Minnesota Stroke Registry
From 2012 to 2015, the Minnesota Stroke Registry achieved significant improvements in the percentage of patients for whom an NIHSS score was recorded (62% to 84%, P < .0001) and who were screened for dysphagia (74% to 80%, P < .0001) in 61 participating hospitals through facilitation of hospital performance improvement activities and regional education workshops for hospitals and EMS agencies.
Before 2007, the Minnesota Department of Health (MDH) participated in the Great Lakes Regional Stroke Network, which required that each state form a statewide body of partners from multiple sectors of the health care system to address stroke care. The resulting Minnesota Stroke Partnership contributed to establishing relationships with partners, building capacity for stroke care delivery, and developing a statewide plan for stroke systems of care. Building on this groundwork, MDH established the Minnesota Stroke Registry during the 2007–2012 CDC Paul Coverdell National Acute Stroke Program funding cycle to support efforts to implement the statewide plan. MDH then received funds from the 2012–2015 Coverdell Program to improve EMS-to-hospital transitions of care for stroke patients. During this time, Minnesota passed legislation authorizing MDH to designate hospitals as stroke centers; the state later passed an amendment requiring designated hospitals to participate in the stroke registry. The American Heart Association and other partners led the advocacy efforts for the new legislation; MDH supported these efforts with voluntary QI initiatives.
Using Coverdell funds, MDH focused on improving EMS-to-hospital transitions of care for stroke patients at 61 participating hospitals by implementing the following QI activities: (1) facilitating regional education workshops with hospitals and EMS, and (2) providing technical assistance through site visits and quarterly conference calls, and guiding performance improvement projects at participating hospitals.
The regional education workshops provided an opportunity to engage participating hospitals and EMS agencies in rural settings, and to feature local experts on stroke care. Workshop topics included stroke care guidelines, the NIHSS, and acute stroke-ready designation. During these workshops, hospital and EMS staff shared lessons and examples. One of these examples was the MDH EMS data collection pilot. A comprehensive stroke center (covering 20% of the state population) and five EMS agencies in the same county participated in the pilot, which proved to be a valuable model for stroke system changes across the state.
“We had dedicated time for EMS and hospitals to talk through some of the processes, including patient handoff, pre-hospital stroke protocols, and feedback tools.” — Regional Workshop Participant
MDH conducted quarterly conference calls and site visits and maintained regular communication with leadership at participating hospitals. As part of the performance improvement project, MDH provided a toolkit of performance improvement activities, encouraging hospitals to tailor the activities to their own needs and capacity. Another component, the Performance Improvement Collaborative, helped catalyze meaningful system changes, including decreased door-to-imaging time. The Emergency Care for Stroke Initiative of the Performance Improvement Collaborative also encouraged hospitals to coordinate EMS protocols, improve the coordination of patient handoff, provide EMS feedback, and enhance stroke education and awareness for EMS.
MDH’s efforts led to changes that improved the transition of stroke patients from EMS to hospital care. The pilot comprehensive stroke center enacted practice changes such as regularly disseminating stroke care guidelines to staff, providing EMS with feedback forms, and standardizing the use of the Cincinnati Prehospital Stroke Scale. The EMS Council active in the same county also standardized care protocols for its five local EMS agencies.
MDH’s focused technical assistance and QI initiatives also contributed to improvements in the quality of stroke care. Performance measure data from the state stroke registry of participating hospitals show improvements in 6 of the 12 key Coverdell Program quality-of-care performance measures from 2012 to 2015 (Table 1). The two measures that showed the greatest improvement over time were the percentages of patients for whom an initial NIHSS score was recorded and who were screened for dysphagia, which increased 22% and 6%, respectively.
Table 1. Improved Coverdell Program Quality of Stroke Care Measures, 2012–2015
|Screened for dysphagia||74%||80%||<.0001|
|Assessed for rehabilitation||98%||99%||<.05|
|Discharged on antithrombotic therapy||98%||99%||<.0001|
|Anticoagulation therapy for atrial fibrillation/flutter||91%||95%||<.01|
|Recording of NIHSS score||62%||84%||<.0001|
The Minnesota Stroke Registry reported that federal and state funding is critical to the sustainability of current program efforts, along with having the necessary data to demonstrate improved outcomes. The long-standing partnership with American Heart Association/American Stroke Association and other partners demonstrated the importance of collaboration to implement stroke systems of care. Continuing these partnerships will be instrumental to sustain efforts in supporting hospitals and EMS agencies in stroke care. The Minnesota Stroke Registry planned to continue building relationships with hospitals throughout the state and continue providing technical assistance to hospitals interested in improving stroke systems of care, focusing on smaller, rural hospitals with limited capacity. The Minnesota Stroke Registry received 2015–2020 Coverdell funding 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.