Wisconsin Coverdell Stroke Program: Hospitals

The Participating Hospital Guide, P-01137 (PDF) explains the benefits, how to join, and activities of the Wisconsin Coverdell Stroke Program.

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”
• Access to Hemispheres free online stroke education as resources are available
• Free BE FAST community education materials
• Networking opportunities with other Coverdell hospitals
• Member of the Stroke Coordinators of Wisconsin
• Member of the Coverdell Learning Collaborative
• Technical assistance to answer questions regarding stroke care and 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 quality improvement 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
• Maintain chart re-abstraction results according to Centers for Disease Control and Prevention standards for quality and security
• Free development of annual agreement reports for each site to ensure your data quality remains high
• Quarterly report cards of quality measures along the continuum of care which provide benchmark groups for comparison, and have established goals for each measure to assist in motivating and gauging progress
• Facilitated peer-to-peer and mentoring opportunities between hospitals to share best practices
• Coverdell Champion Agreement, F-01649 (PDF)

The long-term outcomes of the Paul Coverdell National Acute Stroke Program are:

1. Increased access to care and improved quality of care for stroke patients
2. Decreased disparities in access to care and quality of care for populations at highest risk for stroke events

The following are Coverdell program strategies to achieve the long-term outcomes:

1. Track and monitor clinical measures to improve data infrastructure across stroke systems of care
2. Implement a team-based approach to enhance quality of care for those at highest risk for stroke events and stroke patients across systems of care
3. Link community resources and clinical services that support those at highest risk for stroke events and stroke patients across systems of care

Wisconsin’s participation in the Coverdell Registry is facilitated by the 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 CDC (Centers for Disease Control and Prevention) 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 care quality improvement 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 All Saints Hospital
• Ascension Columbia St. Mary's Milwaukee
• Ascension Columbia St. Mary's Ozaukee
• Ascension NE Wisconsin Mercy Campus
• Ascension NE Wisconsin St. Elizabeth Campus
• Ascension St. Francis Hospital
• Ascension SE Wisconsin Hospital - Elmbrook Campus
• Ascension SE Wisconsin Hospital - Franklin Campus
• Ascension SE Wisconsin Hospital - St. Joseph's Campus
• Aspirus Divine Savior
• Aspirus Eagle River
• Aspirus Iron River Hospital
• Aspirus Ironwood Hospital
• Aspirus Keweenaw Hospital
• Aspirus Langlade Hospital
• Aspirus Medford Hospital
• Aspirus Merrill Hospital
• Aspirus Ontonagon Hospital
• Aspirus Plover Hospital
• Aspirus Rhinelander Hospital
• Aspirus Riverview Hospital and Clinics
• Aspirus Stanley Hospital
• Aspirus Stevens Point Hospital
• Aspirus Tomahawk Hospital
• Aspirus Wausau Hospital
• Aurora BayCare Medical Center
• Aurora Lakeland Medical Center
• Aurora Medical Center Bay Area
• Aurora Medical Center Grafton
• Aurora Medical Center Kenosha
• Aurora Medical Center Manitowoc County
• Aurora Medical Center Mount Pleasant
• Aurora Medical Center of Washington County
• Aurora Medical Center Oshkosh
• Aurora Medical Center Summit
• Aurora Memorial Hospital of Burlington
• Aurora St. Luke's Medical Center
• Aurora St. Luke's South Shore
• Aurora Medical Center Sheboygan County
• Aurora Sinai Medical Center
• Aurora West Allis Medical Center
• Bellin Memorial Hospital
• Beloit Health System
• Essentia Health-St. Mary's Hospital of Superior
• Froedtert Hospital
• Froedtert Menomonee Falls
• Froedtert West Bend
• Gundersen Boscobel Area Hospital and Clinics
• Gundersen Health System
• Gundersen Moundview Hospital and Clinics
• Howard Young Medical Center (Aspirus)
• Marshfield Medical Center Ladysmith
• 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
• ProHealth Care Waukesha Memorial Hospital- Mukwonago
• Sacred Heart Hospital of the Hospital Sisters of the Third Order of St. Francis
• Stoughton Hospital
• St. Vincent Hospital of the Hospital Sisters of the Third Order of St. Francis
• ThedaCare Medical Center- Appleton
• ThedaCare Medical Center- Berlin
• ThedaCare Regional Medical Center- Neenah
• ThedaCare Medical Center- New London
• ThedaCare Medical Center- Shawano
• ThedaCare Medical Center- Wild Rose
• ThedaCare Medical Center- Waupaca
• The Richland Hospital
• University of Wisconsin Hospital and Clinics
• UW Health East Madison Hospital

