Though the “window”
for thrombolytic therapy for acute ischemic stroke may be as long as 4.5 hours,
those stroke patients who do best are those who receive thrombolytic therapy
within the first 60 minutes from onset of symptoms, termed the “golden hour”.
Yet only a small minority of acute stroke patients arrive at the hospital
within the golden hour. There is one group of patients who theoretically should
be ideal for thrombolytic therapy within the golden hour: those patients
having a stroke while already an inpatient in the hospital. But we’ve
lamented in several of our columns that times to diagnosis and treatment may be
paradoxically prolonged in patients having in-hospital strokes. In our March
18, 2014 Patient Safety Tip of the Week “Systems
Approach Improving Stroke Care” we noted a study that mentioned times
to treatment are often paradoxically increased in patients having in-hospital
strokes (Meretoja 2012).
And in our September 23, 2014 Patient
Safety Tip of the Week “Stroke
Thrombolysis: Need to Focus on Imaging-to-Needle Time” we noted a study (Sauser
2014) that had the interesting observation that decisions take longer when the physician has more time
available. Those authors also noted prior studies have demonstrated patients
with shorter onset-to-arrival (OTA) times often have longer door-to-needle
(DTN) times.
Then in our January
27, 2015 Patient Safety Tip of the Week “The
Golden Hour for Stroke Thrombolysis” we reiterated the seeming paradox that
patients having an in-hospital stroke tend to get delays in evaluation and
management compared to those having community-onset strokes. One of the studies
we highlighted had only been reported in an abstract presented at the
Canadian Stroke Congress 2014 (Saltman 2014). Results of that study have now been published
in their entirety and provide considerable insight into the complex nature of
the problems associated with in-hospital stroke and demonstrate that the issue
is not so clear-cut (Saltman
2015).
The study was a prospective cohort study conducted in
Ontario, Canada and included almost 1000 patients with in-hospital stroke
compared to almost 29,000 patients with community-onset stroke. Patients with
in-hospital stroke had significantly longer times from symptom recognition to
neuroimaging (median, 4.5 vs 1.2 hours)
and both lower use of thrombolysis (12% vs 19%) and longer time from stroke
recognition to administration of thrombolysis (median 2.0 vs 1.2 hours). Those
with in-hospital stroke had a longer median length of stay following stroke
onset (17 vs 8 days), were more likely to be dead or disabled at discharge (77%
vs 65% with modified Rankin Scale score of 3-6), and were less likely to be
discharged home from the hospital (35% vs 44%). However, after adjustment for
age, stroke severity, and other factors, mortality rates at 30 days and 1 year
after stroke were similar in those with in-hospital stroke and community-onset
stroke.
So the results
confirm previous observations that patients with in-hospital strokes seem to
get less timely and less appropriate interventions. But a real highlight of the
study is that patients having in-hospital stroke may be a significantly
different patient population than those having community-onset stroke.
Though the two groups had similar rates of independent functional status prior
to admission, those with in-hospital strokes were generally older, had more
comorbidities and vascular risk factors, and greater stroke severity. In those
cases where no thrombolytic therapy was given the stated reason was
contraindication to thrombolytic therapy in 46% of in-hospital stroke patients
compared to 9% in community-onset patients. This may reflect a high percentage
of patients that had just recently had surgery during their hospital admission.
But very few of the
in-hospital stroke patients were cared for on a specialized stroke unit or even
had their stroke care being primarily overseen by a neurologist. They also
tended to have lower rates of evaluations usually done in stroke patients (eg. swallowing evaluations, carotid imaging, etc.).
There were also
differences with regard to the location where the patient had their in-hospital
stroke. As you might expect, those having a stroke in the angiography suite had
shorter median times to neuroimaging and were more likely to receive
thrombolytic therapy whereas those on cardiac surgical services had the longest
median time to neuroimaging and were least likely to receive thrombolytic
therapy.
So Saltman and colleagues really come to two conclusions: (1)
there is considerable room for improvement of diagnosis and care of patients
having in-hospital stroke and (2) there are unique characteristics of the
patients having in-hospital stroke. They suggest that there probably should be
special protocols and algorithms for management of patients with in-hospital
stroke, with appropriate education and training of all parties involved, and
activation of stroke teams to deal with such patients expediently.
Recognition of
stroke signs and symptoms in patients already hospitalized may be difficult in
some cases due to things like sedation, mechanical ventilation, dressings and
casts and arm boards impairing limb movement, etc. Also, staff on some services
(eg. surgical services) may not be as aware of what
to do when signs or symptoms of stroke appear. Compared to the emergency
department, staff on such units may not know how to activate the “stroke team”
or even be aware that a “stroke team” exists.
