Delays in Care for In-Hospital Stroke Patients
Researchers are reporting significant adverse differences in care for patients experiencing a stroke while in the hospital compared with those coming through the emergency department.
Their study showed that compared with patients with community-onset stroke, those with in-hospital stroke had higher rates of comorbid illness, more severe strokes, and a longer time from symptom recognition to neuroimaging and were less likely to receive thrombolysis.
The results suggest the need for interventions to improve in-hospital stroke care, said study author Moira Kapral, MD, professor, medicine, University of Toronto, Ontario, Canada.
"Health care providers should recognize that in-hospital stroke is as much of an emergency as stroke that comes through the emergency department, and hospitals should look at initiatives to improve the care of in-hospital stroke patients," Dr Kapral said.
The results were published online May 4 in JAMA Neurology.
Neuroimaging Delays
From the Ontario Stroke Registry database, researchers selected all patients who presented to any of the 11 regional stroke centers across the province of Ontario who had an acute stroke or were diagnosed as having a stroke while in the hospital between July 1, 2003, and March 31, 2012.
The study sample consisted of 29,810 patients: 973 with an in-hospital stroke and 28,837 with a community-onset stroke.
In-hospital stroke patients were older and were more likely to have vascular risk factors and other comorbid conditions than those with community-onset stroke. They were also more likely to have ischemic stroke as opposed to hemorrhagic stroke and to have a more severe stroke.
Patients with in-hospital stroke had significantly longer times from symptom recognition to neuroimaging (median, 4.5 hours vs 1.2 hours for community-onset stroke patients; P < .001). They were also less likely to get brain imaging within 2 hours of symptom recognition (32% vs 63%; adjusted odds ratio, 0.21; 95% confidence interval, 0.18 - 0.24; P < .001).
The relatively long time between stroke recognition and brain imaging among in-hospital patients was probably the most worrisome finding of the study, Dr Kapral told Medscape Medical News. "Until that imaging is done, it's impossible to determine whether it's a stroke or something else, what kind of stroke it is, and whether the person is likely to be eligible for treatments like thrombolysis."
In-hospital stroke patients also had lower rates of thrombolysis (12% vs 19%), and fewer of them received thrombolysis within 90 minutes of diagnosis (29% vs 72%).
Some delays for surgical patients make some sense. For example, they may have had a recent anesthetic and it might have been difficult to even determine whether a stroke had occurred, said Dr Kapral.
"It might not have been possible to transport them outside of the surgical area for investigation, and they probably wouldn't be eligible for thrombolysis anyway."
But for patients who had a stroke while on the medical ward, the delays "may be more related to processes of care and not having an organized protocol in place to make sure that tests and treatment are done quickly," she said.
These in-hospital patients also had a longer median length of hospital stay and were more likely to die, or be disabled at discharge, even after adjustment for sex, age, comorbid condition, and stroke type and severity.
There were differences even within the in-hospital group, depending on where patients were at the time of their stroke. For example, those having a stroke during angiography had more rapid brain imaging and were more likely to receive thrombolysis than patients admitted to medical or surgical services.
A neurologist cared for only a minority of in-hospital stroke patients. Non-neurologist physicians may have less familiarity and training in stroke care, said the authors.
Again, said Dr Kapral, this might be related to lack of protocols. "When someone has a stroke and comes to the emergency department, most centers will have a protocol in place that allows for rapid brain imaging and assessment by a stroke team. In the hospital, those procedures may not be in place."
Dr Kapral called for targeted code protocols of in-hospital stroke patients, similar to those used in the emergency department. "So when a stroke is recognized by any of the medical personnel, there's a central call number where the brain imaging department can be activated to receive the patient, and where the stroke team can be notified that there's a potential stroke, and then the assessment can happen."
Protocols for out-of-hospital stroke — for example, the use of thrombolysis, stroke units, and multidisciplinary stroke teams — that are in place in Ontario and elsewhere in Canada are similar to those across the United States.
"Striking" Finding
In an accompanying editorial, Douglas Dulli, MD, Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, called the median time from stroke recognition to neuroimaging among in-hospital patients "an especially striking finding," as was the large interquartile range between these patients and community-onset stroke patients (15.8 vs 2.5 hours).
"These data suggest that code stroke protocols were not applied to many or most patients with in-hospital stroke in this cohort."
Dr Dulli noted that the results of the new study are consistent with those of previous research. These studies, he said, "reveal a paradox in which a critical therapy is limited or delayed in a group of patients whose need for it may be greater."
