Wisconsin Coverdell Stroke Program: Hospitals

Image of a patient being wheeled in a gurney in a hospitalWisconsin hospitals of all types and sizes are invited to be part of Wisconsin’s Coverdell Stroke Program. Hospitals can choose to participate in one or more ways:

  • Paul Coverdell National Acute Stroke Registry
  • Wisconsin Stroke Coalition (WSC)
  • Stroke Coordinators of Wisconsin (SCOW)
  • Educational events
  • Coverdell Learning Collaborative (CLC)
  • Partner Hospital Agreement
  • Champion Hospital Agreement

Overview

Stroke Care Partners Coverdell Program Support. Participating stroke care partners in the Wisconsin Coverdell Stroke Program receive multiple benefits, such as:

  • Access to “Building Blocks of a Stroke Program Toolkit.”
  • Phone assistance to plan and implement stroke-related activities.
  • Collaboration with American Heart Association/American Stroke Association for technical assistance on data collection.
  • Invitations to stroke education opportunities.
  • Recognition on the state stroke program website.
  • A press release template on being a Stroke Care Partner to use for local publicity.
  • Coverdell Stroke Partner Agreement, F-01648 (PDF).

Champion Hospitals Coverdell Program Support. Participating Champion Hospitals in the Wisconsin Coverdell Stroke Program receive multiple benefits such as:

  • Learning opportunities for stroke teams.
  • Resources for stroke care QI and community stroke education.
  • Coordinated development of Coverdell-related abstracts and presentations (e.g., for professional meetings) when appropriate.
  • Safe and secure management of all de-identified data submitted by the hospital.
  • Chart re-abstraction results according to Centers for Disease Control and Prevention standards for quality and security.
  • Facilitated peer-to-peer and mentoring opportunities between hospitals to share best practices.
  • Inclusion in the Coverdell Champion Agreement, F-01649 (PDF).

Coverdell Registry

The mission of the Paul Coverdell National Acute Stroke Registry is to:

  • Measure, track, and improve the quality of care and access to care for stroke patients from onset of stroke symptoms through rehabilitation and recovery.
  • Decrease the rate of premature death and disability from stroke.
  • Eliminate disparities in care.
  • Support the comprehensive stroke care system across the continuum of care.
  • Improve access to rehabilitation and opportunities for recovery after stroke.
  • Increase the workforce capacity and scientific knowledge of stroke care within stroke systems of care.

Wisconsin’s participation in the Coverdell Registry is facilitated by the Wisconsin Division of Public Health and MetaStar.

About the Registry Process

Participating hospitals enter and track stroke data using an online quality improvement tool where data is abstracted for 10 consensus measures. Measures were established by the Centers for Disease Control and Prevention (CDC) in collaboration with The Joint Commission and the American Heart Association/American Stroke Association based on evidence from multiple clinical trials in peer-reviewed journals. These provide the foundation for stroke QI in Wisconsin:

  • Venous Thromboembolism (VTE) Prophylaxis
  • Discharged on Antithrombotic Therapy
  • Anticoagulation Therapy for Atrial Fibrillation/Flutter
  • Thrombolytic Therapy
  • Antithrombotic Therapy by End of Hospital Day 2
  • Discharged on Statin Medication
  • Stroke Education
  • Assessed for Rehabilitation
  • Smoking Cessation Counseling
  • Dysphagia Screening

