Hatim Attar, MD

Kassardjian CD, Willems JD, Skrabka K, Nisenbaum R, Barnaby J, Kostyrko P, et al. In-Patient Code Stroke: A Quality Improvement Strategy to Overcome Knowledge-to-Action Gaps in Response Time. Stroke. 2017

On account of various comorbidities, procedures, and acute ongoing illnesses, hospitalized patients suffer an increased risk of strokes as compared to the general population. About 7–15% of all acute cerebrovascular insults affect in-patients. A larger percent of these strokes are noted in the peri-operative period and following cardiac procedures. The authors point out that an intuitive assumption would suggest that in-hospital strokes would meet with better outcome. This would be due to a presumed higher rate of stroke symptom recognition, immediate availability of nurses and physicians, proximity to neuroimaging, and a streamlined system for management. However, time and again, it has been seen that in-patient strokes are paradoxically associated with worse outcomes. Prior studies that have been cited in this paper have identified various factors, like inadequate education about stroke symptoms, delayed notification of the appropriate personnel, and poor communication of symptoms between the different teams and need for urgent evaluation and management.

In this original study, Kassardjian et al have identified and confirmed these gaps by interviewing all personnel involved in the acute stroke process. The authors then successfully administered educational sessions, which had well-described learning objectives, including the ability to identify different types of stroke, understand the ramifications of acute stroke and available interventions, and describe the role of the medical teams in code stroke. An algorithm was created and made readily available throughout a tertiary care academic teaching hospital.

The primary outcome was time taken from Last Seen Normal (LSN) to initial assessment. The data was adjusted for demographics, stroke severity, and even baseline cardiovascular risk factors. Standard statistical analysis was completed.

The study identified a total of 245 in-patient strokes. Of these, 27 were excluded, as the LSN was over 72 hours prior identification, indicative of pre-existing or non-acute conditions. A sample of 218 strokes was analyzed, 131 prior to implementation of the educational tools and algorithm, while 87 were after this intervention. Data analysis was able to highlight interesting features, including commonly recognized symptoms and frequency of strokes among different medical/surgical subspecialties. For the entire cohort of in-hospital strokes, the median time from LSN to initial assessment decreased from 600 minutes pre-intervention to 160 minutes post-intervention. The median time from LSN to brain imaging dropped from 925 minutes to 348 minutes after intervention. For the subset of patients in whom a stroke code was activated, the median time from LSN to initial assessment was 75 minutes and to CT scanner was 125 minutes; both were significantly shorter than pre-intervention.

The age-old adage of “time is brain” cannot be highlighted enough. The authors discuss that many institutions have well-oiled systems in place for strokes arriving through the emergency department, but the same is lacking for in-hospital strokes. The educational tools trained hospital personnel in identifying the subtler stroke symptoms. Review of the available data shows that in-hospital strokes often fall behind on quality of care metrics. This is an area that is most amenable to improvement. Little education is required for personnel who are already skilled in dealing with patients, making this an easy intervention.

Additionally, the algorithm generated by the authors was user-friendly and took all scenarios into account. Integration of appropriate protocols and guidelines would streamline this process, similar to the management of strokes coming into the emergency department.

This study was able to impact most of the timed measures in acute stroke care. It demonstrated that the limitations to better times in-hospital can be overcome with practical interventions. Institutions need to compete with themselves — to decrease in-hospital stroke times in comparison to the ones that come from outside, subsequently improving national averages. One thing is certain — when it comes to acute stroke care, there is always a need for speed.