Georgia Coverdell Acute Stroke Registry (GCASR)
From 2012 to 2015, the Georgia Coverdell Acute Stroke Registry (GCASR) achieved significant improvements in the percentage of patients for whom an NIHSS score was recorded (68% to 86%, P < .0001) and who received thrombolytic therapy (alteplase) within 60 minutes of arrival (46% to 65%, P < .0001) in 65 participating hospitals, through a QI pilot program with hospital and EMS staff and performance improvement reviews with hospitals.
In 2004, the CDC Paul Coverdell National Acute Stroke Program awarded funds to the Georgia Department of Public Health to establish GCASR. In 2008, the Georgia General Assembly passed legislation to establish a primary stroke center designation, which required hospitals to participate in GCASR to be recognized as primary stroke centers, further strengthening hospital-based care for stroke patients. Using 2012–2015 Coverdell funds, GCASR expanded its focus from in-hospital stroke care to improving EMS-to-hospital transitions for stroke patients.
The main GCASR QI activities included (1) an EMS and hospital QI pilot program, (2) technical assistance through performance reports for hospitals and bi-monthly webinars offered jointly to EMS agencies and hospitals, and (3) free Advanced Stroke Life Support (ASLS) instructor trainings.
Using guidance from the Georgia Office of Emergency Medical Services, GCASR engaged nine EMS agencies and the hospitals they serve in a QI pilot program. At the in-person pilot launch meeting in February 2014, EMS and hospital representatives worked together to identify strategies to improve stroke care coordination and timely patient care. The pilot program facilitated communication between hospitals and EMS through shared activities and convening stakeholders. It also catalyzed regional QI initiatives on topics such as transporting patients to the most appropriate facility and improving pre-notification.
GCASR provided technical assistance to hospitals and EMS, including bi-monthly webinars and training for hospital staff on data abstraction. GCASR used registry data to guide QI activities and to update hospitals and EMS agencies on their performance.
GCASR trained 48 new instructors to teach ASLS courses. These courses were important not just for the content but also for the opportunity to teach EMS medics and hospital staff together in the same class, which sometimes led to joint troubleshooting of stroke care protocols across care settings.
“When Coverdell provided the ASLS materials to many pre- and in-hospital facilities, we taught medics and nurses in the same class. Medics practiced giving a radio report, and could get direct feedback on the best practices and effective ways of giving pre-notifications. This opens the dialogue.” — Medic
GCASR’s efforts improved several stroke care practices, including encouraging the use of a single pre-hospital stroke scale and developing an inter-hospital transport protocol to standardize the treatment of patients who receive thrombolytic therapy (alteplase) at one hospital before being transferred to another hospital with greater stroke care capacity.
Participation in GCASR also contributed to better quality of care for stroke patients. Performance measure data from participating hospitals revealed improvements in 6 of the 12 key Coverdell Program quality-of-care measures (Table 1). The two measures that had the largest increase over time were the percentages of patients who received thrombolytic therapy within 60 minutes of arrival (door-to-needle time ≤ 60 minutes) and of patients for whom an NIHSS score was recorded, which increased 19% and 18%, respectively.
Table 1. Improved Coverdell Program Quality of Stroke Care Measures, 2012–2015
|Thrombolytic therapy (alteplase)||70%||81%||<.001|
|Venous thromboembolism (VTE) prophylaxis||96%||99%||<.0001|
|Discharged on statin medication||93%||96%||<.0001|
|Door-to-needle time ≤ 60 minutes||46%||65%||<.0001|
|Recording of NIHSS score||68%||86%||<.0001|
GCASR staff reported that future directions for stroke care in Georgia include increasing hospital and EMS ownership of stroke QI activities and implementing a remote stroke treatment hospital designation. One way that GCASR aims to increase hospital and EMS ownership is by promoting peer-to-peer learning through a professional alliance of hospital staff, EMS agencies, and other practitioners. Georgia hopes to provide greater access to stroke care for rural residents by implementing a protocol to designate remote stroke treatment centers, thereby supporting remote hospitals to work closely with more established hospitals. GCASR received 2015–2020 Coverdell funds to continue its work in stroke care.
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.