Champion Hospitals

  • Ascension | Columbia St. Mary's Milwaukee
  • Ascension | Columbia St. Mary's Ozaukee
  • Ascension | Wheaton Franciscan Elmbrook Campus
  • Ascension | Wheaton Franciscan Healthcare-All Saints
  • Ascension | Wheaton Franciscan Healthcare-Franklin
  • Ascension | Wheaton Franciscan Healthcare-St. Francis
  • Ascension | Wheaton Franciscan-St. Joseph's Campus
  • Aspirus Grand View Hospital
  • Aspirus Iron River Hospital and Clinics
  • Aspirus Keweenaw Hospital
  • Aspirus Langlade Hospital
  • Aspirus Medford Hospital and Clinics
  • Aspirus Ontonagon Hospital
  • Aspirus Riverview Hospital and Clinics
  • Aspirus Wausau Hospital
  • Aurora BayCare Medical Center
  • Aurora Lakeland Medical Center
  • Aurora Medical Center Grafton
  • Aurora Medical Center Kenosha
  • Aurora Medical Center Manitowoc County
  • Aurora Medical Center Oshkosh
  • Aurora Medical Center Summit
  • Aurora Medical Center of Washington County
  • Aurora Memorial Hospital of Burlington
  • Aurora St. Luke's Medical Center
  • Aurora St. Luke's South Shore
  • Aurora Sheboygan Medical Center
  • Aurora Sinai Medical Center
  • Aurora West Allis Medical Center
  • Bellin Memorial Hospital
  • Beloit Health System
  • Froedtert and Medical College of Wisconsin
  • Gundersen Health System
  • Gundersen Moundview Hospital and Clinics
  • Mayo Clinic Health System Eau Claire
  • Mayo Clinic Health System-Franciscan Healthcare La Crosse
  • Mercy Hospital and Trauma Center, Janesville
  • Meriter UnityPoint
  • ProHealth Care Oconomowoc Memorial Hospital
  • ProHealth Care Waukesha Memorial Hospital
  • HSHS Sacred Heart Hospital
  • SSM Health St. Mary's Hospital-Janesville
  • SSM Health St. Mary's Hospital-Madison
  • St. Mary's Hospital Medical Center of Green Bay, Inc.
  • St. Nicholas Hospital of the Hospital Sisters of the Third Order of St. Francis
  • St. Vincent Hospital of the Hospital Sisters of the Third Order of St. Francis
  • ThedaCare Regional Medical Center-Neenah
  • University of Wisconsin Hospital and Clinics

Partner Hospitals

  • Beaver Dam Community Hospitals, Inc
  • Black River Memorial Hospital
  • Community Memorial Hospital
  • Cumberland Healthcare
  • Divine Savior Healthcare
  • Hayward Area Memorial Hospital and Waters Edge
  • Mercy Walworth Hospital
  • Ministry Sacred Heart
  • Ministry St. Mary's
  • Reedsburg Area Medical Center
  • St. Joseph's Hospital-West Bend
  • ThedaCare Medical Center-Berlin
  • Upland Hills Health

Coverdell Learning Collaborative

The Coverdell Learning Collaborative (CLC) meets for one hour quarterly, either in person or by teleconference. The meeting provides participating Wisconsin Coverdell Hospitals the opportunity to network with fellow stroke coordinators, ask questions, and share best practices. The meeting consists of updating members on Wisconsin Stroke Coalition (WSC) and stroke systems of care development, recruitment, outreach, and QI initiatives. The CLC reviews blinded data to identify areas where stroke care can be improved. Attendance is required at three of four (75 percent) of these meetings.

Performance Improvement Program

In support of the ongoing quality improvement efforts of participating hospitals, the CLC analyzes Wisconsin Coverdell Stroke Program aggregated hospital stroke data and discusses evidence-based practices and processes that are involved in achieving sustained high performance.

At our June 2018 meeting we acknowledged and celebrated the Stroke Coordinators with the fastest and most improved arrival to CT completion times. The coordinators shared QI efforts which assisted their sites in reaching this high level of performance.

  • Fastest time to CT initiation in those stroke patients arriving <4.5 hours from Last Known Well for Q1 2018:
    • Gundersen Moundview Hospitals and Clinics
  • Most improved Arrival to CT initiation in those stroke patients arriving <4.5 hours from Last Known Well for Q1 2018:
    • St. Vincent Hospital of the Hospital Sisters of the Third Order of St. Francis

We also acknowledged and supported the three hospitals with 100% defect-free care within the 10 Coverdell performance measures for Q1 2018

  • Ascension | Wheaton Fransican-Elmbrook Campus
  • Aspirus Medford Hospital and Clinics
  • Aurora West Allis Medical Center

Another notable achievement identified by Coverdell Learning Collaborative (CLC) belongs to the four hospitals with 100% agreement between two abstractors for Q4 2017 re-abstractions.

  • Ascension Columbia St. Mary's Ozaukee
  • Ascension Columbia St. Mary's Milwaukee
  • Aspirus Wausau Hospital
  • Oconomowoc Memorial Hospital

A PI focus for our Coverdell Learning Collaborative (CLC) is the EMS Pre-notification measure. Hospitals who achieved 100% EMS Pre-notification in Q1 2018 shared their best practices:

  • Aspirus Medford Hospital and Clinics
  • Aurora Medical Center Manitowoc County
  • Aurora Medical Center of Washington County
  • Gundersen Moundview Hospital and Clinics
  • ProHealth Care Oconomowoc Memorial Hospital
  • ProHealth Care Waukesha Memorial Hospital
  • Thedacare Regional Medical Center-Neenah
  • University of Wisconsin Hospitals and Clinics

We also explored the possible barriers in attaining this information.

