In-Hospital Stroke Patients Wait Longer for Care

Pauline Anderson

October 09, 2014

Up to 17% of strokes occur in patients already hospitalized, but a new Canadian study shows that they wait longer for neuroimaging and thrombolysis than those who have a stroke at home and are brought to the emergency department (ED).

Doctors in hospitals should keep stroke on their radar in the same way that they do for a heart attack, lead study researcher, Alexandra Saltman, MD, resident, core internal medicine, University Health Network, University of Toronto, Ontario, Canada, told Medscape Medical News. "They should keep an open mind that some subtle symptoms may represent stroke, and if they're worried, they should act on it quickly."

Dr Saltman presented the study at the Canadian Stroke Congress in Vancouver, British Columbia.

"Shocking Difference"

For the study the investigators gathered data from charts for all adults with stroke at 11 regional stroke centers in Ontario, Canada, from 2003 to 2012. This included 1048 patients who were admitted to the hospital with another condition and had a stroke while there, and 32,227 who were brought to the hospital after sustaining a stroke. Most hospitalized patients were admitted for medical reasons (30%) or surgery other than cardiac (30%).

The mean age for the entire cohort was 73 years.

To compare "in hospital" and "community-onset" strokes, the authors used the Heart and Stroke Foundation's Canadian stroke best practice recommendations and the American Heart Association (AHA) best practice guidelines for stroke care.

The study results showed that in-hospital patients waited an average of 4.5 hours from the time symptoms were recognized to undergo computed tomography compared with 1.3 hours for patients brought to the ED.

"To me that's a shocking difference," said Dr Saltman.

About 29% of in-hospital stroke patients met the "benchmark" best practice of getting thrombolysis within 90 minutes of symptom onset compared with 72% of patients coming from the community, said Dr Saltman.

In addition, the in-hospital group was less likely to receive thrombolysis (12%) than the group admitted after having a stroke outside the hospital (19%), even if they were eligible for this intervention, she added.

In-hospital patients stayed longer in the hospital (17 days vs 8 days), were more likely to be discharged to a rehabilitation facility (40% vs 32%), and were less likely to be sent home (35% vs 44%).

Although the "in-hospital" patients had more vascular risk factors and comorbidities than the "in-community" group, researchers adjusted for these factors. "We accounted for age, sex, all the vascular comorbidities, stroke severity, and type of stroke, and even when we account for those factors, the in-hospital patients still did worse," said Dr Saltman.

The in-hospital patients also had a higher mortality rate, but after adjustments, this difference went away (adjusted odds ratio at 1 year for post-stroke mortality, 0.99; 95% confidence interval, 0.85 - 1.16), although the other outcomes — rates of disability at discharge, length of hospital stay, place of discharge — remained significant, said Dr Saltman.

Need for In-Hospital Protocols

Dr Saltman said part of the large between-group difference may be attributable to the fact that hospital medical staff just don't have stroke on their radar.

"They're not thinking about it because these patients are admitted for heart attack or hip fracture or something completely unrelated, and they are often very medically or surgically complex," she said.

Stroke symptoms can be masked in patients being treated for something else, she added.

"If we were to have a stroke at home, there would be an obvious weakness on one side or obvious difficulty with speech or obvious facial droop, but in these in-hospital patients, it's often more subtle, particularly in the really sick patients.

"They might be in an intensive care unit and might not be awake; they might be on sedative medication or on a ventilator, or breathing tube, so they can't tell you they're experiencing symptoms," she said.

In the community, protocols are in place where emergency medical services personnel flag potential stroke patients and alert ED staff who await the "code stroke," noted Dr Saltman. In contrast, she said, there are no in-hospital standardized practices to handle stroke.

That, she said, will be the next part of her study.

"We're hoping to develop a protocol that's potentially a modification of the ED protocol already being used in downtown Toronto, to pilot it at a couple of hospitals, and then study it to see if there's a difference pre- and post-intervention, and if it's effective, to then implement it Ontario-wide."

She admitted that this will be "a couple years down the road."

A limitation of the study was that if lacked information on reasons for delays in diagnosis or treatment, on medical and surgical diagnoses, and on long-term functional status or quality of life.

Stroke Alert

Commenting on the findings for Medscape Medical News, Ralph Sacco, MD, professor and chair, neurology, Miller School of Medicine, University of Miami, Florida, said the analysis suggests that strokes occurring in the hospital are not being treated as quickly as those in patients arriving through the ED.

He pointed out that even for community-onset strokes, patients who arrive by emergency medical transport get more rapid diagnosis and triage than those arriving by private transport. 

"When a stroke occurs in the hospital, we need to react just as quickly as in the ED," said Dr Sacco. "Just as a cardiac arrest code is called in a hospital, a stroke alert needs to be called and special protocols initiated to rapidly diagnose and treat such patients."

In the United States, most stroke centers certified by the Joint Commission and the AHA have stroke protocols, but these centers need to ensure that they work just as well on the hospital wards as in the ED, said Dr Sacco.  "All hospital personnel need to be just as well trained as ED and stroke team members on the stroke warning signs and what to do if they spot a stroke."

Dr Saltman and Dr Sacco have disclosed no relevant financial relationships.

Canadian Stroke Congress. Presented October 6, 2014. Abstract 8094.


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