Conference Coverage

Conference News Update—Fifth Canadian Stroke Congress



Care May Be Delayed When Strokes Occur in the Hospital
Delays in performing the appropriate tests and obtaining the right drugs can be longer when people experience a stroke in a hospital, compared with outside a hospital, according to researchers.

Investigators from the University of Toronto Faculty of Medicine, the Institute for Clinical Evaluative Sciences, and the University Health Network analyzed data from acute care facilities in Ontario, Canada, over nine years. They examined stroke care delivery and outcomes for about 32,000 individuals who had a stroke in the community, and for more than 1,000 people who had a stroke while hospitalized for another reason such as a hip replacement.

Using the Heart and Stroke Foundation’s Canadian Stroke Best Practice Recommendations and the American Heart Association best practice guidelines for stroke care, the researchers compared stroke care delivery and outcomes between the two groups. Compared with the patients brought into a hospital from the community, people with in-hospital strokes waited significantly longer from the time stroke symptoms were recognized to the time of neuroimaging.

People with in-hospital strokes also waited longer from the time a stroke was confirmed to receive clot-busting drugs. These people also were less likely to receive clot-busting drugs than were patients who were admitted following strokes that occurred outside hospitals, even when they were eligible. After adjusting for age and other factors, the investigators found that patients with in-hospital strokes had longer hospital stays and were more likely to be disabled.

“There is evidence that people do worse when they have a stroke in the hospital, and not just because they are already sicker,” said Alexandra Saltman, MD, a third-year internal medicine resident at the University of Toronto and one of the authors of the study. Two possible explanations may explain the apparent lag in response, she continued.

First, the signs of a stroke often are overlooked. When patients are admitted for other medical reasons (eg, heart surgery or pneumonia), hospital staff on that ward are focused on that ailment or condition and are not specifically looking for stroke symptoms. “We’re all human, and things get missed,” said Dr. Saltman. “In a medically or surgically complicated patient, it may be harder to detect the stroke symptoms than in someone with no other acute issues.”

Second, hospitals lack a standardized approach to stroke that occurs on their premises. When patients are taken to the hospital with a suspected stroke, “code stroke” protocols are in place. A team is ready to assess the patient, obtain and read images, and implement the appropriate treatment. “When somebody has a stroke on a ward, no such standardized approach exists,” said Dr. Saltman.

The study highlights an opportunity for increased awareness, standardized protocols, and better coordination between internal departments throughout all acute care hospitals, said Patrice Lindsay, Director of Stroke Best Practices and Performance for the Heart and Stroke Foundation. “Hospitals already have sound protocols on handling strokes coming in from the community. We need the same awareness and services within the hospital for patients who are already admitted, to ensure their rapid access to stroke care.”

Period of High Risk for Repeat Stroke May Last for Years
People who have had a stroke or transient ischemic attack (TIA) are at high risk for a second similar event or other serious medical problems for at least five years and need better follow-up and strategies to prevent these problems, researchers reported.

At present, most patients with stroke or TIA in Canada are followed closely by specialty clinics for approximately 90 days after an event, which is the period during which they are considered at highest risk for a repeat event. If no such incident occurs during that period, the patients often are transferred back to community care (eg, a family physician).

Data indicate, however, that these patients have an approximately 10% risk in the first year of having a repeat stroke, dying, having a heart attack, or being admitted to long-term care. Over the long term, these patients remain at high risk. After five years, these individuals’ risk of such events was double that of people of the same age and sex who did not have a previous stroke or TIA.

“This high long-term risk was surprising and shows that we need to develop better strategies and interventions for these patients to prevent as many of these serious problems as we can,” said Richard Swartz, MD, PhD, Director of the University of Toronto Stroke Program and lead author of the study.

The research was performed at the Institute for Clinical Evaluative Sciences using data from the Ontario Stroke Registry, which includes about 34,000 patients discharged from the hospital following a stroke or TIA from 2003 to 2011.

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