The New York State Coverdell Stroke Quality Improvement and Registry Program (Coverdell)

Coverdell Learning Collaborative

NYSDOH's Learning Collaborative is an initiative to provide in-depth education to Coverdell hospitals. During bi-weekly calls, stroke coordinators share their objectives and planned activities related to improving performance with our Quality Improvement Advisor. Hospitals also submit monthly planning reports documenting planned PDSA cycles. Past Learning Collaborative webinars have covered topics related to: decreasing door-to-needle times, t-PA administration for patients with low NIHSS, increasing the use of statins and timing of dysphagia screening, and patient education programs.

One of the QI activities of the Learning Collaborative is to focus on decreasing door-to-needle times through pre-notification from EMS.

Learning Collaborative Resources

Examples of hospital's self-identification of areas of strengths, weaknesses, and suggestions for improvement
Overall Strength Overall Weakness Overall Suggestion for Improvement
Monthly stroke simulation drill is a great intervention. Key is tracking the timing and identification of all weak links. Limited number of stroke cases and no record of the improvements for all of the Coverdell measures. Expand the team membership and submit the improvements in the area of dysphagia screening, statins, and patient education.
Stroke coordinator has been systematically adopting best practices and engaging the team in supporting acute stroke management. Many initiatives occurring over the same period of time. May be worth doing fewer initiatives and measuring the impact using a PDSA cycle for continuous improvement. If not already in process expand Stroke Order Sets in the EMR.
Strong team support and commitment Staffing changes may impact ongoing work. In addition to weakness on dysphagia screening. It sounds as though there is inconsistent RN staffing and the float and per diem staff are not screening. System is needed to address this issue. Community physicians with variable practice standards. Suggest all stroke cases are flagged in the ED and have the first dysphagia screen done in the ED and added to stroke order set. Also physician leaders should share individual performance data with community physicians and set standard of practice.
Stroke coordinator and physician have been able to move forward with the support of the ED staff to make improvements to acute stroke management. Stroke coordinator has multiple duties and also practices as a Physician Assistant, thereby limiting her ability to spend enough time on the Coverdell Program Consider identifying champions to manage the individual Coverdell measures and appoint them on various shifts and weekends. Arrange brief huddle with champions to de-brief on progress and needed support.
New Chief Medical Officer has taken a strong position on working the positions to drive improvements to acute stroke management. Criteria for stroke identification needs to be expanded to be more inclusive of subtle signs and symptoms of stroke. Criteria should be expanded and used for dysphagia screening to avoid the misses in screening.
There appears to be a tremendous amount of education and feedback to the staff. Quality improvement staff is active in retrospective chart review. The Stroke team is very much centered on the quality management department. It appears from the team submission there is no ED engagement and much of the work is through QI chart audits and feedback. This potentially diminishes the ability to provide an intervention prior to patient discharge. Engage a more diverse number of staff on the team and include night and weekend staff, work with EMS to do pre-notification, address the potential to move patients directly to CT scan and have t-PA concurrently mixed.
Strong stroke coordinator and support. Have an online education system for all of the staff to access and track performance. Continues to develop new programs for patient education and time to t-PA. CT scan is outside of the ED Have stroke team meet patient at CT scan and circumvent ED. Keep t-PA kit in the CT scan to administer immediately once stroke confirmed.
Ongoing team support and engagement at all levels. CMO is engaged in reviewing the data with individual physicians. Very "people" driven processes for the management of stroke patients. Education may not have the desired outcomes. Processes have to get hard-wired into the system to avoid failures based on an individual's absence, weekend and night cases, and other people dependent failures.
Strong commitment to rapid feedback of performance and medical director engagement. Standard order sets include hard stops to assure proper ordering of medications. Team does not include ED staff. Consider expanding the core team membership to include ED staff and speech pathologists.
Strong stroke coordinator that takes the lead in changing practice and education of staff. Team is limited to two people and lacks ED presence. Stroke coordinator is driving all of the improvements and the neurology dept. has to take the lead in the ED to manage stroke patients. ED physicians should be trained and empowered, along with ED staff, to manage stroke patients to avoid any potential delays. Ongoing mock stroke drills should be performed to train the ED staff on both stroke management and documentation.