Ohio Coverdell Stroke Program
From 2012 to 2015, the Ohio Coverdell Stroke Program achieved significant improvements in the percentage of patients for whom an NIHSS score was recorded (77% to 90%, P < .0001) and who received thrombolytic therapy (alteplase) within 60 minutes of arrival (41% to 59%, P < .0001) in 46 participating hospitals through education, training, and consultation with hospitals based on aggregated data reports.
The Ohio Department of Health received Paul Coverdell National Acute Stroke Program funding from CDC in 2007 and in 2012. From 2007 to 2012, the Ohio Coverdell Stroke Program focused on acute care QI initiatives and achieved high levels of in-hospital quality of stroke care. In 2012, the Ohio Coverdell Stroke Program determined that 27 of the 42 participating hospitals were already working toward improving transitions of care, either hospital-wide or for conditions other than stroke, through various federally funded initiatives. Ohio Coverdell established a data collection component within their American Heart Association Get With the Guidelines® (GWTG)—Stroke platform to collect data on follow-up appointment scheduling. This strategically poised the Ohio Coverdell Stroke Program to expand its focus to include improving transitions of care from hospitals to post-hospital facilities using 2012–2015 Coverdell funds.
The Ohio Coverdell Stroke Program’s main QI activities included (1) providing technical assistance and report development to hospitals for in-hospital and post-hospital stroke care initiatives, and (2) scheduling follow-up appointments for patients discharged home to improve transitions of care from acute care to post-hospital settings.
During 2012–2015, the program expanded the number of participating hospitals from 42 to 46. Program staff supported hospitals’ stroke care efforts by providing technical assistance and aggregate data reports of GWTG care quality measures. The Ohio Coverdell Stroke Program used baseline hospital data to identify QI needs and opportunities. Based on the needs and opportunities identified, the Coverdell QI specialist collaborated with partners to offer education, training, and consultation to hospitals to continually improve the quality of data entered into GWTG.
“…[A] local hospital…did a great job of 60% to 70% [patients] leaving the hospital with an appointment. Then they took it further to see of those that had an appointment how many actually went to it. And they had phenomenal success, they had 80% to 90% show up to that appointment. And it was exciting for them to see how many actually showed up.” — Program Staff Member
To address stroke transitions of care from hospital to post-hospital settings, the Ohio Coverdell Stroke Program focused on increasing the rate at which participating hospitals scheduled follow-up appointments for stroke patients discharged home and to other health care facilities. Hospitals developed scheduling processes and recorded the number of follow-up appointments in a GWTG tab. The Ohio Department of Health provided reports to hospitals on the percentage of patients discharged home who had a follow-up appointment scheduled with their primary care provider or neurology provider. Hospitals used the data to drive increases in scheduling rates. The Ohio Coverdell Stroke Program also designed and facilitated a pilot project with four hospitals to determine whether patients were keeping their follow-up appointments. The pilot included a root-cause analysis that hospitals used to identify where the breakdown in the scheduling process might be occurring.
Ohio Coverdell Stroke Program activities contributed to practice and systems changes in participating hospitals. For example, scheduling process changes resulted in an increase in the number of follow-up appointments made for patients before discharge, and documenting data in the GWTG tool facilitated QI within partnering hospitals.
Performance measure data from the state stroke registry of participating hospitals revealed improvement in all 12 Coverdell Program quality-of-care performance measures from 2012 to 2015 (Table 1). The two measures with the greatest increase over time were the percentages of eligible patients treated with thrombolytic therapy (alteplase) within 60 minutes of hospital arrival (door-to-needle time) and for whom an initial NIHSS score was recorded, which increased 18% and 13%, respectively.
Table 1. Improved Coverdell Program Quality of Stroke Care Measures, 2012–2015
|Thrombolytic therapy (alteplase)||80%||87%||<.05|
|Screened for dysphagia||85%||88%||<.0001|
|Venous thromboembolism (VTE) prophylaxis||98%||100%||<.0001|
|Antithrombotic therapy by end of hospital day 2||97%||98%||<.0001|
|Assessed for rehabilitation||98%||99%||<.001|
|Smoking cessation counseling||96%||99%||<.0001|
|Discharged on antithrombotic therapy||98%||99%||<.0001|
|Discharged on statin medication||95%||98%||<.0001|
|Anticoagulation therapy for atrial fibrillation/flutter||94%||97%||<.01|
|Door-to-needle time ≤ 60 minutes||41%||59%||<.0001|
|Recording of NIHSS score||77%||90%||<.0001|
In the future, the Ohio Coverdell Stroke Program aims to collaborate with hospitals to address contextual factors, such as transportation and caregiver education, that could prevent patients from attending follow-up appointments. Additionally, the Ohio Coverdell Stroke Program plans to sustain its networking activities to ensure that stroke care providers have future opportunities to share information on best practices. The program also plans to develop workforce capacity by providing education, training, clinical consultation, and technical assistance to hospital stroke teams. Further, the program wants to continue providing data reports to participating hospitals. These reports are valuable as stroke coordinators often do not have time to aggregate program data or create reports for administrative and stroke center certification purposes. The Ohio Department of Health 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.