Washington Coverdell Stroke Program Works with Rural Hospitals to Improve Stroke Care
In 2018, stroke was the sixth leading cause of death in the state of Washington. Nearly 3,000 Washingtonians died of a stroke that year.
Between December 2018 and June 2020, quality improvement managers and stroke program coordinators from 13 rural hospitals in the Washington Rural Health Collaborative (WRHC) participated in a Coverdell-sponsored quality improvement project. The hospitals aimed to achieve at least the 75th percentile on three of the American Heart Association’s Get With The Guidelines® stroke performance measures.
The Washington Coverdell Stroke Program focused on improving the percentage of stroke patients receiving a computerized tomographic brain imaging scan, commonly called a CT scan, within 25 minutes of arriving at the hospital. That performance measure is called “door to CT.”
Challenge and Approach
Compared with people living in urban areas, people living in rural areas are less likely to get advanced treatment following a stroke. Rural residents are also more likely to die of a stroke.1 Rural hospitals play a critical part in the stroke care system. But with limited resources, often-overburdened staff, and fewer stroke patients, it can be difficult for rural hospitals to monitor and analyze data for quality improvement measures.
Challenges include having the staff and data systems needed to collect and use stroke quality of care data, helping staff address delays in care, and implementing changes to improve performance.
The Washington Coverdell Stroke Program staff tested a new data collection process and interventions to improve stroke patient care among the state’s rural hospitals. Some of the activities that led to involved:
- Partnering with WRHC, which had strong internal leadership, good relationships among members, and hospital administration support.
- Identifying a quality improvement data collection tool. WRHC used Quality Health Indicators, a benchmarking program designed for rural hospitals and clinics to compare performance on selected quality measures and to define best practices.2 The 13 WRHC hospitals were already using Quality Health Indicators for other purposes.
- Engaging participants in choosing the measures they wanted to work on, rather than imposing the measures to be assessed.
- Analyzing barriers to appropriate door-to-CT times. The results were used to develop and tailor interventions for individual hospitals to reduce workflow times to more quickly get stroke patients the treatment and care they need.
- Providing an all-day training to address stroke care guidelines, protocols, and challenges.
“Working with WRHC allowed us to learn from each other and share tips on education, how to shave off door-to-CT scan minutes, and get comfortable with new improvement possibilities. It let us hear about different options such as telestroke and perhaps consider them as a future option.”
The average door-to-CT time went from a baseline of 47 minutes to 30 minutes in the first two quarters of the project and to an average of 25 minutes in the last two quarters. WRHC achieved its goal of 75th percentile performance on the Get With The Guidelines® metric.
Quality improvement managers and stroke coordinators from rural hospitals typically have little time to participate in Coverdell quality improvement activities. It was helpful to offer quality improvement education at WRHC’s regular monthly meetings. The program also provided in-person or virtual assistance to hospitals, helped conduct gap analyses, and shared standardized order sets. The Washington Coverdell Stroke Program provided funding for travel to in-person trainings and chose a location convenient to most of the 13 rural, critical access hospitals. Remote participation was also available for part of the training.
The factors that contributed to success in meeting the Get With The Guidelines® metrics include:
- Partnering with an existing collaborative group that had a quality improvement committee.
- Using Quality Health Indicators, a known data collection tool tailored to the users.
- Engaging participants in the development of the project and the training.
- Using the Model for Improvement and other Institute for Healthcare Improvement tools.3
- Keeping goals realistic and straightforward.
- Using a contract with WRHC, setting clear expectations for deliverables and accountability, and having Coverdell staff directly involved in the project.
To continue their success, the Washington Coverdell team will incorporate what was learned about the technical assistance and training needs of rural hospitals into quality improvement activities. In addition, the team will:
- Bring some of the challenges that rural hospitals face—such as finding beds in tertiary care hospitals for patients who need specialized care—to the state advisory committee and regional quality improvement committees.
- Share tips from the collaborative’s members with other rural hospitals. One tip was to not wait for lab results to treat patients who have ischemic stroke (a stroke caused by a blood clot) with a clot-busting medicine called alteplase in most situations. Alteplase, also called tPA (tissue plasminogen activator), is the standard of care.
The project received positive feedback from participants.
- Hammond G, Luke AA, Elson L, Towfighi A, Joynt Maddox KE. Urban-rural inequities in acute stroke care and in-hospital mortality. Stroke. 2020;51(7):2131–8.
- Kansas Department of Health and Environment Office of Rural Health, Kansas Hospital Association, Kansas Hospital Education and Research Foundation, Kansas Rural Health Options Project. Quality Health Indicatorsexternal icon. Accessed November 18, 2020.
- Institute for Healthcare Improvement. How to Improveexternal icon. Accessed November 12, 2020.