Background and purpose: approximately 4% to 17% of all adult strokes have onset in the hospital. Previous research indicates significant in-hospital evaluation delays and lower adherence to some measures of quality care compared to out-of-hospital strokes.
Methods: quality of care for in-hospital ischemic strokes compared to stroke with out-of-hospital onset was examined using cohort analysis of a statewide stroke database maintained by the Colorado Stroke Alliance.
Results: one-hundred sixteen in-hospital strokes were compared to 4946 out-of-hospital strokes. Patients with in-hospital strokes were significantly more likely to have history of coronary artery disease (36.7% vs 26.5%; P=0.02), and in-hospital strokes were more severe (NIHSS score 9.5 vs 7.0; P=0.01). Time to brain imaging was not significantly different (54 minutes vs 43 minutes; P=0.13) between groups. Patients with in-hospital stroke were significantly more likely to have documentation of stroke education (90.4% vs 73.1%; P=0.0002) and assessment for rehabilitation (67.7% vs 45.2%; P<0.0001). Total deficit-free care defined as adherence to all Get With the Guidelines Stroke (GWTG-Stroke) measures was better for in-hospital strokes compared to strokes in the community (52.8% vs 32.3%; P<0.0001).
Conclusions: adherence to GWTG-Stroke performance measures was better for in-hospital strokes in this statewide registry. Variability in reporting by participating hospitals suggests in-hospital strokes are under-recognized or under-reported. In-hospital stroke evaluation times remain more than twice the recommended benchmark of 25 minutes, representing an opportunity for process improvement.