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Abstract

Introduction: A stroke code system has become implemented in hospitals around the country and now represents the first step in evaluation of patients with a suspected stroke. Various evidence-based literature have shown the benefit of such a rapid-response system in identifying patients who would benefit from reperfusion therapy, improving overall outcomes, and shortening inhospital treatment delays. Most literature studies have supported the use of a focused history (especially discerning whether the patient has a history of CVA/TIA) physical examination, and neurologic testing to risk stratify patients and minimize unnecessary testing. However in clinical practice, this can sometimes be uncommon and physicians can activate stroke codes without proper initial evaluation. Methods: Single-center, retrospective clinical record review of patients who underwent a stroke code between 3/1/2012 to 5/1/2012. Inclusion criteria: a. Stroke code called to evaluate for acute CVA. b. Stroke code ordered by Emergency Department staff and house staff. c. All ages/sex included Exclusion Criteria a. CT head ordered for reasons other than to diagnose acute CVA. b. Patients who presented to ED following an outside diagnostic imaging test, i.e. MRI brain. Methods: We analyzed data from a retrospective cohort of patients at a single medical center who were already admitted or presented to the Emergency Department and underwent a stroke code from 3/1/2012 to 5/1/2012. We reviewed the charts to see what the primary indication was for the stroke code being called. We then reviewed if the patient was presenting to the ED or if they were already admittd. Then we also checked if the ordering physician documented a focused history, physical exam, or neurologic evaluation. A total number of 147 charts were reviewed. We also reviewed if the patients in the ED were admitted following a negative CT scan and if additional tests were ordered. Results: There were 147 patients who underwent a stroke code in the given months. There were a total of 38 positive CVAs. Thus, 26% of stroke codes were positive for an acute infarct or hemorrhage. Out of the 147 total stroke codes, 38 were called by the housestaff (i.e. resident, intern, floor attending). Of these 38 stroke codes, 19 were positive. Thus, 50% of the stroke codes called by the housestaff were positive. On the contrary, out of the 147 total stroke codes, 109 were called by the ED attending. Of those 109 stroke codes, 19 were positive. Thus, 17% of the stroke codes called by the ED staff were positive. It is also important to note that of the 38 total positive stroke codes, 29 of those patients had a prior history of a CVA. This represents 76% of positive stroke codes. As a result, it becomes important to take into consideration a patient’s prior medical history, especially if the presenting signs and symptoms are not as remarkable. Furthermore this study also recorded the most common complaints associated with a positive stroke code. For example, confusion, aphasia, and focal limb weakness made up 21 of the 38 (55%) positive stroke codes. In addition it is also important to note that a large majority of those patients, especially those presenting with confusion and aphasia, had a prior history of CVA/TIA. Conclusions: There is a large discrepancy between stroke codes and their results when called by the ED and housestaff. All physicians should document a patient’s medical history and symptoms along with a relevant neurologic exam. This would allow for better risk assessment for a CVA/TIA. Patients who have persistent symptoms should be admitted to telemetry. Patients who have transient symptoms but with a prior history of a CVA/TIA should also be admitted to telemetry, given their risk of progression. Patients with transient symptoms without a history of CVA/TIA or risk factors may be admitted to a regular bed or discharged from the ED after a focused work-up with extremely close follow up with their PCP and a neurologist.