Hospitals a bad place to have a stroke, study finds

Patients get brain scans and medication faster if they are stricken at home and go to emergency

Hospital patients wait longer to get clot-busting drugs than a person who suffers a stroke at home, the Canadian Stroke Congress will hear today in Vancouver.

Dr. Alexandra Saltman says her unpublished findings reflect what she and colleagues at the Institute for Clinical Evaluative Sciences, the University of Toronto Faculty of Medicine and the University Health Network found after examining the records of 1,048 hospital patients and 32,227 people who were at home when they suffered a stroke between 2003 and 2012.

Saltman is in the third year of residency to become an internal medicine specialist and said she has noticed differences in the way strokes are treated in hospital wards other than the emergency room.

Her subsequent research project found it took an average of 1.3 hours for someone who had a stroke in the community to get a brain scan, yet 4.5 hours for a patient already in hospital. Four-and-a-half hours is the time limit for administering medication that could break up the blood clot causing the stroke.

The average time from the first symptoms of a stroke to administering anti-clot medication was 1.1 hours in the community; two hours in hospital.

In some cases, the medication can reverse effects of a stroke such as weakness on one side or the inability to speak.

“Intuitively, you would imagine that having a stroke in the hospital is the best place possible, and that is just not the case,” says Saltman. “There is evidence that people do worse when they have a stroke in the hospital, and not just because they are already sicker.”

A stroke is a sudden loss of brain function caused by a blockage in blood flow to the brain, called an ischemic stroke, or broken blood vessels in the brain, called a hemorrhagic stroke. Eighty per cent of strokes are ischemic.

Time is of the essence in treating a stroke because the lack of blood to the brain kills about 1.9 million brain cells every minute, according the Canada’s Heart and Stroke Foundation.

More than 300,000 Canadians are living with the effects of a stroke, which vary depending on severity but include problems walking, speaking and thinking. It’s a top cause of death and disability among adults.

A key reason why strokes are not noticed as readily in hospital is that a patient may already be incapacitated for another reason — a hip operation for instance — so a nurse wouldn’t necessarily notice weakness on one side of the body. Staff might also be focused on the illness that brought the patient to the hospital and less likely to look for another condition.

Another factor is that a patient who just had surgery or is taking blood thinners cannot be given a clotbusting medication because of the risk of bleeding.

But Saltman says researchers took those factors into consideration and still found a difference in treatment between the two groups, both with an average age of 73.

The research also found that a surprising 17 per cent of all strokes happen in hospital.

“They’re not getting the same standard of care and as a result they are staying in hospital longer, they’re more likely to be disabled and they’re more likely to go to a nursing home,” Saltman said in a phone interview.

In contrast, there is a standard protocol for emergency responders who are called to a home. Once the symptoms are recognized — dizziness, headache or slurred speech — it triggers a “code stroke.” By the time the patient reaches the hospital, a medical team is ready so there will be a neurologist on hand and a brain scan can be performed and interpreted immediately.

“All the pieces are lined up even before a patient walks in the door.”

Saltman would like to see a similar “code stroke” system introduced on hospital wards.

“The protocol already exists in the hospital in the emergency ward. It seems so easy and intuitive to take a protocol in one area and apply it, obviously with some refinement, to another area and possibly make a difference.”

Even if patients can’t be given a clot busting drug, they would still benefit from having the stroke recognized so that staff could help them control blood sugar and high blood pressure and have them treated by a physiotherapist and speech therapist, she says.

The study concluded that death rates were similar in both groups, but the hospital patients were more likely to be disabled.