In-hospital strokes represent a "large problem with unique challenges," and they typically occur where brain imaging and state-of-the-art stroke therapy are only "an elevator ride" away, he said.
Challenges in Hospital
The delays uncovered by the study weren't surprising to Jin-Moo Lee, MD, PhD, director, Cerebrovascular Disease Section, Department of Neurology, Washington University, St. Louis, Missouri. Unlike within the hospital, it's relatively easy to detect and treat a stroke in the emergency department (ED), Dr Lee told Medscape Medical News.
"Everything is right at your fingertips," he said. "The CT [computed tomography] scanner is just down the hall; tPA [tissue plasminogen activator] is right there in the ED and everyone is geared towards giving tPA immediately. So it's a well-rehearsed protocol."
But a stroke that occurs on a hospital floor, for example, on the general surgery service, poses some "real challenges," said Dr Lee. "First of all, it takes a while to know that someone's having a stroke, and then there's not a CT scanner down the hall; you have to roll the patient down to radiology. And then, tPA is not readily available throughout the hospital."
Joint Commission–certified stroke centers in the United States are expected to have an in-hospital stroke protocol, he added. Dr Lee's hospital, for example, has what he called a "stroke code team" — a group of specialists that has access to a stroke "box" that includes tPA and blood pressure medicines — that can be quickly mobilized so a patient can be swiftly treated on site.
But while such a protocol improve in-hospital access to stroke treatment, it doesn't address the stroke detection issue. That, said Dr Lee, requires education on how to detect stroke and "who to call in the event that they think a stroke is happening."
Currently, he said, practitioners on the surgical wards generally don't do a complete neurologic exam. "So it may be awhile before they pick up the stroke. It may have happened several hours ago."
The Ontario Stroke Registry is funded by the Canadian Stroke Network and the Ontario Ministry of Health and Long-Term Care. The Institute for Clinical Evaluative Sciences is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. This work was supported by an educational grant from the Canadian Stroke Network. Dr Kapral is supported by a career investigator award from the Heart and Stroke Foundation, Ontario Provincial Office. Dr Kapral And Dr Dulli have disclosed no relevant financial relationships.
JAMA Neurol. Published online May 4, 2015. AbstractEditorial
Researchers are reporting significant adverse differences in care for patients experiencing a stroke while in the hospital compared with those coming through the emergency department.
Their study showed that compared with patients with community-onset stroke, those with in-hospital stroke had higher rates of comorbid illness, more severe strokes, and a longer time from symptom recognition to neuroimaging and were less likely to receive thrombolysis.
The results suggest the need for interventions to improve in-hospital stroke care, said study author Moira Kapral, MD, professor, medicine, University of Toronto, Ontario, Canada.
"Health care providers should recognize that in-hospital stroke is as much of an emergency as stroke that comes through the emergency department, and hospitals should look at initiatives to improve the care of in-hospital stroke patients," Dr Kapral said.
The results were published online May 4 in JAMA Neurology.
Neuroimaging Delays
From the Ontario Stroke Registry database, researchers selected all patients who presented to any of the 11 regional stroke centers across the province of Ontario who had an acute stroke or were diagnosed as having a stroke while in the hospital between July 1, 2003, and March 31, 2012.
The study sample consisted of 29,810 patients: 973 with an in-hospital stroke and 28,837 with a community-onset stroke.
In-hospital stroke patients were older and were more likely to have vascular risk factors and other comorbid conditions than those with community-onset stroke. They were also more likely to have ischemic stroke as opposed to hemorrhagic stroke and to have a more severe stroke.
Patients with in-hospital stroke had significantly longer times from symptom recognition to neuroimaging (median, 4.5 hours vs 1.2 hours for community-onset stroke patients; P < .001). They were also less likely to get brain imaging within 2 hours of symptom recognition (32% vs 63%; adjusted odds ratio, 0.21; 95% confidence interval, 0.18 - 0.24; P < .001).
The relatively long time between stroke recognition and brain imaging among in-hospital patients was probably the most worrisome finding of the study, Dr Kapral told Medscape Medical News. "Until that imaging is done, it's impossible to determine whether it's a stroke or something else, what kind of stroke it is, and whether the person is likely to be eligible for treatments like thrombolysis."
In-hospital stroke patients also had lower rates of thrombolysis (12% vs 19%), and fewer of them received thrombolysis within 90 minutes of diagnosis (29% vs 72%).
