Patients with in-hospital stroke face delays for diagnosis and treatment

Patients who had a stroke while hospitalized for another reason waited longer before being diagnosed and receiving treatment compared with those who had strokes before entering the hospital, according to an analysis of a Canadian registry.

They were also more likely to have a comorbid illness, experience a more severe stroke, have a greater disability and stay in the hospital longer. However, there was no difference between the groups in mortality at 30 days or one year after strokes.

Lead researcher Alexandra P. Saltman, MD, of the Department of Medicine at the University of Toronto in Canada, and colleagues published their findings online in JAMA Neurology on May 4.

Based on their findings, they recommended establishing an algorithm and protocol for diagnosing and treating patients with in-hospital stroke.

“These results add to the growing body of evidence in favor of the development of a standardized approach to the recognition and management of in-hospital stroke,” the researchers wrote. “In particular, we advocate for the development of targeted code stroke protocols for the in-hospital stroke population, similar to those used in the emergency department.”

The researchers examined the Ontario Stroke Registry, which included patients with stroke or transient ischemic attack seen in the emergency department or at 11 regional stroke centers in Ontario from July 1, 2003 to the present. For this study, they included adult patients (18 years or older) with acute stroke or diagnosed with in-hospital stroke between July 1, 2003 and March 31, 2012. They excluded patients with transient ischemic attack.

Of the 29,810 patients in the study, 973 had in-hospital stroke and 28,837 had community-onset stroke. Patients who had an in-hospital stroke were more likely to be older than 65 and to have diabetes, hypertension, hyperlipidemia or atrial fibrillation.

The median time from symptom recognition to neuroimaging was 4.5 hours in patients with an in-hospital stroke compared with 1.2 hours for patients with a community-onset stroke. Within two hours of symptom recognition, 32 percent of the in-hospital stroke group and 63 percent of the community-onset stroke group had undergone brain imaging.

In addition, within 90 minutes of stroke diagnosis, 29 percent of the in-hospital stroke group and 72 percent of the community-onset stroke group had received thrombolysis.

The researchers said the registry did not include reasons for delays in diagnosis or treatment, specific surgical and medical diagnoses and long-term functional status or quality of life measurements following strokes.