Identifying Best Practices to Improve Evaluation and Management of In-Hospital Stroke: A Scientific Statement From the American Heart Association

Abstract

This scientific statement describes a path to optimizing care for patients who experience an in-hospital stroke. Although these patients are in a monitored environment, their evaluation and treatment are often delayed compared with patients presenting to the emergency department, contributing to higher rates of morbidity and mortality. Reducing delays and optimizing treatment for patients with in-hospital stroke could improve outcomes. This scientific statement calls for the development of hospital systems of care and targeted quality improvement for in-hospital stroke. We propose 5 core elements to optimize in-hospital stroke care: 1. Deliver stroke training to all hospital staff, including how to activate in-hospital stroke alerts. 2. Create rapid response teams with dedicated stroke training and immediate access to neurological expertise. 3. Standardize the evaluation of patients with potential in-hospital stroke with physical assessment and imaging. 4. Address barriers to treatment potentially, including interfacility transfer to advanced stroke treatment. 5. Establish an in-hospital stroke quality oversight program delivering data-driven performance feedback and driving targeted quality improvement efforts. Additional research is needed to better understand how to reduce the incidence, morbidity, and mortality of in-hospital stroke.

Derivation and Validation of an Algorithm to Detect Stroke Using Arm Accelerometry Data

“…In‐hospital stroke is a major public health issue that accounts for a meaningful portion of all strokes and is associated with delayed assessment and treatment, poor outcome, and dramatically increased cost and length of stay. 7 , 8 , 9 , 10 , 11 , 12 Importantly, periprocedural stroke accounts for the majority of cases in most series, and stroke rates for common procedures, such as aortic valve surgery, are much higher than commonly reported when prospective assessments are performed. 7 , 8 , 9 , 29 , 30 , 31 Given that the algorithm detects asymmetry and is not based on change in movement patterns from a baseline period, it is particularly well suited to detect stroke in the perioperative setting, where patients may awaken from anesthesia with weakness.…”

“…There are several studies that have attempted to identify clinical predictors of in‐hospital stroke. 11 However, the algorithm was intentionally designed to not require any patient‐specific clinical information to detect asymmetric movement seen in acute stroke. This is analogous to cardiac telemetry monitors that have built‐in automated detection of life‐threatening arrhythmias but do not rely on clinical parameters such as history of coronary artery disease or congestive heart failure.…”

“… 7 , 8 , 9 Compared with strokes that occur in the community, in‐hospital stroke is associated with delayed detection and assessment, fewer interventions, and worse outcomes. 7 , 8 , 9 , 10 , 11 Thus, these complications lead to markedly increased cost, length of stay, morbidity, mortality, and medicolegal liability for hospitals and caregivers. 7 , 8 , 10 , 11 , 12 , 13 , 14 …”

“… 7 , 8 , 9 , 10 , 11 Thus, these complications lead to markedly increased cost, length of stay, morbidity, mortality, and medicolegal liability for hospitals and caregivers. 7 , 8 , 10 , 11 , 12 , 13 , 14 …”

Nurses Lead the Way for In-Hospital Stroke Care

“…Although I agree wholeheartedly with these positions, it remains challenging for nurses to find a voice in the larger, nonnursing scientific community. This difficulty presents itself in the recently published scientific statement for in-hospital stroke care 3. Having authored on this topic,4 I was excited to read the new recommendations from the American Stroke Association (ASA) and see how they incorporated nursing research into their work.…”