Partner hospitals

• Bellin Health Oconto Hospital and Clinics
• Black River Memorial Hospital
• Crossing Rivers Health
• Mercy Walworth Hospital
• Mile Bluff Medical Center
• SSM Health St. Mary's Hospital - Janesville
• SSM Health St. Mary's Hospital - Madison
• St. Croix Health
• St. Mary’s Hospital Medical Center, Green Bay, Inc.
• St. Nicholas Hospital of the Hospital Sisters of the Third Order of St. Francis
• Upland Hills Health

The Coverdell Learning Collaborative (CLC) meets for 1.5 hours quarterly, either in-person or virtually. The meeting provides members the opportunity to network with fellow stroke coordinators as well as ask questions and share best practices. The meeting consists of:

• Review blinded data across the stroke systems of care (SSoC) to identify areas where efficiency and quality of care can be improved
• Discuss, explore, and share best practices on the role of community health workers and patient navigators in post-discharge care
• Identify and create collaborative quality improvement initiatives for Plan-Do-Study-Act (PDSA) cycles
• Update on EMS practices
• Inform on stroke-related activities at the state level

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.

In March we met virtually via a Zoom meeting which was recorded for those who had a conflict. We acknowledged and celebrated the Stroke Coordinator with the fastest arrival to CT completion time. The coordinator shared QI efforts which assisted their site in reaching this high level of performance.

We acknowledged and celebrated the Stroke Coordinator with the fastest arrival to CT completion time. The coordinator shared QI efforts which assisted their site 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 Q4 2022:
  • Aurora Memorial Hospital of Burlington
  • Prohealth Care Waukesha Memorial Hospital with Prohealth Care Waukesha Memorial Hospital- Mukwonago

We also acknowledged and supported the two hospitals with 100% defect-free care within the 10 Coverdell performance measures for Q4 2022.

• Essentia Health- St. Mary's Hospital of Superior
• The Richland Hospital

Another notable achievement identified by the Coverdell Learning Collaborative (CLC) belongs to the nine hospitals with 100% agreement and the nine hospitals with 99% agreement between two abstractors for the Q3 2022 agreement process. WI Coverdell was at 97% agreement for this process in Q3 2022.

• Hospitals who achieved 100% agreement:
  • Ascension Columbia St. Mary's Milwaukee
  • Ascension SE Wisconsin Hospital- Elmbrook Campus
  • Ascension SE Wisconsin Hospital- Franklin Campus
  • Ascension St. Francis Hospital
  • Aspirus Wausau Hospital
  • Aurora Memorial Hospital of Burlington
  • Bellin Memorial Hospital
  • HSHS Sacred Heart Hospital
  • HSHS St. Mary's Hospital Medical Center, Green Bay
• Hospitals who achieved 99% agreement:
  • Ascension All Saints
  • Ascension NE Wisconsin St. Elizabeth Campus
  • Ascension Columbia St Mary's Ozaukee
  • Ascension SE Wisconsin Hospital - St. Joseph Campus
  • Aspirus Medford Hospital
  • Aurora Lakeland Medical Center
  • Aurora Medical Center Grafton
  • Aurora St. Luke's Medical Center
  • SSM Health St. Mary’s Hospital – Janesville

A PI focus for the CLC is the EMS Pre-notification measure. In Q4 2022 there were ten hospitals who achieved 100%.

