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In-hospital strokes — defined as those occurring during hospitalization for another diagnosis — are relatively common, affecting between 35,000 and 75,000 patients each year in the US.

While the hospital may seem like the optimal setting for a stroke to occur to ensure good care and outcomes, these strokes actually have worse outcomes than those occurring in the community, said Fernando D. Testai, MD, PhD, professor of vascular neurology and fellowship director at UI Health, Chicago.

Testai is also a co-author of the recent American Heart Association (AHA) scientific statement on best practices to improve in-hospital stroke care. “Patients who experience a stroke during hospitalization are more likely to experience delays in symptom recognition and initiation of treatment and worse outcomes compared to strokes occurring in the community,” Testai said in an email interview with Medscape Medical News.

Hospitalists, he said, can play an important role in improving that scenario. Like other non-neurologists, they can “serve as the first line of defense in recognizing new signs and symptoms of stroke and engaging the stroke team,” he said.

“Beyond the acute setting, they play a critical role in delivering comprehensive, longitudinal healthcare,” he said, helping patients manage vascular risk factors and encouraging lifestyle modifications to reduce recurrent stroke risk — both for those patients affected after they have been admitted and those who arrive seeking treatment for a suspected stroke.

Stroke Treatment Advances Increase Awareness

In years past, options to treat acute stroke were limited, and management was largely supportive, Testai said. “This led to a somewhat nihilistic attitude toward acute stroke management in the medical community. However, over the past 15 years, significant advances have transformed the acute stroke landscape.”

As a result, he said, a new generation of non-neurologists realize that effective treatments exist. They also realize prompt treatment is crucial. “In stroke care, time is brain,” Testai said.

Testai recommends that hospitalists maintain a high index of suspicion about stroke when caring for patients and that they promptly engage the stroke team if needed — because that will maximize the chances of timely treatment, in the process minimizing brain injury and improving patient outcomes.

It’s important, too, he said, to be able to differentiate between stroke mimics — any condition that presents with signs or symptoms similar to a stroke but not vascular in origin — and a stroke chameleon — an actual stroke that presents atypically and masquerades as a non-stroke. Confusion due to hyperglycemia might appear as a stroke mimic, for instance, while nonsensical speech in a postsurgical patient might be thought to be an anesthesia effect but could be an evolving stroke.

Testa’s advice: “Given the potential consequence of missing a true stroke, sensitivity is prioritized over specificity.” Maintain a low threshold for activating a stroke code, he said.

A Neurohospitalist’s Perspective

In a session at the Society of Hospital Medicine’s CONVERGE conference, neurohospitalist Joseph “Caleb” McCall, MD, MBA, Neurohospitalist Division chief and clinical assistant professor at Thomas Jefferson University, Philadelphia, discussed the past, present, and future of stroke care, citing studies, guidelines, and developments that hospitalists should know about.

Among the highlights of his talk:

• Of the 795,000 strokes in the US each year, 75% are first, the others are recurrent; 87% are ischemic, 10% are intracerebral, and 3% are subarachnoid hemorrhage.
• Stroke care phases involve hyperacute, acute, subacute, rehabilitation, and chronic.
• Priorities: After identifying the stroke type, initiate reperfusion therapy, manage acute complications, and stabilize the patient.
• Become familiar with the Get With the Guidelines on Stroke.
• Among recent studies to be aware of, ZODIAC, finding those with large-vessel occlusion stroke awaiting thrombectomy did better when placed at zero-degree head position than at 30 degrees. The TIMELESS study found that eligible patients given tenecteplase after the 4.5-hour window did not have a significantly higher rate of intracranial hemorrhage compared with those given placebo, suggesting the 4.5- to 24-hour window is safe.

In a post-conference interview with Medscape Medical News, McCall said: “There’s sort of a micro and macro perspective on stroke. The micro is for each patient, and that’s hard to encapsulate in an overview. The macro has to do with the [healthcare center’s] platform and how to deliver care to all.”

Hospitalists should become familiar with the resources of their own hospital, McCall said. That means knowing procedures starting from the emergency room “to the critical imaging and testing that has to be done in radiology, all the way down to the system that helps you link those things, such as patient transport.”

Hospitalists will generally be providing care outside that hyperacute window, McCall said. He encourages developing a good relationship with the neurologists on staff and the therapy and rehabilitation team. “All are going to be really important for care.”

Be aware of your facility’s policy for when a patient needs referral to a higher level of care, whether to the ICU or another hospital, he said. If your facility has no guidance, “it makes sense to work with your allies inside the institution to create guidance,” McCall said.

Become familiar with tools such as the National Institutes of Health Stroke Scale.

Hospitalist’s Perspective

“For stroke patients, every decision we make as hospitalists carries the profound power to shape their future,” said Gurdeep Singh, DO, a hospitalist and associate professor at The University of New Mexico, Albuquerque, New Mexico, who currently serves as the past president of the Society of Hospital Medicine’s New Mexico chapter.

“While we may care for 16 or more patients in a single day, each patient often has only one doctor — and, in that moment, our presence and attention can mean everything.”

His advice: “Know your protocols.” These may be different, he said, if a stroke occurs in the emergency department vs on the floors. If you are the first doctor to become aware of the stroke, know how to respond and place orders. “If you’re further down the chain, then what do you need to verify as well as implement?”

Quality Improvement for In-Hospital Stroke

“One of the problems is that the focus of stroke accreditation institutions and hospitals is typically centered in the emergency department,” Testai said. As a result, he said, there is substantial variability among hospitals in terms of what constitutes stroke education for staff and how widely it is disseminated in each institution.

In the AHA scientific statement, issued in 2022, five core elements to optimize in-hospital stroke care are proposed:

• Deliver stroke training to all staff in the hospital, including how to activate in-hospital stroke alerts.
• Create rapid response teams with dedicated training in stroke; have immediate access to neurologic expertise.
• Standardize the evaluation of patients with suspected stroke with physical assessment and with imaging.
• Address barriers to treatment, such as interfacility transfer if advanced treatment is needed.
• Create an in-hospital stroke quality oversight program.

‘Captures the Very Essence’

“Stroke care captures the very essence of what it means to be a hospitalist,” Singh said. “In these moments, we care for individuals during some of the most vulnerable — and often most frightening — days of their lives. Through clear communication, rapid deployment of resources, and the thoughtful application of medical knowledge, we have the opportunity to make a profound difference.”

Testai, McCall, and Singh had no relevant disclosures.