Strokes in the Hospital

By Deborah Gesensway, Today’s Hospitalist.

Studies show that it can take as long as 20 hours to recognize when an inpatient is having a stroke

Because they work at a Joint Commission-certified primary stroke center, the doctors and nurses at Seattle’s Swedish Medical Center have gotten pretty good at working up—in less than 45 minutes—any patient who comes to the emergency room with a suspected stroke. That quick evaluation allows them to offer time-limited lytic drugs like tissue plasminogen activator (tPA) or reperfusion therapies to as many patients as possible.

On the wards, however, it can be a different story. Studies have shown that it takes as long as 20 hours for a medical team to recognize a stroke in inpatients being treated for another condition. “Inpatients are at much higher risk for mortality and morbidity from stroke because they are already ill.”–Sandeep Sachdeva, MD Swedish Medical Center.

“That turns out to be a dirty little secret, that patients have strokes in the hospital,” says hospitalist Sandeep Sachdeva, MD. “And Swedish, like any tertiary care center where a lot of cardiovascular procedures are done, is certainly not immune to that phenomenon.”

To address that troubling situation, Dr. Sachdeva has been involved in an intensive effort at Swedish over the last few years to institute a brain attack response team (BART). In what’s basically a scaled-down version of a cardiac-respiratory collapse code blue-style rapid response team, BART responds only to suspected in-hospital strokes.

The team’s goal is to work up these cases within 45 minutes, just as if the patients were in the emergency department. But while the clinical protocol guiding that evaluation is the same, the logistical challenges are quite different.

Calamitous strokes

While strokes are threatening for people in the overall community, they tend to be worse for inpatients. Overall mortality for strokes is about 30%, but Dr. Sachdeva said that nearly 54% of patients who suffer a stroke while hospitalized die.

Between 5% and 15% of strokes nationwide occur in hospitalized patients, meaning that 35,000 to 70,000 strokes take place each year in inpatients.

“Inpatients are at much higher risk for mortality and morbidity from stroke because they start out already ill,” Dr. Sachdeva explains. “They have longer lengths of stay and increased costs of care.” At Swedish, for instance, the average BART patient ended up staying in the hospital 10.9 days, compared to a system-wide average length of stay of 4.3 days.

And recognizing strokes in inpatients can be trickier than in outpatients. That’s because there are so many possible explanations for mental changes and other stroke-like symptoms in sick or post-surgical inpatients.

When an elderly hospitalized patient has neurological changes, stroke is not the No. 1 differential diagnosis, Dr. Sachdeva points out. “You tend to think it’s probably the medication that you gave, like a benzodiazepine, that caused the symptom change. Or, if it’s an orthopedics case, maybe it’s the surgery that’s making them weak in that arm or leg.”

Physicians tend to reassure patients that symptoms are probably nothing to worry about. “But the next day,” he says, “the patient is still weak. Then you start wondering what is happening here.”

Predicting high-risk patients

Only a few studies provide data on how to identify at-risk patients. Risk factors include older age, female gender, history of heart disease or atherosclerotic vascular disease, and having had procedures that involved catheters through arteries.

According to Dr. Sachdeva, physicians also need to put preventive actions in place to reduce the chance of stroke, such as providing adequate bridging therapy for anticoagulation patients who have their regular therapy stopped before surgery. Nurses caring for these patients, moreover, can be taught to be particularly vigilant and suspicious of stroke-like symptoms.

In fact, Dr. Sachdeva says, education is one of the most important reforms. It’s critical to teach floor nurses—who typically are the ones who recognize the onset of stroke—to trust their knowledge and to make the call.

Hospitals also need to develop a system for stroke-specialist doctors, nurses and technicians to respond and follow an efficient algorithm for timely evaluation, just like when patients are in the emergency room, rather than in a bed on a medical floor.

Deciding who’s on the team

That’s where the idea for BART came in. As he started mapping out the new team, Dr. Sachdeva realized that sending in the regular code blue team (called code 199 at his medical center) didn’t seem wise.

To start, sending 15 people plus equipment into a conscious patient’s hospital room would create unnecessary anxiety. Dr. Sachdeva wanted an option that would respond to pages seriously, but in a manner that produced less chaos.

As a result, the BART team contains about half the number of people as a code blue team. The team includes the on-call hospitalist who administers the NIH stroke scale, completes the history and physical, and determines the time of onset. The team is rounded out by an ICU nurse (from the code 199 team); a nurse or midlevel practitioner from the hospital’s stroke team; an EKG technician; an IV nurse or lab tech to draw CBCs, coagulation and metabolic labs; and a transporter who is available immediately—without any wait—to take the patient for a head CT scan.

Others who get the BART page include radiology, to make sure the CT table gets cleared and to alert the radiologist on call to be prepared to read the scan immediately. The stroke team’s on-call neurologist is also paged in case the patient turns out to be a candidate for reperfusion.

“It was a challenge to get everybody’s pagers synchronized,” says Dr. Sachdeva. “We don’t want to generate 10 phone calls and slow the system down.”

Physician buy-in

In addition to clearing logistical hurdles, Dr. Sachdeva says, another challenge was to get hospitalist buy-in to BART.

Some doctors worried that they would have to squeeze another code into their already packed schedules. Others were concerned that they weren’t skilled in administering tPA or trained in the NIH stroke scale. Education followed for both the hospitalists and the nurses.

Getting BART up and running required overcoming both ignorance and inertia. But a year and half later, Dr. Sachdeva says he is convinced the end result was worth the effort.

A couple of patients have received post-stroke reperfusion therapy that may have been missed before, he notes. The next step is to put processes in place to predict which patients are at higher risk and to improve preventive therapies for them.

Better delirium care

The BART experience has also produced an unexpected side benefit: better care for delirium patients.

Of the 153 BART calls made during the year starting February 2006, 67 turned out to be a stroke or TIA. Another 73 were determined to be cases of acute mental status change, largely delirium.

“That prompted us to look more at delirium, and we found that delirium is also a bad player,” Dr. Sachdeva explains. “Patients who have delirium in the hospital tend to have poorer outcomes, with a one-year mortality rate between 34% and 40%, which is pretty much the same as an acute myocardial infarction.” The BART protocol has since been revised to include a quick evaluation for delirium.

For hospitalists thinking of instituting something similar in their hospitals, Dr. Sachdeva offers this advice: Recognize that logistical issues take time to overcome in a complicated hospital system.

The protocol to be followed for evaluating possible stroke in inpatients will be basically the same as in the emergency department. But the logistical challenges will be much greater, he says, because staff and equipment are not already in one place.

Getting a hospitalized patient worked up within 45 minutes takes buy-in from departments as diverse as radiology and transportation, he adds. And hospitalists should expect to spend time re-educating everyone from nurses to doctors so that staff begin to see that a suspected stroke in a hospitalized patient is a true emergency.

Diagnosing stroke

The National Institutes of Health stroke scale is a systematic assessment tool designed to measure the neurologic deficits most often seen with acute stroke patients. The scale assigns points to different levels of the following factors.

Level of consciousness
Best gaze
Visual fields
Facial palsy
Motor arm
Motor leg
Limb ataxia
Sensory loss
Best language
Dysarthria
Extinction and inattention

 Sept. 2007

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