A patient who presents at hospital
with stroke symptoms today is likely to fare much better
than he would have done a decade ago. But bizarrely,
patients who are already in hospital when their stroke
occurs do markedly worse than patients brought in to
the ED, according to alarming new Canadian research.
Inpatients wait longer for a brain
scan - 61 minutes on average compared to 30 minutes
for outpatients. They wait longer for thrombolytic tPA
treatment - 138 minutes compared to 75 minutes for outpatients.
And they have worse outcomes, with a 30% times greater
chance of dying from their stroke, and less chance of
recovering full mobility after discharge.
The study that came up with these
worrying findings, carried out by the Canadian Stroke
Network, was presented on February 20 at the International
Stroke Conference in New Orleans. A team led by Dr Frank
Silver, a professor of medicine at the University of
Toronto, used data from the Canadian Stroke Network
registry. It included 12,506 patients with proven acute
ischaemic stroke who were admitted to 12 stroke centres
in Ontario and Nova Scotia between July 2003 and March
2007. Of these strokes, 535 occurred on a hospital ward.
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"You would think that if you were going to have a stroke,
there'd be no better place to be than in the hospital,"
said Dr Silver at the conference. "But what we've found
is that it takes longer to get you treated."
Even adjusting for the fact that
in-hospital patients are sicker, he said, their post-stroke
mortality rate, 14.3%, is higher than that of patients
who enter hospital through the ER, at 10.9%.
Most medical and surgical wards
don't have constant supervision, points out Dr Silver.
Patients may be checked every four to six hours, but
that's long enough that the entire window for aggressive
thrombolytic treatment can pass by before the stroke
is even discovered. Patients may be linked to a heart
monitor, but there's no such thing as a stroke monitor
on the wards.
Some research suggests that as
many as 15% of strokes occur in hospitalized patients.
Surgery can dramatically increase the short-term risk
of a blood clot. Staff on a neurology ward are likely
to be attuned to the risks of stroke, but those on an
orthopedic ward, say, often aren't.
"In the ER, there's a well-oiled
machine to triage stroke and a CT scanner nearby. But,
on a hospital ward, personnel are less likely to expect
a stroke," noted Dr Silver. It can take longer to arrange
a CT scan in hospital than in the ER, where the machine
is typically right there. Sometimes patients must wait
for an orderly to bring them to the radiology department.
In fact, some hospitals, recognizing the inadequacy
of ward arrangements, bring stroke-smitten inpatients
to the ED to speed up care.
"What this study shows is that
unlike calling 'Code Blue' for a patient with a cardiac
arrest there's no system on many hospital wards to call
for help when a patient has a stroke," Dr Silver said.
"We need to have an education program on non-neurology
floors so that hospital personnel know how to recognize
an acute stroke and who to call. In-hospital stroke
is not that rare."
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