Pub Date: Wednesday, Feb 09, 2022
Author: David Likosky MD, FAHA, FAAN, SFHM, FACP
Affiliation: Departments of Neurology/Internal Medicine EvergreenHealth Medical Center- Kirkland Washington, Departments of Neurology/Internal Medicine Overlake Hospital Medical Center- Bellevue Washington, Department of Neurology, University of Washington Medical Center- Seattle Washington
We have grown progressively and dramatically better at treating acute stroke when it happens “in the real world.” However, we have not brought the same rigor and attention to the inpatient population. As the authors write, these patients bring another level of complexity and risk. They are, however, already in our care, well known to us, and are potential candidates for meaningful intervention. Importantly, these patients currently have relatively poor outcomes. However, when treated in a timely and appropriate manner they have results on par with community-onset stroke. This scientific statement presents clear guidance on how best to approach in-hospital stroke (HIS) given what we know, highlighting the need to develop the systems, provide the training, empower our staff and hold each other accountable to providing optimal care while we research this population further.1
A systems approach to stroke care for patients with IHS is critical. Our emphasis on stroke systems of care for emergency medical services, emergency department pathways and intervention processes over recent years has been incredibly productive. In parallel, we have seen rapid response programs implemented nationally in an effort to identify and treat deteriorating inpatients quickly. These rapid response teams are currently a fixture in hospitals2. The opportunity now is to bring this same energy and rigor to connecting these two movements. We need to be able to provide stroke care in the hospital that is at least on par with what we provide outside the hospital.
In-hospital training for the entire healthcare team on both identification and management of stroke is rightly emphasized by the authors. Given the high incidence of stroke in patients who have recently had a cardiovascular diagnosis or procedure, engaging our cardiothoracic surgery and cardiology colleagues is of paramount importance. While identification of stroke is a core competency for cardiologists and internal medicine hospitalists3,4, neurologic change may be minimized by providers and nurses who are either uncomfortable with the neurological examination or unaware of the positive outcomes that modern stroke care brings. Instead, many still live in the era of widespread therapeutic nihilism.5 In years past, there has been debate about what group is best to care for stroke patients, whether that might be a vascular neurologist, neurohospitalist or hospitalist.6,7 The reality is that hospital care is a multidisciplinary, 24/7, high acuity, team endeavor. Our practice needs to match this dynamic. We need to recognize the critical role of those who are often called first, the internal medicine hospitalists, cardiologists and other interventionalists. The responsibility of the neurologist, whether that person is a stroke neurologist or a neurohospitalist should be to lead, educate and work with our entire healthcare team to encourage rapid identification and treatment.
Staff empowerment, particularly of nursing, is another fundamental component of effective inpatient care. Nurse education unsurprisingly correlates with both decreased hospital mortality and length of stay.8 Nurses and frontline care providers are integral to the timely treatment of IHS given their role in identifying symptoms and initiating the response. Amongst the most striking statistics quoted by the authors are that IHS patients are less likely to be treated within the first hour, and thrombolytic administration is delayed by a mean of 30% when compared to community-onset stroke.1 Our care is only as good as the eyes on the patient. This includes our ability to determine last known well based on documentation. Few of us welcome a phone call at 2 am, but explaining the rationale for decisions that are made and, when necessary, providing education on the neurological exam and what pieces of information are critical improves the care that we all give. This, rather than a terse or dismissive response, has the potential to impact both the patient in question as well as future patients while empowering staff and reinforcing a culture of teamwork.9
The notably multidisciplinary author group presents a critical call to action to all of us who work in hospitals. The five core elements identified present a challenge and a clear path forward. Stroke programs have developed high functioning teams who are able to convey patients to the hospital and rapidly assess and intervene. We now need to implement this scientific statement’s best practices and participate in further research in this population. Care for patients with IHS necessitates embracing the dynamic and complex nature of the modern hospital. In doing so, we must lead and work in partnership with nurses, hospitalists, cardiologists and other specialists who may rarely see stroke. Our colleagues need to have the resources and knowledge to identify symptoms and activate well-designed pathways which deliver optimal and effective stroke care for our inpatients. We can and will do better: it’s time to get the house in order.
Nouh A, Amin-Hanjani S, Furie KL, Kernan WN, Olson DWM, Testai FD, Alberts MJ, Hussain MA, Cumbler EU; on behalf of the American Heart Association Stroke Council; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Lifestyle and Cardiometabolic Health. Identifying best practices to improve evaluation and management of in-hospital stroke: a scientific statement from the American Heart Association [published online ahead of print February 9, 2022]. Stroke. doi: 10.1161/STR.0000000000000402
- Nouh A, Amin-Hanjani S, Furie KL, Kernan WN, Olson DWM, Testai FD, Alberts MJ, Hussain MA, Cumbler EU; on behalf of the American Heart Association Stroke Council; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Lifestyle and Cardiometabolic Health. Identifying best practices to improve evaluation and management of in-hospital stroke: a scientific statement from the American Heart Association [published online ahead of print February 9, 2022]. Stroke. doi: 10.1161/STR.0000000000000402
- Rapid Response Systems | PSNet. (2019, September 8). PSnet. https://psnet.ahrq.gov/primer/rapid-response-systems
- Halperin, J. L., Williams, E. S., Fuster, V., Fuster, V., Halperin, J. L., Williams, E. S., Cho, N. R., Iobst, W. F., Mukherjee, D., Vaishnava, P., Smith, S. C., Bittner, V., Gaziano, J. M., Giacomini, J. C., Pack, Q. R., Polk, D. M., Stone, N. J., Wang, S., Balady, G. J., … Williams, J. L. (2015). ACC 2015 Core Cardiovascular Training Statement (COCATS 4) (Revision of COCATS 3). Journal of the American College of Cardiology 2015; 65(17), 1721–1723. https://doi.org/10.1016/j.jacc.2015.03.017
- Nichani S, Fitterman N, Lukela M, Crocker J, the Society of Hospital Medicine, Stroke. 2017 Hospital Medicine Revised Core Competencies. J. Hosp. Med 2017;4;S36-S37. https://doi.org/10.12788/jhm.3032
- Biller, J., & Love, B. B. (1991). Nihilism and stroke therapy. Stroke 22(9), 1105–1107. https://doi.org/10.1161/01.str.22.9.1105
- Caplan L. Stroke is best managed by neurologists. Stroke. 2003;34:2763.
- Likosky, D. J., & Amin, A. N. (2005). Who Will Care for Our Hospitalized Patients? Stroke, 36(6), 1113–1114. https://doi.org/10.1161/01.str.0000167415.05791.13
- Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Griffiths P, Busse R et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014;383:1824–30. https://doi.org/10.1016/S0140-6736(13)62631-8.
- Siedlecki, S., Hixson, E., (August 31, 2015) "Relationships Between Nurses and Physicians Matter" OJIN: The Online Journal of Issues in Nursing Vol. 20 No. 3.
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-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --