Arkansas Stroke Registry
From 2012 to 2015, the Arkansas Stroke Registry achieved significant improvements in the percentage of stroke patients for whom an NIHSS score was recorded (39% to 69%, P <0.001) and ischemic stroke patients who were given thrombolytic therapy (alteplase) (25% to 71%, P <0.001) in 42 participating hospitals through performance improvement reviews with hospitals and a pilot training program for EMS staff.
In 2005, the Arkansas General Assembly created an Acute Stroke Care Task Force to combat the high prevalence of stroke in the state. The Task Force recommended that Arkansas create a statewide stroke registry and stroke telemedicine program, which later became the AR Stroke Assistance through Virtual Emergency Support (AR SAVES) program. In 2011, the Task Force secured funding to design and implement the Arkansas Stroke Registry. Early work on the stroke registry positioned the Arkansas Department of Health to receive funding from CDC through the 2012–2015 Paul Coverdell National Acute Stroke Program. With these funds, Arkansas focused on improving EMS-to-hospital transitions for stroke patients, and developing a statewide stroke system of care plan.
The Arkansas Stroke Registry engaged in three key quality improvement (QI) activities: (1) conducting program reviews of performance measures with participating hospitals; (2) providing training and technical assistance for EMS and hospital staff; and (3) establishing a pilot program, Code Stroke, to improve the EMS-to-hospital transition of stroke patients.
Through partnerships with the Task Force, American Heart Association/American Stroke Association, and AR SAVES, the Arkansas Stroke Registry recruited 42 hospitals to participate in program performance measure reviews. Participating hospitals received their scores on 20 key stroke care measures and were awarded certificates for excellent performance. The Arkansas Stroke Registry used the data to provide customized technical assistance during hospital site visits and to implement QI activities.
The Arkansas Stroke Registry also provided training to hospital and EMS staff, including training for hospital staff on data abstraction, regional workshops for EMS staff on transition of stroke patients to the Emergency Department, and training for providers on Advanced Stroke Life Support (ASLS).
The Code Stroke pilot program trained more than 1,000 EMS staff on the importance of time management for stroke patients and providing an early pre-notification to the hospital for suspected stroke patients. Before this initiative, Arkansas did not provide stroke-specific education to EMS staff.
“We brought ASLS to the state through Coverdell. That was not in the state before, so now AR SAVES have instructors teaching this throughout the state, and so now we have 200 people across the state as providers.” — Program Staff Member
QI activities and training led to systems changes that improved the transition of stroke patients from EMS agencies to hospitals. The Code Stroke pilot program improved transitions of stroke patients so that they went directly into the CT scanner upon hospital arrival. Participating hospitals also enacted changes such as administering thrombolytic therapy while the patient was in the CT scanner and streamlining the dysphagia screening process.
Arkansas Stroke Registry activities contributed to better quality of care for stroke patients. Performance measure data from the state stroke registry of participating hospitals revealed significant improvements in 9 of the 12 key Coverdell Program quality-of-care measures from 2012 to 2015 (Table 1). The two measures that improved the most over time were the percentages of patients who had an initial NIHSS score recorded and of eligible patients receiving thrombolytic therapy, which improved 30% and 46%, respectively.
Table 1. Improved Coverdell Program Quality of Stroke Care Measures, 2012–2015
|Thrombolytic therapy (alteplase)||25%||71%||<.0001|
|Venous thromboembolism (VTE) prophylaxis||90%||99%||<.0001|
|Antithrombotic therapy by end of hospital day 2||92%||97%||<.0001|
|Assessed for rehabilitation||92%||97%||<.001|
|Smoking cessation counseling||87%||93%||<.01|
|Discharged on antithrombotic therapy||96%||98%||<.01|
|Discharged on statin medication||82%||93%||<.0001|
|Recording of NIHSS score||39%||69%||<.0001|
Through its established partnerships, the Arkansas Stroke Registry plans to support a new stroke systems of care plan that will promote using a standard of care protocol. Additionally, potential state legislation may change the stroke system of care by mandating stroke center designations recognized by the state health department. The state health department may also establish and implement EMS standard of care protocols and destination protocols for EMS transport.
Acronyms Used in the Summaries
CDC: Centers for Disease Control and Prevention
EMS: Emergency Medical Services
NIHSS: National Institutes of Health Stroke Scale
NQF: National Quality Forum
QI: Quality Improvement
Other Terms Defined
Primary Stroke Center: The Joint Commission’s Certificate of Distinction for Primary Stroke CentersExternal recognizes centers that make exceptional efforts to foster better outcomes for stroke care. Achieving certification signifies that the services provided have the critical elements to achieve long-term success in improving outcomes. The certification is based on the Brain Attack Coalition’s “Revised and Updated Recommendations for the Establishment of Primary Stroke CentersExternal” and includes the requirement to report on eight core standardized measures from the Joint Commission.