Some delays for surgical patients make some sense. For example, they may have had a recent anesthetic and it might have been difficult to even determine whether a stroke had occurred, said Dr Kapral.
"It might not have been possible to transport them outside of the surgical area for investigation, and they probably wouldn't be eligible for thrombolysis anyway."
But for patients who had a stroke while on the medical ward, the delays "may be more related to processes of care and not having an organized protocol in place to make sure that tests and treatment are done quickly," she said.
These in-hospital patients also had a longer median length of hospital stay and were more likely to die, or be disabled at discharge, even after adjustment for sex, age, comorbid condition, and stroke type and severity.
There were differences even within the in-hospital group, depending on where patients were at the time of their stroke. For example, those having a stroke during angiography had more rapid brain imaging and were more likely to receive thrombolysis than patients admitted to medical or surgical services.
A neurologist cared for only a minority of in-hospital stroke patients. Non-neurologist physicians may have less familiarity and training in stroke care, said the authors.
Again, said Dr Kapral, this might be related to lack of protocols. "When someone has a stroke and comes to the emergency department, most centers will have a protocol in place that allows for rapid brain imaging and assessment by a stroke team. In the hospital, those procedures may not be in place."
Dr Kapral called for targeted code protocols of in-hospital stroke patients, similar to those used in the emergency department. "So when a stroke is recognized by any of the medical personnel, there's a central call number where the brain imaging department can be activated to receive the patient, and where the stroke team can be notified that there's a potential stroke, and then the assessment can happen."
Protocols for out-of-hospital stroke — for example, the use of thrombolysis, stroke units, and multidisciplinary stroke teams — that are in place in Ontario and elsewhere in Canada are similar to those across the United States.
"Striking" Finding
In an accompanying editorial, Douglas Dulli, MD, Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, called the median time from stroke recognition to neuroimaging among in-hospital patients "an especially striking finding," as was the large interquartile range between these patients and community-onset stroke patients (15.8 vs 2.5 hours).
"These data suggest that code stroke protocols were not applied to many or most patients with in-hospital stroke in this cohort."
Dr Dulli noted that the results of the new study are consistent with those of previous research. These studies, he said, "reveal a paradox in which a critical therapy is limited or delayed in a group of patients whose need for it may be greater."
In-hospital strokes represent a "large problem with unique challenges," and they typically occur where brain imaging and state-of-the-art stroke therapy are only "an elevator ride" away, he said.
Challenges in Hospital
The delays uncovered by the study weren't surprising to Jin-Moo Lee, MD, PhD, director, Cerebrovascular Disease Section, Department of Neurology, Washington University, St. Louis, Missouri. Unlike within the hospital, it's relatively easy to detect and treat a stroke in the emergency department (ED), Dr Lee told Medscape Medical News.
"Everything is right at your fingertips," he said. "The CT [computed tomography] scanner is just down the hall; tPA [tissue plasminogen activator] is right there in the ED and everyone is geared towards giving tPA immediately. So it's a well-rehearsed protocol."
But a stroke that occurs on a hospital floor, for example, on the general surgery service, poses some "real challenges," said Dr Lee. "First of all, it takes a while to know that someone's having a stroke, and then there's not a CT scanner down the hall; you have to roll the patient down to radiology. And then, tPA is not readily available throughout the hospital."
Joint Commission–certified stroke centers in the United States are expected to have an in-hospital stroke protocol, he added. Dr Lee's hospital, for example, has what he called a "stroke code team" — a group of specialists that has access to a stroke "box" that includes tPA and blood pressure medicines — that can be quickly mobilized so a patient can be swiftly treated on site.
But while such a protocol improve in-hospital access to stroke treatment, it doesn't address the stroke detection issue. That, said Dr Lee, requires education on how to detect stroke and "who to call in the event that they think a stroke is happening."
Currently, he said, practitioners on the surgical wards generally don't do a complete neurologic exam. "So it may be awhile before they pick up the stroke. It may have happened several hours ago."
The Ontario Stroke Registry is funded by the Canadian Stroke Network and the Ontario Ministry of Health and Long-Term Care. The Institute for Clinical Evaluative Sciences is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. This work was supported by an educational grant from the Canadian Stroke Network. Dr Kapral is supported by a career investigator award from the Heart and Stroke Foundation, Ontario Provincial Office. Dr Kapral And Dr Dulli have disclosed no relevant financial relationships.
JAMA Neurol. Published online May 4, 2015. AbstractEditorial