Stroke is a significant cause of death that requires multiple systems of care to work together to prevent incidence and improve patient outcomes. The Wisconsin Coverdell Stroke Program partnered with a Model Hospital to understand and improve the stroke system of care in one community. Developmental evaluation (DE) is an approach in which evaluators collaborate closely with project stakeholders to examine complex processes and systems within changeable contexts to develop interventions to improve outcomes. DE was used to assess this community’s stroke systems across the care continuum through process mapping with Model Hospital staff and through key stakeholder interviews with Model Hospital and emergency medical services staff, patients, and caregivers. Process mapping identified how patients and health care data flow through the system of care and highlighted areas where streamlining could improve the movement of patients and data across the care continuum. Interviews with stakeholders unveiled challenges and successes about how patient data are accessed and shared across the care continuum, and ideas for improving systems to be more efficient and supportive of stroke prevention and patient outcomes. Overall, DE was valuable in gaining an in-depth understanding of this complex environment to develop strategies to enhance stroke systems of care.
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.
Background and Purpose: EMS pre-notification of a suspected acute stroke patient assists the hospital in mobilizing the appropriate personnel and resources before the patient arrives. The pre-notification by EMS and mobilization of the hospitals stroke team will increase the probability of the appropriately screened acute stroke patient receiving thrombolytic therapy. The Wisconsin Coverdell Stroke Program (Coverdell) performed a multi-quarter analysis of the successes and barriers hospitals were experiencing with EMS pre-notifying, with an overarching goal to increase this percentage to >80%. Methods: Coverdell’s 66 participating hospitals represent 78% 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, EMS pre-notification times are analyzed and discussed. Stroke Coordinators at hospitals’ performing at a high level shared with the CLC their performance improvement activities and best practices related to EMS pre-notification. Methods used consisted of, educating and training EMS caregivers on improving pre-arrival notification by communicating in plain language stroke symptoms or verbalizing a “possible stroke”; educating and training emergency department caregivers on where to document the EMS pre-arrival report in the EHR; and educating the stroke data abstractor on where the EMS pre-hospital report is located in the EHR. Findings: In analyzing quarterly data from Q1 2017 to Q1 2019, our multi-disciplinary approach demonstrates impressive results. EMS pre-notification rose from 68.1% to 77.0%, with 82% reached in Q2 2018. Associated with this the median DTN time for those arriving by EMS decreased from 49 to 44 minutes, with the lowest median time in Q2 2018 of 42.5 minutes. Furthermore, thrombectomy therapy (alteplase and mechanical thrombectomy) administration rates increased from 21.5% to the highest in Q2 2018 at 26.8%. Conclusion: A multi-faceted approach focused on improving communication between EMS and hospitals by pre-notifying of a suspected stroke patients arrival, has led to remarkable improvements in Coverdell’s outcome data.
Background and Purpose: Hospitals’ communication with EMS on pre-arrival evidence based measures is essential in ensuring the best care for stroke patients in their community. To assist in assessing EMS pre-hospital care, the Wisconsin Coverdell Stroke Program (Coverdell) developed a quarterly report card for each of our participating hospitals. Coverdell’s 66 participating hospitals represent 78% of annual stroke admissions to Wisconsin hospitals. Coverdell utilizes the data entered into Get With The Guidelines® (GWTGs) - Special Initiatives tab. The data in the report card can be used to identify gaps in quality stroke care, followed by identifying performance improvement opportunities which can be initiated to address these gaps in care. Methods: Coverdell hospitals participate in the quarterly Coverdell Learning Collaborative (CLC) where they review several aggregated data points. CLC recognized a report card would provide an opportunity for participating hospitals to discuss the pre-arrival quality measures with their EMS providers and assist in developing a trusting relationship. To develop the report card, Coverdell’s Epidemiologist and Stroke Project Specialist analyzed the data measures from the GWTGs- Special Initiatives tab. We determined the need to provide benchmark groups for comparison, and to have established goals for each measure to assist in motivating and gauging progress of quality improvement initiatives. Findings: Coverdell released the pilot quarterly report card in Q3 2018. We then met with Stroke Coordinators whose hospitals were entering into the GWTGs Special Initiatives tab to discuss the goals, measures, and the need for modifications. The Q4 2018 report card incorporated the identified edits. Conclusion: Providing quarterly report cards with EMS pre-arrival measures will assist hospitals and their EMS providers in jointly identifying, planning, and implementing performance improvement initiatives in efforts to ensure seamless transitions of care for stroke patients in their community.
Background and Purpose: Ensuring the quality of a registry’s data is essential to its credibility and reliability of the information gathered. The Wisconsin Coverdell Stroke Program (WI Coverdell) monitors inter-rater reliability (IRR) through quarterly re-abstraction of five patient records from each of its participating hospitals. The goal for individual sites is 90% or greater concordance rate for each of the 28 data elements measured. This quarterly process ensures two abstractors at participating sites are familiar with the oftentimes difficult stroke data entry process. It also provides added benefit to hospitals by supporting continued quality improvement initiatives, as well as assists in meeting their certification bodies’ requirements. Methods: Participating hospitals gain access to two stroke data entry sites. One site is for entry of stroke abstracts; the second is utilized solely for re-abstraction entry. Quarterly, WI Coverdell performs an analysis of data agreement of the abstractions and re-abstractions. A subsequent quality report is sent to the hospital contact where the data elements that had mismatches are highlighted. Findings: Over nine quarters we have found individual sites agreement rates between two abstractors have varied from 70% to 100%. Whereas, WI Coverdell hospitals aggregated agreement rate has been stable at 92%-94%. Perceived rationales for agreement rates that are <90% include (1) the need for an identified source of truth for certain data elements, and (2) as new abstractors or re-abstractors begin stroke data entry, due to turnover in their roles, educational opportunities exist for understanding or clarification of the stroke coding instructions. Conclusions: A quarterly IRR process ensures two abstractors are proficient at data entry at participating hospitals, demonstrates the need for creating a source of truth document, and identifies learning opportunities for individual data abstractors.
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