An in depth review of the Coverdell Post Hospital Transition of Care (TOC) Measures occurred. We discussed the opportunity and benefits of collecting these data elements in the new Coverdell Post Discharge Mortality and Readmissions Tab within the Get With The Guidelines® IQVIA PMT® system.

Stroke Coordinators of Wisconsin (SCOW)

The Stroke Coordinators of Wisconsin (SCOW) Committee is a performance improvement and learning collaborative focused on improving stroke care and patient outcomes. The group is open to all stroke coordinators in Wisconsin. Members meet quarterly to review blinded data, identify areas where stroke care can be improved, and share experiences in implementing best practices. This forum is a great opportunity to:

  • Hear from outside speakers on a variety of stroke topics.
  • Learn from others in the areas of data collection, quality improvement initiatives, and stroke systems of care.
  • Gain insight on preparing for stroke center certification or recertification.
  • Network with stroke coordinator peers throughout Wisconsin.

The Stroke Coordinators of Wisconsin Committee has an advisory council that:

  • Provides leadership and oversees progress on meeting SCOW recommendations.
  • Develops meeting agendas based on the group’s interest and quality improvement priorities.
  • Assists in recruiting speakers.

SCOW Mentor Program

Need guidance from a fellow stroke coordinator or stroke leader?

Mentors have volunteered to offer insight and resources as you plan and implement stroke quality improvement initiatives and continue to develop an evidenced-based program. Requesting mentorship is easy.

To become a mentee:

  1. Identify your learning need.
  2. Decide on a mentor with the expertise you are seeking. Current SCOW mentors are detailed in the table below.
  3. Email the mentor who best meets your learning need using the contact email provided. Please include your name, hospital, contact information, availability, and a brief description of your learning interests.
  4. If the mentor accepts, discuss your learning needs and agree on a date/time to meet via phone or in person.

Please note that mentors may not be immediately available, depending on their schedules and workloads.

Interested in becoming a SCOW mentor?

Please contact Dot Bluma at dbluma@metastar.com with your name, hospital (including city), preferred contact information, and areas of expertise in which you would welcome mentoring fellow stroke coordinators.

Current SCOW mentors:

Anne Remley-Haines
Meriter Unity Point Hospital Madison
Email: anne.remley-haines@unitypoint.org
Certification in PSC
General stroke care and treatment
Professional certification (SCRN, CNRN)
Kristin Randall
Theda Clark Medical Center Neenah
Email: kristin.randall@thedacare.org
Certification in PSC
Developing a stroke team
General stroke care and treatment
Performance data to drive quality improvement
Professional certification (SCRN, CNRN)
Kathy Polum
Bellin Health Green Bay
Email: kathy.polum@bellin.org
Certification in PSC
Developing a stroke team
Developing processes for acute stroke response
Engaging EMS
General stroke care and treatment
Performance data to drive quality improvement
Paul Vilar
Aurora St. Luke's Medical Center Milwaukee
Email: paul.vilar@aurora.org
Certification in PSC
Developing a stroke team
Developing processes for acute stroke response
Performance data to drive quality improvement
Jeannie Pittenger
Sacred Heart Hospital Eau Claire
Email: Jeannie.pittenger@hshs.org
Certification in PSC
Developing a stroke team
Developing processes for acute stroke response
Engaging EMS
General stroke care and treatment
Mock stroke survey
Performance data to drive quality improvement
Professional certification (SCRN, CNRN)

 

Resources for Hospitals

Articles, Guidelines, and Conference Recordings

Process Documents

Maps

Community Stroke Education

Hospital Accreditation Services

The resources presented on this web page are a sampling of available materials and do not necessarily constitute an endorsement by the Department of Health Services or the American Heart Association/American Stroke Association.

 


Logo for the Wisconsin Coverdell Stroke ProgramMore Information:
Dot Bluma, BSN, RN, CPHQ
Stroke Project Specialist, MetaStar
dbluma@metastar.com

Last Revised: June 28, 2018