Top Things to Know: Identifying Best Practices to Improve Evaluation & Management of In-Hospital Stroke
Published: February 09, 2022
Prepared by Anne Leonard MPH, BSN, RN, FAHA, Senior Science and Medicine Advisor - Lead
- In-hospital stroke or IHS is defined as a stroke that occurs during a hospitalization for another diagnosis.
- IHS affects in roughly 35,000-75,000 hospitalized patients annually in the United States and commonly occurs in patients who have undergone a recent procedure or an invasive diagnostic test.
- The major treatments for acute ischemic stroke, including intravenous alteplase and mechanical thrombectomy, were developed in clinical trials that mostly enrolled patients who were evaluated in emergency departments after developing stroke symptoms in the community. Clinical practice guidelines focus on acute care of stroke patients in the emergency department (ED). Translation of these therapies and guidelines for IHS is difficult due to unique clinical processes beyond the ED and the lack of standard protocols.
- This scientific statement encourages the development of hospital systems of care and targeted quality improvement for in-hospital stroke.
This statement proposes five core elements to optimize in-hospital stroke care:- Deliver stroke training to hospital staff including how to activate in-hospital stroke alerts.
- Create rapid response teams with dedicated stroke training and immediate access to neurologic expertise.
- Standardize the evaluation of potential in-hospital stroke patients with physical assessment and imaging.
- Address barriers to treatment potentially including interfacility transfer to advanced stroke treatment.
- Establish an in-hospital stroke quality oversight program delivering data-driven performance feedback and driving targeted quality improvement efforts.
- Approximately one half of all IHS stroke alerts are ultimately determined to be a stroke mimic. Suspected stroke symptoms in hospitalized patients are often non-focal and can be confounded by medications, metabolic encephalopathy, and comorbid illness. Altered mental status without focal symptoms is more likely to be a stroke mimic.
- Patients with suspected IHS require acute management in accordance with current AHA/ASA treatment guidelines.
- Hospitals unable to provide acute stroke treatment in the inpatient setting need to engage leadership, identify key barriers and development pathways to facilitate and expedite necessary transfers to a higher level of care.
- Ongoing stroke education for all hospital staff should include recognition of stroke symptoms and how to activate a stroke alert.
- IHS stroke response teams need to be trained for consistent care for all patients with stroke. Written protocols are recommended to expedite treatment and ensure consistency.
- Quality improvement for IHS includes evaluation of performance and examination of quality data to keep focus on optimal outcomes for IHS patients.
Citation
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