1. Strokes Occurring In the Hospital: Quality of Care and Outcome in a Tertiary Academic Medical Center
Haris Kamal, MD; Ashkan Mowla, MD,FAHA ; Navdeep S. Lail, MBBS; Peyman Shirani, MD; Babar Cheema, MBBS; Annemarie Crumlish. CCRC; Karanbir Singh, MBBS; Marilou Ching, MD, MPH; Robert N. Sawyer, MD Department of Neurology, State University of New York at Buffalo
Introduction
Discussion
Location of Patient during recognition of stroke symptoms compared with percentage of patient who are eligible for intravenous or intra-arterial thrombolysis.
Emergency Room or Intensive Care Unit: 44% patients received treatment.
Regular floors: only 25% of patients received
treatment.
Mean Modified Ranking scale (mRS) on discharge was 2.37 (+2.16)
Mortality Rate was 13%
In 15 patients (28%), there was a delay in symptoms recognition or treatment given due to medical error.
Results
Studies have shown that 4-17% of acute strokes occur in the patients hospitalized for another reason.
However, scanty data is available about the care delivery and outcomes of this patient population.
We present one of the largest single center studies in the US on quality of care and outcome of in-hospital strokes from our large volume comprehensive stroke center at Buffalo General Hospital, Buffalo, NY
Clinical presentation of the patients at the time of Stroke :
Aphasia (28%)
Dysarthria (28%)
Left Sided Hemiparesis (22%)
Mean NIHSS at time of Stroke is 10.1 (+9.72)
Time of symptom recognition to Neuroimaging
Mean time was 7 hours (+14.4 hours).
Only 4 patients had CT scan within 25 minutes as recommended by ASA/AHA guidelines.
42 patients(79%) underwent Brain Imaging within 6 hours of symptoms onset.
In this retrospective study, we found 53 patients who suffered an acute ischemic stroke proven on brain imaging after being hospitalized for another reason in the study period.
Males were 26 (49%)
Females were 27 (51%)
Mean Age was 69.4 Years (+ 13.1)
Mean NIHSS on admission was 0
Site of Infarction-- Out of 53 patients:
38 had Acute infarction in Anterior circulation
(72%)
10 had acute Infarction in Posterior Circulation (19%)
5 patients had acute infarction in both Anterior and Posterior Circulations (9%)
Methods
All patients who suffered an acute ischemic stroke after being admitted for another reason to our tertiary academic medical center from January 2006 till June 2015 were included.
Following variables were included
Demographics
Comorbid illnesses
NIHSS on admission
Clinical presentation and NIHSS at the time of stroke
Location of infarction on brain imaging
Location of the patient while stroke occurred
Treatment undertaken
Quality of care measures
Modified Rankin Scale( mRS) on Discharge
Conclusion
Increased Symptoms recognition was found within the Intensive Care Units and Emergency Room cohorts staffed by Specialized Nurses.
This indicates that improving awareness of stroke symptoms among medical staff including nurses and physicians leads to more timely initiation of treatment and better outcome.
Due to many logistic problems, only a small number of patients with in-hospital strokes received brain imaging according to ASA/AHA guideline recommendations which is an important opportunity for quality improvement efforts for this group of patients.
Rapid Response Team for Stroke Emergency
Thrombolytic treatment stats:
11 Patients (26%) received intravenous
thrombolysis with in 4.5 hours of symptom
onset.
7 patients (17%) underwent intra-arterial
thrombolysis.
References
Alexandra P. Saltman, MD1; Frank L. Silver, MD1,2,3; Jiming Fang, PhD2; Melissa Stamplecoski, BSc2; Moira K. Kapral, MD, MSc Care and Outcomes of Patients With In-Hospital Stroke JAMA Neurol. 2015;72(7):
Kimura K, Minematsu K, Yamaguchi T. Characteristics of in-hospital onset ischemic stroke. Eur Neurol. 2006;55:155–159.
Get With The Guidelines-Stroke. American Stroke Association Web Site. Available at
Alvaro LC, Timiraos J, Sa´daba F. In-hospital stroke: clinical profile and expectations for treatment. Neurologia. 2008;23:4 –9
Ethan Cumbler, et al Quality of Care for In-Hospital Stroke Analysis of a Statewide Registry Stroke. 2011;42:
Gates Vascular Institute and Buffalo General Hospital, Buffalo