California Stroke Registry/California Coverdell Program (CSR/CCP)
From 2013 to 2015, the California Stroke Registry/California Coverdell Program (CSR/CCP) achieved significant improvements in the percentage of patients who were given venous thromboembolism (VTE) prophylaxis (97% to 99%, P < .05) and who had an NIHSS score recorded (82% to 90%, P < .0001) in 50 hospitals through activities to improve agreement with specific performance measures and integration of patient-level data across hospitals and EMS agencies.
In 2007, the California Department of Health collaborated with the American Heart Association/American Stroke Association to develop a state stroke registry that aligned with the objectives and scope of the CDC Paul Coverdell National Acute Stroke Program. Early work on this registry positioned California to be competitive for future funding opportunities with CDC and laid a foundation for improving stroke care in California. The California Department of Health received Coverdell funding in 2012 to support and expand their earlier efforts. With these funds, the CSR/CCP focused on improving data collection and reporting, as well as stroke patient care in both the EMS and hospital care settings.
The CSR/CCP concentrated a majority of its resources on creating an integrated data system to support QI efforts and enable the development and evaluation of local stroke systems of care. In California, local EMS agencies establish stroke systems of care, which include hospital designation, screening and treatment practices, and patient transfer and transport protocols. The CSR/CCP worked closely with 3 of California’s 33 local EMS agencies and provided summary data tables highlighting the performance of the designated hospitals. These data were essential for driving local-level QI efforts and for evaluating the local systems of care.
In addition to working toward an integrated data system, the CSR/CCP engaged in two key QI activities: (1) improving data quality and (2) sharing best practices related to time-to-treatment measures (i.e., door to CT scan and door to needle).
To address issues with data quality, the CSR/CCP focused on two areas for Coverdell-participating hospitals: (1) incomplete records, which may be emblematic of other performance concerns; and (2) missing data for the time last known well variable, which is key for informing patient care for a given episode. Time last known well is the time at which the patient was last known to be without the signs and symptoms of the current stroke; it is used to calculate some of the in-hospital quality performance measures. The CSR/CCP provided technical assistance for those hospitals with the greatest proportion of missing data and incomplete records.
“If [time last known well] is not there, there’s no data to support the rest of patient care for a given episode.” — Program Staff Member
The CSR/CCP observed a wide range of performance on the door-to-needle time measure across Coverdell hospitals. To support improvements for time-to-treatment measures, the CSR/CCP did the following: First, for the lower-performing hospitals, the CSR/CCP conducted a survey to assess each hospital’s capacity for participating in QI activities related to improving door-to-needle time. At the same time, the CSR/CCP conducted interviews with personnel from the higher-performing hospitals to learn about the protocols implemented to improve door-to-needle times. Then the CSR/CCP shared and discussed these best practices and how they might be implemented at the lower-performing hospitals. These practices included viewing every suspected stroke as an actual stroke upon arrival, using Target: Stroke* tools, using data to inform feedback loops, and incentivizing performance. Finally, the CSR/CCP followed up with these hospitals to offer additional assistance and to track improvement.
The CSR/CCP activities contributed to system and practice changes in participating hospitals. For example, training and technical assistance improved data completeness in 14 hospitals, particularly for the time last known well variable.
The CSR/CCP activities contributed to better quality of care for stroke patients. While performance measure data indicated that many CSR/CCP hospitals already had a high capacity for stroke care at baseline, participating hospitals achieved improvements in 2 of the 12 key Coverdell Program quality-of-care performance measures from 2013 to 2015 (Table 1). The two measures that improved were the percentages of eligible patients receiving venous thromboembolism (VTE) prophylaxis and for whom an initial NIHSS score was recorded, which improved 2% and 8%, respectively.
Table 1. Improved Coverdell Program Quality of Stroke Care Measures, 2013–2015
|Venous thromboembolism (VTE) prophylaxis||97%||99%||<.05|
|Recording of NIHSS score||82%||90%||<.0001|
The CSR/CCP plans to sustain the work accomplished during the 2012–2015 program. In addition to expanding reach and infrastructure for stroke care, the CSR/CCP aims to continue work on developing an integrated data system for stroke patient care. Additionally, initiatives and collaborations outside of Coverdell-funded activities will help maintain key partnerships with the American Heart Association/American Stroke Association and the California Emergency Medical Services Association. The CSR/CCP received 2015–2020 Coverdell funding to continue its work in stroke care.
*Target: StrokeExternal is a national quality improvement initiative of the American Heart Association/American Stroke Association Get With the Guidelines®–Stroke program. The initiative focuses on improving acute ischemic stroke care by reducing door-to-needle times for eligible patients being treated with tPA.
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.