Diane, for your attorney.
http://www.theheart.org/article/1543035.do?utm_medium=email&utm_source=20130527_heartwire&utm_campaign=newsletter
Patients
who have a stroke receive better care if they have their stroke outside
the hospital than while admitted, a new study based on data from the American Heart Association's Get With the Guidelines-Stroke program has found.
Worse outcomes
The specialist advantage
"Maybe the emergencies we are least prepared for are the emergencies that happen right in our very backyard," Dr Ethan Cumbler (National Stroke Association, Centennial, CO) said here at Hospital Medicine 2013.
Approximately 35 000 to 75 000 in-hospital
strokes are reported annually in the US, but even this high number may
underestimate cases, often underreported, noted Cumbler.
In an interview, Cumbler said these data point
to the need for improvements in rapid recognition of stroke symptoms by
hospital providers as well as systematic changes to allow inpatients to
receive appropriate thrombolysis in a timely manner.
"Patients who suffer their stroke while under
our care deserve the same consideration for treatment, which could
reduce their deficits and improve their outcome, as any patient who has a
stroke at home," he emphasized.
Session moderator Dr Eduard Vasilevskis
(Vanderbilt University Medical Center, Nashville, TN) said, "I
definitely agree that the data clearly show an opportunity for
improvement with regard to inpatient stroke."
He added, "Hospitalized patients who are
already sick and then have a stroke are going to do worse. The question
is, if we improve quality, can we at least diminish how much worse
they're going to do?"
Worse outcomes
Data for the study came from 1280 hospitals
reporting at least one in-hospital stroke to the Get With the Guidelines
program. Investigators compared patient characteristics, comorbid
illnesses, medications, quality-of-care measures, and outcomes between
the 21 349 in-hospital ischemic strokes and 928 885 community-onset
ischemic strokes.
The in-hospital stroke patients had more
thromboembolic risk factors, including atrial fibrillation, prosthetic
heart valves, carotid stenosis, and heart failure (p<0.001). However,
they were less likely to have had a prior stroke, hypertension, or use
tobacco (p<0.0001).
In-hospital strokes were more severe, with a
median National Institutes of Health Stroke Scale score of 9.0 compared
with 4.0 for the community strokes (p<0.001).
Achievement of the Get With the Guidelines
quality metrics for the in-hospital stroke patients was significantly
worse for all seven achievement measures and for all but three of the
eight quality measures.
Stroke education didn't differ between the two
groups, and both rehabilitation assessment and intensive statin
treatment were better for the in-hospital stroke patients.
The gap in defect-free care was larger than I expected.
Defect-free care, defined as the proportion of
patients who received all of the achievement measure interventions for
which they were eligible, was significantly worse for the in-hospital
stroke group, just 60.8% vs 82.0% for community-onset stroke
(p<0.0001).
"The gap in defect-free care was larger than I expected," Cumbler said.
However, of the 11% of in-hospital stroke
patients who did receive appropriate thrombolysis, multivariate analysis
showed a lower rate of intracranial hemorrhage compared with community
strokes (odds ratio [OR] 0.80, p=0.049).
"Many patients with in-hospital stroke are
candidates for aggressive intervention with thrombolysis and do not
appear to have higher rates of hemorrhage when treated," Cumbler pointed
out.
Deaths during hospitalization occurred in 14%
of in-hospital stroke patients, compared with 5% for community strokes
(OR 2.72, p<0.0001). Patients with in-hospital strokes were less
likely to be discharged home (OR 0.37) and less able to ambulate
independently at discharge (OR 0.42).
"It makes sense that two problems are worse
than one problem. If you come in with a heart attack, you will do worse
than if you only had a stroke. However, there's also the disquieting
hypothesis that some of these discrepancies in outcomes are related to
the discrepancies in performance of quality metrics," Cumbler said.
Vasilevskis noted that most patients who have a
stroke in the community arrive at the hospital in the emergency
department, which is prepared to provide rapid stroke care. "In the ER,
there's a stroke alert, there's a stroke team, everyone comes, there's
an order set. It's all been worked out for the ER," he said. "We just
haven't worked it out for the inpatient setting because it's much less
common."
And he added that family members may be better
than hospital personnel at detecting sudden differences in a person's
usual behavior that might signal a stroke.
The specialist advantage
Cumbler said that beyond basic differences in
workflow between the ER and the wards that affect the ability to respond
to time-critical emergencies, strokes from the community are often
cared for by dedicated neurology or stroke services. Patients who are
already hospitalized may be on cardiology, cardiothoracic surgery, or
medicine services staffed by personnel who are "less attuned to the
elements of quality processes for stroke care."
The solution, he said, is for both individual
providers to learn to better recognize new neurologic deficits and
systems to be improved to allow evaluation and treatment decisions to
occur within 60 minutes of symptom recognition.
"As individuals, we need to get the stroke
program involved at the onset of stroke symptoms so that the quality
metrics can be met and reported appropriately. As systems, we need to
create bundles of these interventions, which can be an overlay onto
existing orders for patients who experience stroke during
hospitalization," he said.
And because there is evidence that in-hospital
strokes are underreported, "We should be reporting in-hospital strokes
just as we do community-onset strokes to quality databases so that we
can accurately understand the quality of care we are providing, identify
gaps, and perform process improvement to close any discrepancies."
Thanks, Dean! Yes, certainly looks like it's better to have a stroke in your own backyard....
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