North Carolina Stroke Care Collaborative (NCSCC)
From 2012 to 2015, the North Carolina Stroke Care Collaborative (NCSCC) achieved significant improvements in the percentage of patients provided with stroke education (75% to 91%, P < .0001) and for whom an NIHSS score was recorded (71% to 80%, P < .0001) in 57 participating hospitals through educational outreach with hospitals and EMS agencies and grant awards for collaborative QI projects.
In 2004, CDC awarded funds to the North Carolina Division of Public Health (NC DPH) through the CDC Paul Coverdell National Acute Stroke Program. This funding helped establish the NCSCC to use data from the registry to drive QI in stroke care. NC DPH received 2012–2015 Coverdell funds to improve EMS-to-hospital transitions of care for stroke patients.
NCSCC’s key QI activities included (1) developing an EMS and hospital data linkage portal; (2) providing educational events and peer-to-peer sharing among hospitals and EMS agencies; and (3) awarding grants for collaborative QI activities.
From 2012 to 2015, NCSCC focused significant resources on improving data linkages between EMS agencies and hospitals. NCSCC launched a data linkage pilot program, giving participating hospitals and their EMS counterpart agencies the opportunity to select data elements to be included in online data linkage reports. NCSCC contracted with a data vendor to develop a portal that linked specific stroke-related EMS and hospital electronic medical record data elements. After testing the portal, EMS agencies and hospitals provided survey feedback on the usefulness of the pilot data to NCSCC. Simultaneously, NCSCC also continued to improve its custom data tool to address and improve in-hospital care.
NCSCC coordinated regional workshops, monthly webinars, and 20-minute informal discussions as requested about stroke treatment and care, four listservs to connect stroke care professionals, and a peer-to-peer mentoring network for stroke care coordinators. These activities provided opportunities for hospital and EMS staff to network and share knowledge. Registry data guided the selection of QI topics and speakers. By leveraging its partners’ education network, NCSCC was able to increase the percentage of EMS professionals attending regional workshops from 17% to 40%.
“We [hospital and associated EMS agencies] moved to the MEND exam* so that what we’re doing and what they’re doing is the same. Before this QI workshop, we weren’t communicating the specifics.” — Hospital Staff Member
Using additional funding from the state of North Carolina, the NCSCC was able to award grants in amounts up to $20,000 to hospitals to improve stroke care, requiring that they partner with their local EMS counterparts. Two examples of QI projects funded through the grant program included a hospital collaborating with local EMS agencies to develop an EMS education module and another hospital working with a local EMS agency on a blood draw pack labeling system to ensure that the samples were collected and transferred efficiently between care settings.
NCSCC’s efforts contributed to stroke care systems and practice changes in participating hospitals. For example, as a result of attending a regional workshop, one participating hospital worked with the local EMS agency to implement a standardized stroke screening process and to develop a better defined transfer of care protocol.
Participation in NCSCC also contributed to better care for stroke patients. Performance measure data from the state stroke registry of participating hospitals revealed significant improvements in 6 of the 12 key Coverdell Program quality-of-care measures from 2012 to 2015 (Table 1). The two measures with the greatest improvement over time were the percentages of patients who received stroke education and for whom an NIHSS score was recorded, which increased 16% and 9%, respectively.
Table 1. Improved Coverdell Program Quality of Stroke Care Measures, 2012–2015
|Venous thromboembolism (VTE) prophylaxis||98%||99%||<.05|
|Assessed for rehabilitation||90%||96%||<.0001|
|Discharged on statin medication||84%||91%||<.0001|
|Anticoagulation therapy for atrial fibrillation/flutter||90%||92%||<.01|
|Recording of NIHSS score||71%||80%||<.0001|
Future proposed directions for stroke care in North Carolina included an expansion of the data linkage pilot program and efforts to raise public awareness of stroke symptoms and the existence of the registry. Through its partnerships, NCSCC aims to raise awareness about stroke prevention, especially in rural parts of the state, and to communicate the value of the registry within the stroke system of care to the public. In addition, NCSCC plans to collaborate with key stakeholders across the state to move across the care continuum to improve transitions of care in the post-discharge stroke care arena.
*The Miami Emergency Neurological Deficit (MEND) exam is a focused neurological assessment that can be used in both the pre-hospital setting and the in-hospital setting.
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.