In-hospital strokes get worse care than those presenting to ER, study finds

Be careful out there, don't get sick while in the hospital.
Diane, for your attorney.
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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.

"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."