In-hospital stroke ‘neglected’
MedWire News: Inpatients who have a stroke face delays to treatment, even in an institution with established protocols for treating patients who have stroke out of hospital, researchers reported at the European Stroke Conference in Lisbon, Portugal.
The results emerge from a study carried out at Kings' College Hospital in London, UK. The hospital's stroke unit is well established and is one of the top-scoring units in the regular UK Royal College of Physicians' stroke audit.
The researchers therefore hypothesized that inpatients and outpatients with stroke would have similar assessment-to-treatment times. But they found a large disparity.
The average door-to-treatment time was 57 minutes in 306 patients with out-of-hospital stroke, reported Jithesh Choyi (Kings' College Hospital). The equivalent for 19 patients with in-hospital stroke - the assessment-to-treatment time - was a much longer 1 hour and 40 minutes.
However, patients with in-hospital stroke had shorter times between symptom onset and first specialist assessment than those who had stroke out of hospital, at 33 versus 55 minutes. Consequently, the two groups had similar onset-to-treatment times, of 2 hours and 14 minutes for inpatients and 2 hours and 30 minutes for patients with out-of-hospital stroke.
On multivariate analysis, patients with in-hospital stroke were 2.8-fold more likely to die than those who had a stroke out of hospital. But this association was entirely due to the high rate of cardiac disease in the inpatient group (53%), compared with the out-of-hospital stroke patients (26%). Cardiac disease raised patients' mortality risk 2.7-fold.
Other important predictors of mortality were age and baseline National Institutes of Health Stroke Scale (NIHSS) score. Inpatients were a similar age to those who had out-of-hospital stroke, but had more severe strokes, with baseline NIHSS scores of 16.2 versus 13.2.
In-hospital stroke was not associated with functional outcomes or with the risk for symptomatic intracranial hemorrhage.
Although outcomes were similar between the two groups, Choyi suggested that inpatients should have a "natural advantage" to receive very rapid treatment, and that they appear to lose this because of a lack of pathways to treat in-hospital stroke. Further research will be needed to establish whether faster treatment improves their outcomes, he added.
In response to an audience question, Choyi said that a major contributor to in-hospital stroke delays was arranging a prompt computed tomography scan.
By Eleanor McDermid