Iowa Coverdell Stroke Program (ICSP)
From 2012 to 2015, the Iowa Coverdell Stroke Program (ICSP) achieved significant improvements in the percentage of patients provided with stroke education (87% to 94%, P < .001) and prescribed anticoagulation therapy for atrial fibrillation/flutter (86% to 93%, P < .05) in 30 participating hospitals by establishing interdisciplinary learning communities and providing education to EMS agencies.
In 2008, CDC funded the Iowa Department of Public Health to develop a heart disease and stroke prevention program. The following year, the Iowa Department of Public Health received additional funding from CDC to create the Iowa Stroke Registry, and participating hospitals began collecting data on stroke-related measures on a voluntary basis. The Iowa Department of Public Health received 2012–2015 CDC Paul Coverdell National Acute Stroke Program funds to continue the registry and improve EMS-to-hospital transitions for stroke patients.
Through a partnership with the Iowa Healthcare Collaborative, the Iowa Department of Public Health engaged 30 hospitals in data-driven QI. ICSP’s two main QI activities included (1) the development of stroke action teams through learning communities and (2) EMS education, including calls, webinars, tutorials, and trainings.
Learning communities provided a forum for education on quality and performance tools for hospital staff from primary stroke centers and stroke-capable hospitals and EMS staff. The learning communities fostered the creation of stroke action teams—interdisciplinary teams within local networks that participated in educational and QI activities together.
ICSP provided educational opportunities specifically for EMS to improve treatment in the field and EMS routing. For example, ICSP created an EMS run sheet to indicate where patients will receive the best care for different kinds of strokes. The run sheet was based off ICSP-created maps of primary and stroke-capable hospitals and corresponding drive times. ICSP reviewed these maps with EMS staff. Together, they identified each EMS agency’s location on the map and the facilities they should deliver patients to in order to improve drive time.
“Some EMS would just bring people to the closest hospital, not knowing if it was stroke-capable or not. But, I think the EMS agencies we work with now know where they should go.” — Program Staff Member
ICSP’s efforts led to systems changes that improved EMS-to-hospital transitions for stroke patients. With CDC funds, ICSP implemented practice changes such as switching from the standard neurological assessment to a more comprehensive scale, modifying the EMS protocol to ensure that all stroke patients would eventually be transported to a primary stroke center, and increasing the number of stroke-capable facilities in the state.
ICSP’s work also contributed to maintaining and improving quality of stroke care in participating hospitals. Performance measure data from the state stroke registry of participating hospitals revealed improvements in 3 of the 12 key Coverdell Program quality-of-care measures from 2012 to 2015 (Table 1). The two measures that showed the greatest improvements over time were the percentages of patients provided with stroke education and of patients prescribed anticoagulation therapy for atrial fibrillation/flutter; both increased 7%.
Table 1. Improved Coverdell Program Quality of Stroke Care Measures, 2012–2015
|Discharged on statin medication||96%||99%||<.01|
|Anticoagulation therapy for atrial fibrillation/flutter||86%||93%||<.05|
ICSP staff reported that future directions for stroke care in Iowa include technology and legislation changes to improve data linkages. In 2015, all EMS providers switched to new software that expands the stroke-related indicators collected by EMS providers. Furthermore, the software is able to transfer information directly into the registry, which could facilitate the use of electronic records and potentially phase out paper records. Stroke care in Iowa may also change if the Iowa Code changes to make stroke a mandatory reportable condition. This change could increase participation in the registry across the state and improve data linkages across the continuum of 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.