utilized. The questions, reflected in the graph below, were utilized to measure changes in confidence when performing several tasks related to stroke record abstraction and data interpretation. Participants were asked to self-identify confidence level in performing the tasks on a scale of 1-4 at pre-session and again at post-session, where 1 is not at all confident, 2 is not very confident, 3 is somewhat confident and 4 is very confident. Results: Three abstraction trainings from April 2016 to April 2017 found a robust confidence level increase in all surveyed items. The chart displays each element’s mean based on the 1-4 scale. An overall confidence score was calculated at pre-session and at post-session. Internal reliability was measured using Cronbach’s alpha, and alpha coefficient for the six items is .924 indicating high internal consistency. Conclusions: The respondents had a mean of 2.37 pre-session compared to 3.28 post-session. This demonstrates an increase of 0.91 points from pre- to post-session, indicating a significant increase in confidence of data entry following the four-hour training course.
Background and Purpose: In 2013, the Wisconsin Coverdell Stroke Program (WI Coverdell) initiated an analysis of EMS and hospital data. These examinations revealed opportunities for improvement in transitions of care (toc) for timelier stroke treatment. Due to the importance of pre-hospital triage and teamwork on stroke outcomes, WI Coverdell knew it was essential to conduct joint performance improvement among EMS and hospital staff. Methods: WI Coverdell’s 61 participating hospitals represent 77% of annual stroke admissions to Wisconsin hospitals. Coverdell hospitals participate in the quarterly Coverdell Learning Collaborative (CLC) where they review several aggregated data points. Of these, arrival to computed tomography (CT) initiation and door to needle (DTN) times are analyzed and discussed. Stroke Coordinators at hospitals’ performing at a high level share with the CLC their performance improvement (PI) activities and best-practices. Establishing a cooperative, trusting relationship with hospitals EMS services is essential. Since November 2013 many Outreach events to Coverdell participating hospitals acute stroke teams (AST) and their EMS service providers have occurred. These events aim to foster a trusting relationship between EMS providers and Coverdell hospitals AST. The Outreach event focuses on the toc from EMS to the hospitals, and emphasizes the important role of EMS in the stroke patient’s chain of survival. The areas of education for EMS providers include content on triage, treatment, and pre-notification to the hospital of the suspected stroke patient. The AST caregivers gain an increased awareness of EMS’s existing knowledge and triage processes that occur in the field. Findings: In analyzing annual data from 2013 to 2017 our multi-disciplinary approach demonstrates impressive results. For arrival to CT initiation, the median time decreased from 22 minutes in 2013 to 13 minutes in 2017. The percentage of acute ischemic stroke patients who received alteplase in 60 minutes or less increased 33.7% from 2013 to 2017. Finally, the N increased from 111 in 2013 to 359 in 2017. Conclusion: A multi-disciplinary approach focused on improving toc between EMS and hospitals have led to remarkable improvements in WI Coverdell’s outcome data.
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