Original Research

Quality of Care for Veterans With In-Hospital Stroke

Veterans who develop an in-hospital stroke and those who present to the emergency department with stroke symptoms received similar care, but some differences suggest the need to better standardize stroke care regardless of care setting.

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Stroke is a leading cause of death and long-term disability in the US.1 Quality improvement efforts for acute stroke care delivery have successfully led to increased rates of thrombolytic utilization.2 Increasing attention is now being paid to additional quality metrics for stroke care, including hospital management and initiation of appropriate secondary stroke prevention measures at discharge. Many organizations, including the Veterans Health Administration (VHA), use these measures to monitor health care quality and certify centers that are committed to excellence in stroke care.3-6 It is anticipated that collection, evaluation, and feedback from these data may lead to improvements in outcomes after stroke.7

Patients who experience onset of stroke symptoms while already admitted to a hospital may be uniquely suited for quality improvement strategies. In-hospital strokes (IHS) are not uncommon and have been associated with higher stroke severity and increased mortality compared with patients with stroke symptoms prior to arriving at the emergency department (ED).8-10 A potential reason for the higher observed mortality is that patients with IHS may have poorer access to acute stroke resources, such as stroke teams and neuroimaging, as well as increased rates of medical comorbidities.9,11,12 Furthermore, stroke management protocols are typically created based on ED resources, which may not be equivalent to resources available on inpatient settings.

Although many studies have examined clinical characteristics of patients with IHS, few studies have looked at the quality of stroke care for IHS. Information on stroke quality data is even more limited in VHA hospitals due to the small number of admitted patients with stroke.13 VHA released a directive on Acute Stroke Treatment (Directive 2011-03) in 2011 with a recent update in 2018, which aimed to implement quality improvement strategies for stroke care in VHA hospitals.14 Although focusing primarily on acute stroke care in the ED, this directive has led to increased awareness of areas for improvement, particularly among larger VHA hospitals. Prior to this directive, although national stroke guidelines were well-defined, more variability likely existed in stroke protocols and the manner in which stroke care was delivered across care settings. As efforts to measure and improve stroke care evolve, it is important to ensure that strategies used in ED settings also are implemented for patients already admitted to the hospital. This study seeks to define the quality of care in VHA hospitals between patients having an in-hospital ischemic stroke compared with those presenting to the ED.


As a secondary analysis, we examined stroke care quality data from an 11-site VHA stroke quality improvement study.15 Sites participating in this study were high stroke volume VHA hospitals from various geographic regions of the US. This study collected data on ICD-9 discharge diagnosis-defined ischemic stroke admissions between January 2009 and June 2012. Patient charts were reviewed by a group of central, trained abstractors who collected information on patient demographics, clinical history, and stroke characteristics. Stroke severity was defined using the National Institutes of Health Stroke Scale (NIHSS), assessed by standardized retrospective review of admission physical examination documentation.16 A multidisciplinary team defined 11 stroke quality indicators (QIs; the 8 Joint Commission indictors and 3 additional indicators: smoking cessation and dysphagia screening, and NIHSS assessment), and the chart abstractors’ data were used to evaluate eligibility and passing rates for each QI.


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