This was known way back in December 2016; what EXACTLY has your hospital done to solve this?
If they haven't solved this you better not have a stroke while hospitalized for COVID-19.
Diane and Bob had a similar problem within the hospital.
Stroke outcomes can be worse when they occur in hospital, Canadian study finds
December 2016
The latest here:
In-Hospital Strokes: Plenty of Room for Improvement
Longer care delays, worse functional outcomes than with out-of-hospital onset
In-hospital strokes were increasingly recognized and treated with reperfusion therapy in recent years, though still not on par with out-of-hospital strokes, according to a large registry study.
The proportion of in-hospital stroke among all stroke hospital discharges rose from 2.7% in 2008 to 3.5% in 2018 (P<0.001) in the American Heart Association Get With the Guidelines–Stroke registry, reported a group led by Feras Akbik, MD, PhD, of Emory University Hospital in Atlanta, in JAMA Neurology.
Rates of IV thrombolysis increased over time in patients with in-hospital stroke (from 9.1% to 19.1%, P<0.001). Endovascular therapy also rose (from 2.5% to 6.4%, P<0.001), starting in mid-2015 after the positive thrombectomy trials had been released.
Among stroke patients who received IV thrombolysis without endovascular therapy, the in-hospital onset group waited longer from stroke recognition to cranial imaging (33 vs 16 minutes, P<0.001) and to thrombolysis bolus (81 vs 60 minutes, P<0.001), compared with the out-of-hospital onset group.
"Activating acute stroke responders, identifying the appropriate radiology suite, and mobilizing an interdisciplinary team to transport the patient are likely slower in the inpatient setting as opposed to the emergency department, where higher volumes and numbers of dedicated personnel can facilitate the acute stroke treatment pathway," according to Akbik's group.
"Even after the initial CT scan, the present study found that there were still longer delays to both IVT [IV thrombolysis] bolus and arterial access for EVT [endovascular therapy]. These delays likely reflect the lack of rigorous protocol use and adherence, similar to the early experience reported in the interventional cardiology literature, or the inability to rapidly access a legally authorized representative to provide consent," they added.
Delays in care aside, in-hospital onset patients also had worse outcomes, being less likely to ambulate independently at discharge (adjusted OR 0.78, 95% CI 0.74-0.82) and more likely to die or to be discharged to hospice (adjusted OR 1.39, 95% CI 1.29-1.50).
Findings were similar when comparing in-hospital vs out-of-hospital onset stroke patients who received endovascular therapy.
"Dedicated inpatient stroke protocols are advised to bridge this disparity in stroke care," study authors urged.
The study "strongly supports the notion that treatment can be better," commented Amy Yu, MD, MSc, of University of Toronto and Sunnybrook Health Sciences Centre, Ontario, and Michael Hill, MD, MSc, of the University of Calgary, Alberta.
"Contemporary hyperacute stroke care has shifted from a time-based focus to an emphasis on tissue-based assessment using neurovascular imaging to identify patients who may benefit from revascularization with thrombolysis or endovascular thrombectomy. It is therefore highly relevant to reexamine the quality of care and outcomes after short-term reperfusion treatment in patients with in-hospital stroke," they wrote in an accompanying editorial.
Study authors performed a retrospective cohort analysis of a voluntary national stroke registry. Across participating hospitals, there were more than 2.2 million adults discharged with acute ischemic stroke in 2008-2018. Of these individuals, 3.0% (n=67,493) developed a stroke while in the hospital.
Patients were included if they were admitted with acute ischemic stroke via the emergency department or if they experienced one while hospitalized. People admitted via interhospital transfer were excluded.
People who had in-hospital vs out-of-hospital stroke onset tended to have more comorbidities and vascular risk factors. Age and sex were similar between groups whether people received IV thrombolysis only or underwent endovascular therapy.
Symptomatic intracranial hemorrhage rates were no different between groups receiving IV thrombolysis, whereas the in-hospital onset patients had a reduced risk after endovascular therapy, Akbik's team reported.
Reliance on the voluntary registry meant that the study's findings may not be generalizable to non-participating hospitals. There was also the possibility of reporting bias in the study, as well as unmeasured confounding given that the original indication for hospital admission was not recorded for in-hospital stroke patients.
"Nevertheless, the concurrent increase of in-hospital stroke events and the proportion of these patients who receive reperfusion therapies suggest that increased recognition of in-hospital stroke is occurring," Yu and Hill wrote.
"Identifying metrics for quality of stroke care, establishing achievable targets, implementing iterative quality improvement protocols, and monitoring the care and clinical outcomes are necessary for ensuring excellence of care and improving patient outcomes," the editorialists concluded.
![author['full_name']](https://clf1.medpagetoday.com/media/images/author/nicoleLou_188.jpg)
Disclosures
Akbik and Hill had no disclosures.
Study coauthors reported numerous ties to industry.
Yu disclosed grants and awards from the Heart & Stroke Foundation of Canada, the Canadian Institutes of Health Research, and the Heart & Stroke Foundation of Canada.
Primary Source
JAMA Neurology
Secondary Source
JAMA Neurology
Source Reference: Yu AYX, Hill MD "In-hospital acute strokes -- opportunities to optimize care and improve outcomes" JAMA Neurol 2020; DOI: 10.1001/jamaneurol.2020.3368.
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