A hospital can be the worst place to have a stroke, the first study of its kind in Canada has found.
Researchers who looked at more than 33,000 stroke patients in Ontario found those who suffered a stroke while hospitalized for some other medical reason did worse than patients rushed to emergency after having a stroke at home or somewhere else in the community.
They waited nearly three times as long for a CT scan of their brain, were less likely to receive powerful clot-busters, even if they were candidates for the drugs, and were more likely to be left with paralysis, speech loss or other disabilities than people taken to an emergency room with a stroke.
In-hospital strokes make up about seven or eight per cent of all strokes.
“Intuitively, you would imagine that having a stroke in the hospital is the best place possible, and that is just not the case,” said lead author Dr. Alexandra Saltman, an internal medicine resident at the University of Toronto whose study was scheduled to be presented Monday at the Canadian Stroke Congress in Vancouver.
As a first-year resident, Saltman experienced “a couple of really bad, in-hospital strokes” where stroke symptoms were missed, putting the patient outside the window for clot-busting drugs.
“There were big delays in recognition, big delays in getting them to a CT scan and delays in decision making because everything happened more slowly,” she said.
For their study, Saltman’s team looked at every adult in Ontario with stroke seen in an emergency department or admitted to hospital at regional stroke centres in Ontario between 2003 and 2012.
The study included 1,048 patients with in-hospital strokes, and 32,227 with “community-onset” stroke.
“Seventy-two per cent of patients who have a stroke in the community are meeting that benchmark, but only 29 per cent in hospital are,” Saltman said.
Even after researchers took age and underlying risks for stroke, such as heart disease, high blood pressure and diabetes into account, people were 1.6 times more likely to be dead or disabled after having an in-hospital stroke.
Although it’s not clear why, a raft of reasons might explain the differences, Saltman said.
Hospitalized patients are generally sicker already, meaning they’re frailer and more likely to do more poorly.
As well, they may be on medications that make people more likely to bleed, which would make them ineligible for clot-busters, Saltman said.
Hospitalized patients are more medically and surgically complicated, and staff on the wards are more focused on looking for other things, Saltman said. “They’re not looking for stoke,” she said.
It can also be harder to identify stroke symptoms in these patients. They’re often in an intensive care unit; they might not be awake. Staff on the ward “might not appreciate that slurred speech or a facial droop might be a possible sign of a stroke, Saltman said.
There are also stark differences in response times: When someone has a stroke outside a hospital, even before they arrive at emergency a “Code Stroke” protocol kicks in. Paramedics call ahead to the hospital. “There are dedicated people who get a page instantly and know what to do when they get that call,” Saltman said.
“By the time the patient gets to the emergency room there are five or six people waiting for them.”
They get blood work instantly and rapid CT scans so decisions can be made quickly.
By contrast, unlike “Code Blue” for cardiac arrests, there are no stroke protocols when a patient has a stroke on a ward. “Nurses on medical or surgical floors have often not received specific stroke training, nor have the doctors taking care of them,” Saltman said. “And I think that’s what we really need.”
“Despite the fact these patients are sicker, if we had a standardized protocol we could at least help some of them who would be eligible for clot-busting medications do better, if we could get to them more quickly.”
During an ischemic stroke — strokes caused by a blood clot that has lodged in a vessel to the brain — brain cells are starved of oxygen. For every minute of delay in treatment as many as two million brain cells can die or be irreparably damaged.
“The faster you can recognize what is going on and get somebody treatment, the more likely you are to reverse that damage if you can open up that clot,” Saltman said.
For hospitalized patients, or their family members, sudden weakness on one side in an arm, leg or both, facial droops, changes in vision and speech and a sudden severe headache “are all reasons that you should call the nurse and get the nurse to call the doctor right away,” Saltman said.
Calgary neurologist Dr. Michael Hill said many in-hospital strokes occur as a complication of major surgery such as coronary bypass surgery or aortic valve surgery, surgery on the big arteries in the chest.
“You’re dealing with a really sick person who, in some cases, you can’t treat anyway, because the treatments that we would use to unblock arteries could kill them,” said Hill, director of the acute stroke unit at Foothills Medical Centre.