Opinion
EDITORIAL
In-Hospital Stroke Hidden in Plain Sight Douglas A. Dulli, MD, MS
There have been tremendous strides in standardization of the care for acute ischemic stroke since widespread use of thrombolytic therapy began almost 20 years ago. Efficacy is still limited by delayed presentation to the emergency Related article department following stroke symptom onset, although this has also improved in that period with education of emergency medical services and the community at large. The real improvement lies in development of streamlined and standardized protocols for “code stroke,” so that thrombolysis rates of 20% are becoming typical and door-to-needle times are just as typically under 1 hour. These encouraging developments are enhanced yet further by the evolution of stroke units, multidisciplinary stroke teams, and telemedicine to maximize the benefit of whatever window of opportunity presents to the emergency department door. Of course, these developments have primarily been aimed through these years at that door. In this issue of JAMA Neurology, Saltman et al1 explore differences in acute stroke care delivery for 28 837 patients with community-onset stroke compared with 973 patients with in-hospital stroke. They reviewed data of a prospective cohort of patients with stroke culled between 2003 and 2012. Many of their findings could be anticipated, in particular that those with in-hospital stroke had more stroke risk factors and comorbid illness, greater severity of their stroke, and poorer outcomes, particularly in terms of length of stay and disability. Indeed, virtually all studies comparing in-hospital stroke with community-onset stroke in the last 15 years have revealed these findings. 2-5 The authors express concern regarding thrombolysis rates for in-hospital stroke, although considering multiple contraindications that might exist in these patients particularly on surgical services, the 12% thrombolysis rate compares well with the 19% communityonset stroke thrombolysis rate. It is of more concern because
its median time of delivery was longer, at 2.0 vs 1.2 hours from “door” (here to mean symptom recognition). The median time from stroke recognition to neuroimaging is an especially striking finding, however. This was 4.5 hours for in-hospital stroke, compared with 1.2 hours for community-onset stroke. Equally as striking is the large interquartile range: 15.8 vs 2.5 hours for in-hospital stroke vs community-onset stroke, respectively. These data suggest that code stroke protocols were not applied to many or most patients with in-hospital stroke in this cohort. As the authors point out, the individual reasons for these highly variable delays could not be assessed, so we are left to speculate. Nearly half the in-hospital strokes occurred on surgical services, and perhaps for many of them a perioperative contraindication to thrombolytic therapy was the basis for not using code stroke. More of the patients with in-hospital stroke were drowsy or moribund due to their admitting illnesses and medications for these. In such situations both the time of symptom onset and contribution to patients’ overall deficits may have been felt to be too obscure; no code stroke was felt to be warranted. Again, these findings are consistent with those of previous studies on in-hospital stroke, which show significant delay in both evaluation and treatment compared with patients with community-onset stroke.2-4 Whatever the reasons for this delay, these studies reveal a paradox in which a critical therapy is limited or delayed in a group of patients whose need for it may be greater. In-hospital stroke is a large problem with unique challenges, representing between 4% and 17% of all acute stroke3 and typically occurring in hospitals where brain imaging and state-of-the-art stroke therapy are only “an elevator ride” away.6 The authors confirm that evolution must continue in the use of code stroke, not only for patients with stroke discovered at the hospital door but also for those within and hiding in plain sight.
ARTICLE INFORMATION
REFERENCES
Author Affiliation: Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison.
1. Saltman AP, Silver FL, Fang J, Stamplecoski M, Kapral MK. Care and outcomes of patients with in-hospital stroke [published online May 4, 2015]. JAMA Neurol. doi:10.1001/jamaneurol.2015.0284.
Corresponding Author: Douglas A. Dulli, MD, MS, Department of Neurology, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, Madison, WI 53705 ([email protected]). Published Online: May 4, 2015. doi:10.1001/jamaneurol.2015.0370. Conflict of Interest Disclosures: None reported.
jamaneurology.com
2. Cumbler E, Wald H, Bhatt DL, et al. Quality of care and outcomes for in-hospital ischemic stroke: findings from the National Get With The Guidelines–Stroke. Stroke. 2014;45(1):231-238. 3. Kimura K, Minematsu K, Yamaguchi T. Characteristics of in-hospital onset ischemic stroke. Eur Neurol. 2006;55(3):155-159.
4. Bhalla A, Smeeton N, Rudd AG, Heuschmann P, Wolfe CDA. A comparison of characteristics and resource use between in-hospital and admitted patients with stroke. J Stroke Cerebrovasc Dis. 2010;19(5):357-363. 5. Dulli D, Samaniego EA. Inpatient and community ischemic strokes in a university hospital. Neuroepidemiology. 2007;28(2):86-92. 6. Nolan S, Naylor G, Burns M. Code gray: an organized approach to inpatient stroke. Crit Care Nurs Q. 2003;26(4):296-302.
