Code Gray—An Organized Approach to Inpatient Stroke

Nolan, Scot; Naylor, George A; Burns, Melissa

doi:10.1097/00002727-200310000-00005

Cited by 22 publications

(17 citation statements)

References 3 publications

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“…Our study also confirmed the finding that despite being hospitalized, patients who develop IHS are not recognized and evaluated quickly enough [3, 12, 19, 20, 27]. The lack of recognition of stroke symptoms in this study is reflected by the fact that one-third of IHS cases had no time of stroke onset documented.…”

Section: Discussionsupporting

confidence: 85%

“…Substantial delays in the recognition, evaluation, and treatment of IHS cases are common [3, 19, 20]. The origins of these delays are multifactorial and likely include the lack of training and awareness of hospital staff regarding the diagnosis and treatment of stroke, the lack of an urgent in-hospital referral mechanism for suspected stroke patients, the high level of pre-existing morbidity in patients at risk of IHS, and the potential for stroke signs to be misinterpreted due to the current clinical circumstances, including postoperative confusion or weakness, or medication effects [19, 20].…”

Section: Introductionmentioning

confidence: 99%

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In-Hospital Stroke in a Statewide Stroke Registry

Farooq¹,

Reeves²,

Gargano³

et al. 2007

Cerebrovasc Dis

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Background:In-hospital stroke (IHS) represents 5–15% of all hospitalized acute stroke cases, and is associated with poor outcomes. IHS represents an important area for prevention since many cases occur in high-risk patients undergoing cardiovascular procedures. Our objectives were to compare the quality of care, treatments, and outcomes of IHS with out-of-hospital stroke (OHS) cases. Methods: A 6-month prospective cohort of IHS and OHS stroke cases from a statewide acute stroke registry of 15 representative hospitals was assembled. Data were abstracted on demographic, clinical characteristics, in-hospital care (including tPA treatment), discharge instructions, and in-hospital outcomes (mortality and modified Rankin Scale [mRS] at discharge). Results:177 (6.5%) of the 2,743 cases in the registry were IHS cases. 40% of IHS cases were admitted with a cardiovascular or neurologically related problem, and 68% underwent an invasive diagnostic or surgical procedure prior to their stroke. IHS cases were less likely to have the cerebral vasculature examined or to have a lipid panel drawn. Compared to OHS, IHS had higher case fatality (14.6 vs. 6.9%; p = 0.04), greater functional impairment (mRS ≧4) (61 vs. 36%; p < 0.001), and were less likely to be discharged home (23 vs. 52%, p < 0.01). Conclusions:In this prospective registry, 1 in 15 acute stroke cases occurred in the hospital, and almost 70% had an invasive procedure undertaken prior to their stroke event. In-hospital cases received similar quality of care as OHS cases, but had significantly worse outcomes.

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Section: Discussionsupporting

confidence: 85%

Section: Introductionmentioning

confidence: 99%

In-Hospital Stroke in a Statewide Stroke Registry

Farooq¹,

Reeves²,

Gargano³

et al. 2007

Cerebrovasc Dis

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“…However, with explicit quality improvement efforts, there is evidence that response times can be reduced. [24][25][26] Our findings suggest in-hospital stroke time to thrombolytic treatment requires targeted attention.…”

mentioning

confidence: 80%

Quality of Care and Outcomes for In-Hospital Ischemic Stroke

Cumbler

Wald

Bhatt

et al. 2014

Stroke

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Background and Purpose-Analysis of quality of care for in-hospital stroke has not been previously performed at the national level. This study compares patient characteristics, process measures of quality, and outcomes for in-hospital strokes with those for community-onset strokes in a national cohort. Methods-We performed a retrospective cohort study of the Get With The Guidelines-Stroke (GWTG-Stroke) database ofThe American Heart Association from January 2006 to April 2012, using data from 1280 sites that reported ≥1 in-hospital stroke. Patient characteristics, comorbid illnesses, medications, quality of care measures, and outcomes were analyzed for 21 349 in-hospital ischemic strokes compared with 928 885 community-onset ischemic strokes. Results-Patients with in-hospital stroke had more thromboembolic risk factors, including atrial fibrillation, prosthetic heart valves, carotid stenosis, and heart failure (P<0.0001), and experienced more severe strokes (median National Institutes of Health Stroke Score 9.0 versus 4.0; P<0.0001). Using GWTG-Stroke achievement measures, the proportion of patients with defect-free care was lower for in-hospital strokes (60.8% versus 82.0%; P<0.0001). After accounting for patient and hospital characteristics, patients with in-hospital strokes were less likely to be discharged home (adjusted odds ratio 0.37; 95% confidence intervals [0.35-0.39]) or be able to ambulate independently at discharge (adjusted odds ratio 0.42; 95% confidence intervals [0.39-0.45]). In-hospital mortality was higher for in-hospital stroke (adjusted odds ratio 2.72; 95% confidence intervals [2.57-2.88]). Conclusions-Compared with community-onset ischemic stroke, patients with in-hospital stroke experienced more severe strokes, received lower adherence to process-based quality measures, and had worse outcomes. These findings suggest there is an important opportunity for targeted quality improvement efforts for patients with in-hospital stroke.

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“…Acute inpatient stroke teams have been demonstrated to reduce in-hospital delays. 28,[30][31][32] When a general medicine rapid response team is used for in-hospital stroke alerts, additional stroke-specific training for rapid response team members is necessary. If a dedicated neurology response team is utilized, expertise on the team in urgent response to the common cardiopulmonary and metabolic mimics of stroke symptoms is similarly prudent.…”

Section: Quality Improvement Creating An In-hospital Stroke Response mentioning

confidence: 99%

In-Hospital Ischemic Stroke

Cumbler

2015

The Neurohospitalist

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Between 2.2% and 17% of all strokes have symptom onset during hospitalization in a patient originally admitted for another diagnosis or procedure. These in-hospital strokes represent a unique population with different risk factors, more mimics, and substantially worsened outcomes compared to community-onset strokes. The fact that these strokes manifest during the acute care hospitalization, in patients with higher rates of thrombolytic contraindications, creates distinct challenges for treatment. However, the best evidence suggests benefit to treating appropriately selected in-hospital ischemic strokes with thrombolysis. Evidence points toward a ''quality gap'' for in-hospital stroke with longer in-hospital delays to evaluation and treatment, lower rates of evaluation for etiology, and decreased adherence to consensus quality process measures of care. This quality gap for in-hospital stroke represents a focused opportunity for quality improvement.

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Code Gray—An Organized Approach to Inpatient Stroke

Cited by 22 publications

References 3 publications

In-Hospital Stroke in a Statewide Stroke Registry

In-Hospital Stroke in a Statewide Stroke Registry

Quality of Care and Outcomes for In-Hospital Ischemic Stroke

In-Hospital Ischemic Stroke

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