"Intuitively, you would imagine that having a stroke in the hospital is the best place possible, and that is just not the case," according to 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. Other authors on the study came from the University of Toronto Faculty of Medicine, the Institute for Clinical Evaluative Sciences (ICES), and the University Health Network (UHN).
The research team examined data from acute care facilities in Ontario, Canada, over a nine-year period. The team evaluated 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 hospitalised for another reason (just over 1,000 cases), such as, for example, a hip replacement.
The results were surprising, the investigators said. Compared to the patients brought into a hospital from the community, people with in-hospital strokes:
- Waited noticeably longer from the time stroke symptoms were recognised 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.
For the comparisons, the authors used 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 investigators observed that 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," Dr. Saltman pointed out. She cited two possible reasons for what seems to be a lag in response, despite the fact that the patient is surrounded by healthcare professionals.
1. The signs of a stroke are too often overlooked. When patients are admitted for other medical reasons (e.g., heart surgery or pneumonia), hospital staff on that ward are understandably focused on that condition or ailment, and are not specifically looking for stroke symptoms. "In a medically or surgically complicated patient, it may be harder to detect the stroke symptoms than in someone with no other acute issues," Dr. Saltman noted.
Hence, the study serves as an important reminder for hospitals to promote stroke awareness. Knowing the signs of strokes and how to react is important for all healthcare professionals regardless of their specialty, said Patrice Lindsay, director of stroke best practices and performance for the Heart and Stroke Foundation.
2. A lack of standardised approach for handling in-hospital stroke cases. When patients are taken to the hospital with a suspected stroke, Dr. Saltman said, "code stroke" protocols are in place. A team is ready to examine the patient, obtain and read images, and implement the appropriate treatment. When somebody experiences a stroke on a ward, "no such standardised approach" is in place, Dr. Saltman said.
This is mainly an organisational/system issue, not the medical professionals who care for patients, and highlights the need for heightened awareness, standardised protocols and better coordination between internal departments in acute care hospitals, Lindsay pointed out.
"Hospitals already have sound protocols on handling strokes coming in from the community," Lindsay said. "We need the same awareness and services within the hospital for patients who are already admitted, to ensure their rapid access to stroke care."
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