(Reprinted) JAMA Neurology Published online May 4, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a DALHOUSIE UNIVERSITY-DAL-11762 User on 05/18/2015
E1
EDITORIAL
In-Hospital Stroke Hidden in Plain Sight Douglas A. Dulli, MD, MS
There have been tremendous strides in standardization of the care for acute ischemic stroke since widespread use of thrombolytic therapy began almost 20 years ago. Efficacy is still limited by delayed presentation to the emergency Related article department following stroke symptom onset, although this has also improved in that period with education of emergency medical services and the community at large. The real improvement lies in development of streamlined and standardized protocols for “code stroke,” so that thrombolysis rates of 20% are becoming typical and door-to-needle times are just as typically under 1 hour. These encouraging developments are enhanced yet further by the evolution of stroke units, multidisciplinary stroke teams, and telemedicine to maximize the benefit of whatever window of opportunity presents to the emergency department door. Of course, these developments have primarily been aimed through these years at that door. In this issue of JAMA Neurology, Saltman et al1 explore differences in acute stroke care delivery for 28 837 patients with community-onset stroke compared with 973 patients with in-hospital stroke. They reviewed data of a prospective cohort of patients with stroke culled between 2003 and 2012. Many of their findings could be anticipated, in particular that those with in-hospital stroke had more stroke risk factors and comorbid illness, greater severity of their stroke, and poorer outcomes, particularly in terms of length of stay and disability. Indeed, virtually all studies comparing in-hospital stroke with community-onset stroke in the last 15 years have revealed these findings. 2-5 The authors express concern regarding thrombolysis rates for in-hospital stroke, although considering multiple contraindications that might exist in these patients particularly on surgical services, the 12% thrombolysis rate compares well with the 19% communityonset stroke thrombolysis rate. It is of more concern because
its median time of delivery was longer, at 2.0 vs 1.2 hours from “door” (here to mean symptom recognition). The median time from stroke recognition to neuroimaging is an especially striking finding, however. This was 4.5 hours for in-hospital stroke, compared with 1.2 hours for community-onset stroke. Equally as striking is the large interquartile range: 15.8 vs 2.5 hours for in-hospital stroke vs community-onset stroke, respectively. These data suggest that code stroke protocols were not applied to many or most patients with in-hospital stroke in this cohort. As the authors point out, the individual reasons for these highly variable delays could not be assessed, so we are left to speculate. Nearly half the in-hospital strokes occurred on surgical services, and perhaps for many of them a perioperative contraindication to thrombolytic therapy was the basis for not using code stroke. More of the patients with in-hospital stroke were drowsy or moribund due to their admitting illnesses and medications for these. In such situations both the time of symptom onset and contribution to patients’ overall deficits may have been felt to be too obscure; no code stroke was felt to be warranted. Again, these findings are consistent with those of previous studies on in-hospital stroke, which show significant delay in both evaluation and treatment compared with patients with community-onset stroke.2-4 Whatever the reasons for this delay, these studies reveal a paradox in which a critical therapy is limited or delayed in a group of patients whose need for it may be greater. In-hospital stroke is a large problem with unique challenges, representing between 4% and 17% of all acute stroke3 and typically occurring in hospitals where brain imaging and state-of-the-art stroke therapy are only “an elevator ride” away.6 The authors confirm that evolution must continue in the use of code stroke, not only for patients with stroke discovered at the hospital door but also for those within and hiding in plain sight.
ARTICLE INFORMATION
REFERENCES
Author Affiliation: Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison.
1. Saltman AP, Silver FL, Fang J, Stamplecoski M, Kapral MK. Care and outcomes of patients with in-hospital stroke [published online May 4, 2015]. JAMA Neurol. doi:10.1001/jamaneurol.2015.0284.
Corresponding Author: Douglas A. Dulli, MD, MS, Department of Neurology, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, Madison, WI 53705 ([email protected]). Published Online: May 4, 2015. doi:10.1001/jamaneurol.2015.0370. Conflict of Interest Disclosures: None reported.
jamaneurology.com
2. Cumbler E, Wald H, Bhatt DL, et al. Quality of care and outcomes for in-hospital ischemic stroke: findings from the National Get With The Guidelines–Stroke. Stroke. 2014;45(1):231-238. 3. Kimura K, Minematsu K, Yamaguchi T. Characteristics of in-hospital onset ischemic stroke. Eur Neurol. 2006;55(3):155-159.
4. Bhalla A, Smeeton N, Rudd AG, Heuschmann P, Wolfe CDA. A comparison of characteristics and resource use between in-hospital and admitted patients with stroke. J Stroke Cerebrovasc Dis. 2010;19(5):357-363. 5. Dulli D, Samaniego EA. Inpatient and community ischemic strokes in a university hospital. Neuroepidemiology. 2007;28(2):86-92. 6. Nolan S, Naylor G, Burns M. Code gray: an organized approach to inpatient stroke. Crit Care Nurs Q. 2003;26(4):296-302.
(Reprinted) JAMA Neurology Published online May 4, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a DALHOUSIE UNIVERSITY-DAL-11762 User on 05/18/2015
E1
