Investigators from the University of Toronto Faculty of Medicine, the
Institute for Clinical Evaluative Sciences (ICES) and the University
Health Network looked at data from acute care facilities in Ontario over
nine years. They examined stroke care delivery and outcomes for two
groups: those who had a stroke in the community (about 32,000 people),
and those who had a stroke while already hospitalized for another reason
(just over 1,000 cases), such as, for example, a hip replacement. The
results were surprising.
"Intuitively, you would imagine that having a stroke in the hospital
is the best place possible, and that is just not the case," says Dr.
Alexandra Saltman, a third year internal medicine resident at the
University of Toronto, and one of the authors of the Code Stroke on the
Ward study.
Compared to the patients brought into a hospital from the community, people with in-hospital strokes:
- waited significantly longer from the time stroke symptoms were recognized to neuroimaging (i.e., a CT scan);
- waited longer from the time a stroke was confirmed to getting clot-busting drugs; and
- were
less likely to receive clot-busting drugs than those who were admitted
following strokes outside of hospitals, even when they were eligible.
The
study's authors made the comparisons using the Heart and Stroke
Foundation's Canadian Stroke Best Practice Recommendations and the
American Heart Association best practice guidelines for stroke care.
After adjusting for age and other factors, the in-hospital stroke
patients also had longer hospital stays and were more likely to be
disabled.
"There is evidence that people do worse when they have a stroke in
the hospital, and not just because they are already sicker," says Dr.
Saltman.
She suggests two possibilities for what seems to be a lag in
response, despite the fact that the patient is surrounded by health-care
professionals.
First, the signs of a stroke are too often overlooked. When patients
are admitted for other medical reasons (for example, heart surgery or
pneumonia), hospital staff on that ward are understandably focused on
that ailment or condition, and are not specifically looking for stroke
symptoms.
"We're all human, and things get missed," says Dr. Saltman. "In a
medically or surgically complicated patient, it may be harder to detect
the stroke symptoms than in someone with no other acute issues."
This is an important reminder for hospitals to promote awareness of
stroke. "Awareness of stroke signs and how to react is important for all
health care professionals, in any specialty," says Patrice Lindsay,
director of stroke best practices and performance for the Heart and
Stroke Foundation. "The reality is that people can have a stroke in
hospital regardless of why they are hospitalized."
When an in-hospital stroke is identified, Dr. Saltman attributes a
slower than expected response to a second factor: a lack of a
standardized approach. When patients are taken to the hospital with a
suspected stroke, "code stroke" protocols are in place. A team is ready
to assess the patient, obtain and read images, and implement the
appropriate treatment.
"When somebody has a stroke on a ward, no such standardized approach exists," says Dr. Saltman.
Lindsay says that it is mainly a systems and organizational issue,
not the healthcare professionals who care for patients; it highlights an
opportunity for increased awareness, standardized protocols and better
coordination between internal departments throughout all acute care
hospitals.
"Hospitals already have sound protocols on handling strokes coming in
from the community," she says. "We need the same awareness and services
within the hospital for patients who are already admitted, to ensure
their rapid access to stroke care."
Hot topic in stroke: awareness of the signs Recognizing the symptoms
of a stroke and acting quickly can prevent disability and save lives. A
survey for the Heart and Stroke Foundation found that two-thirds of
Canadians arrive at hospital too late to meet the treatment window for
clot-busting drugs (or other interventions that can minimize the effects
of a stroke).
Whether people have a stroke in the community or in the hospital, the
clock is ticking. To respond as fast as possible, it's vital for the
public and health care professionals alike to know the stroke signs and
to treat them as a medical emergency:
- Weakness: Sudden weakness, numbness or tingling in the face, arm or leg.
- Trouble speaking: Sudden temporary loss of speech or trouble understanding speech.
- Vision problems: Sudden loss of vision, particularly in one eye, or double vision.
- Headache: Sudden severe and unusual headache.
- Dizziness: Sudden loss of balance, especially with any of the above signs.
Quick
action in recognizing and responding to the signs of stroke is
essential, as the clot busting drug tPA can reduce the severity of a
stroke and reverse some of the effects, but only if it is administered
within a few crucial hours after symptoms begin for someone who has a
stroke caused by a clot.
Research creates survivors
This research highlights the opportunity to create more survivors
though increasing awareness and developing in-hospital protocols ─ and
for more good news stories such as that of Chloé Rodier.
In 2011, the then 16-year-old, who was hospitalized for pneumothorax,
woke up with a strong headache. "I asked my mom to check with the
nurses if I could have some Aspirin. When I tried to try to take the
pills with my left hand, I saw that it wasn't moving. I looked at my mom
and told her that I couldn't feel my arm. The specialists got there
quickly, and many tests had to be done to diagnose the stroke. The
doctors told me that I was lucky, that things could have been worse: I
could have lost my speech and memory."
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