in-hospital, improvement, inpatient, outcomes, process, quality, stroke, stroke code



  1. Droegemueller, Carol J.
  2. Kashyap, Bhavani
  3. Huna Wagner, Roberta L.
  4. Shibeshi, Hannah
  5. Clayton, Mitchell W.
  6. Fennig, Mary W.
  7. Hussein, Haitham M.


ABSTRACT: BACKGROUND: The incidence rate of stroke in hospitalized patients ranges between 2% and 17% of all strokes-a higher rate than in the community. Delays in recognition and management of stroke in hospitalized patients lead to worse outcomes. At our hospital, the existing in-hospital stroke (IHS) code showed low usage and effectiveness. In a quality improvement (QI) project, we aimed to improve the identification of and the quality of care for inpatient strokes. METHODS: A nurse-driven IHS protocol was implemented, which alerted a specialized stroke team and cleared the computed tomography (CT) scanner. The protocol focused on prioritizing staff education, simplifying the process, empowering staff to activate an IHS code, ensuring adequate support and teamwork, identifying well-defined quality metrics (eg, time to CT and documentation tool use), and providing feedback communication. We analyzed 2 years of postimplementation IHS data for impact on stroke detection and outcomes. RESULTS: In the 2 years post QI, there was a more than 10-fold increase in IHS (pre-QI, n = 8; first year post QI, n = 94; second year post QI, n = 123). In the post-QI cohort, after excluding patients with missing information (n = 26), 69 cases had new stroke diagnoses (63 ischemic, 6 hemorrhagic), and 148 were stroke mimics. The mean (SD) time from IHS to CT was 18.7 (7.0) minutes. Of the 63 new ischemic stroke cases, 25 (39.7%) were treated with thrombolytic therapy and/or mechanical thrombectomy. CONCLUSION: The new IHS protocol has led to a marked increase in cases identified, rapid evaluation, and high utilization rate of acute stroke therapies.