• Aspirus Keweenaw Hospital
• Aspirus Medford Hospital
• Aspirus Riverview Hospital and Clinics
• Aurora Medical Center Grafton
• Aurora Medical Center Summit
• Aurora Medical Center of Washington County
• Mercy Hospital and Trauma Center, Janesville
• Prohealth Care Waukesha Memorial Hospital
• The Richland Hospital
• University of Wisconsin Hospital & Clinics

The SCOW Committee meets quarterly. Any hospital in the state of Wisconsin or surrounding states that has an objective of improving stroke patient outcomes by promoting evidence-based care and quality initiatives may participate. Currently, over 95 hospitals have representation in the SCOW. The mission of the SCOW is to collaboratively improve the quality of stroke care and prevention in Wisconsin, where the goals are to identify quality improvement needs in the state and recognize a process for measuring and monitoring performance. Attendance in-person or virtually is recommended for Coverdell hospitals.

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.

Articles and guidelines

• The Abstracting Stroke Data That Will Work For All Toolkit, P-02467 (PDF) was developed by the WI Coverdell Stroke Program and the American Heart Association. The toolkit consists of two mock charts which meets the abstraction training needs for all levels of stroke certification including Acute Stroke Ready, Primary Stroke Center, Thrombectomy Capable, and Comprehensive Stroke Centers.
• American Heart Association Stroke Statements and Guidelines
• Success Stories

Videos and conference recordings

• Wisconsin's Training of the National Institutes of Health Stroke Scale
• Telestroke Taskforce Clinician Panel

Process documents

• Stroke Follow-Up Call Triage Algorithm P-02361 (PDF)
• 911 DTN Process, P-02257 (PDF)
• Hospital to EMS Quality Report (Word)
• Building Blocks of a Stroke Program Toolkit, P-01141 (PDF)
• Empower People with Knowledge: Community Outreach Stroke Awareness Event Planning Toolkit, P-01861 (PDF)
• A User Guide for Creating a Stroke Data Reliability Process, P-02668 (PDF). Ensuring data reliability of a hospital’s stroke abstracts is essential to its credibility and value. As stroke abstractors range from novice to expert, the need for a process to determine reliability of data entry that will demonstrate knowledge deficits and learning opportunities is essential. This user guide will provide step-by-step directions on how to prepare for, create, and analyze stroke data for reliability. This guide is relevant for hospitals entering into the Get With the Guidelines® (GWTGs) - Stroke Registry
• Abstracting an Accurate Last Known Well, P-02812. (PDF) This document will assist the stroke abstractor in correctly identifying a patient’s LKW time as it can be very difficult, as there are often multiple times documented and coding instructions are complex.
• Wisconsin Telestroke Toolkit, P-03458 (PDF) – When treating a stroke, every second counts. A lack of coordination and/or strict protocols in hospitals due to limited personnel with stroke experience and/or infrequent stroke cases may hinder the ability of the patient to receive expedited care. These hospitals, which are disproportionately smaller and located in rural underserved areas, may benefit from the use of Telestroke, which offers an opportunity for virtual expert neurological consultation regardless of the patient’s physical location. This Telestroke Toolkit provides guidance on initiating and conducting the process through a text-based document and two videos: a Telestroke Task Force Clinician Panel with experts in the field and a demonstration video on conducting the National Institutes of Stroke Scale via telestroke.

Maps

• Wisconsin Critical Access Hospitals
• Wisconsin Hospitals
• Wisconsin EMS Service Center Locations
• Wisconsin Coverdell Program Hospitals
• Drive Time to Coverdell Program Hospitals
• Drive Time to Hospital Stroke Centers
• Wisconsin Coverdell EMS Service and Hospital Partners
• Wisconsin Coverdell Program EMS Services

Community stroke education

• Community Stroke Materials
• Know the Signs of a Stroke (Poster)
• Blood Pressure Wallet Card

Stroke Disease Specific Certified (DSC) hospitals

There are two certifying bodies Wisconsin hospitals have utilized to certify their stroke programs. To find which hospitals are certified in stroke, follow these steps:

• (Det Norske Veritas (DNV)
  • Click on Search Hospitals. Filter by Certification and Filter by State
    • Acute Stroke Ready (ASR)
    • Primary Stroke Center
    • Comprehensive Stroke Center
• The Joint Commission (TJC) (general information)
  • To find Wisconsin certification levels, open the link to Wisconsin certified hospitals
  • In the "Narrow Results" section in the left margin, scroll to "Advanced Certification" and select the desired stroke certification level

The resources presented on this webpage 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.