And, upon further
review, it should not really be surprising that time to neuroimaging might be
prolonged. In our numerous columns on application of LEAN techniques to stroke
care (see list below) we’ve emphasized that hospitals performing well actually
have the patient with community-onset stroke arrive directly at the imaging
suite. But think about how long it takes to mobilize some of our most
critically-ill inpatients for transport to radiology. They have multiple lines
in place and may be on supplemental oxygen or mechanical ventilation and
staffing arrangements need to be made for someone to attend to the patient in
the neuroimaging suite. There are clearly patient safety issues that must be
addressed for such in-hospital transports (see our October 22, 2013 Patient
Safety Tip of the Week “How
Safe Is Your Radiology Suite?”). While the editorial accompanying the Saltman article (Dulli
2015) notes that
neuroimaging facilities are only “an elevator ride” away in most hospitals, the
actual situation for most in-hospital stroke patients is much more complicated
than an “elevator ride”.
Informed consent may
also be an issue since many stroke patients may be unable to communicate.
Typically, community-onset stroke patients arrive at the hospital with some
family who might be able to participate in informed consent. But for patients
with in-hospital stroke it may take longer to contact family or health care
proxies to participate in the informed consent process.
And the issue of
contraindications for thrombolytic agents in patients with recent surgery is a
difficult one. Quite frankly, the evidence base for when such could be used
after surgery (and how it applies to specific surgeries) is not well developed.
There probably are a number of circumstances where thrombolytic therapy could
be given to patients with recent surgery but those need to be better defined.
Those of you who have struggled just to get your surgeons to use low-dose
heparin DVT prophylaxis post-op know what we are talking about! Most surgeons
are very concerned about bleeding in such patients if they were to receive
thrombolytic therapy.
And we understand that
many patients with in-hospital stroke may not (or should not) be transferred to
the stroke unit. They likely have need for the care expertise on the unit where
they were (eg. surgical unit, ICU, etc.). But that
does not mean they should not have access to the expertise of the stroke team.
A hospital stroke team should be available not only for responding to stroke
alerts from the emergency department but also to respond to alerts from
anywhere in the hospital and provide continuing consulting. Importantly,
the stroke team that would follow stroke patients on units other than the
stroke unit should also have a stroke nurse as a critical team member. A
stroke nurse may be more attuned to certain aspects of care (eg. swallowing dysfunction, avoiding contractures, etc.)
than staff on a non-stroke unit.
So what should your
hospital be doing? While we all need to wait for the stroke research community
to help us develop protocols and algorithms for approach to in-hospital strokes
occurring in various inpatient populations, at a minimum you should:
Since at least 4% of strokes and probably more (Saltman
2015 , Kimura
2006) occur in patients already hospitalized for other reason, hospitals
need to be cognizant that they are likely to have such strokes occur in their
facility and be prepared to deal with them promptly.
Some of our previous columns on improving stroke care:
November 6,
2012 “Using
LEAN to Improve Stroke Care”
March 18, 2014 “Systems
Approach Improving Stroke Care”
September 23, 2014 “Stroke
Thrombolysis: Need to Focus on Imaging-to-Needle Time”
January 27, 2015 “The
Golden Hour for Stroke Thrombolysis”
References:
Meretoja A, Strbian
D, Mustanoja S, et al. Reducing in-hospital delay to
20 minutes in stroke thrombolysis. Neurology 2012; 79: 306–313
http://www.neurology.org/content/79/4/306.abstract
Sauser K, Levine DA, Nickles AV, Reeve MJ. Hospital Variation in
Thrombolysis Times Among Patients With Acute Ischemic StrokeThe
Contributions of Door-to-Imaging Time and Imaging-to-Needle Time. JAMA Neurol. 2014;
71(9): 1155-1161
http://archneur.jamanetwork.com/article.aspx?articleid=1886777
Saltman A, et al. Canadian Stroke
Congress. Presented October 6, 2014. Abstract 8094
In-Hospital Stroke Patients Wait Longer for Care. as reported in Medscape Oct 09, 2014.
http://www.medscape.com/viewarticle/833003
Also reported in Canadian Stroke Congress. Code Stroke on
the Ward. Press Release October 6, 2014
Saltman AP, Silver FL, Fang J, et
al. Care and Outcomes of Patients With In-Hospital
Stroke. JAMA Neurol
2015; Published online May 04, 2015
http://archneur.jamanetwork.com/article.aspx?articleid=2277721
Dulli DA. In-Hospital Stroke.
Hidden in Plain Sight. JAMA Neurol 2015; Published online May 04, 2015
http://archneur.jamanetwork.com/article.aspx?articleid=2277719
Kimura K, Minematsu K,
Yamaguchi T. Characteristics of In-Hospital Onset Ischemic Stroke. Eur Neurol 2006; 55(3): 155-159
https://www.karger.com/Article/Abstract/93574
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