Abstract TP254: Frequent Flyers: Retrospective Review of Repeat Stroke Codes

Abstract

Introduction: A stroke code is a standardized pathway for rapidly assessing patients with possible stroke. Inpatients with neurological deficits often trigger repeat stroke codes, even if the etiology is not vascular. We analyzed all repeat stroke codes to look for trends in diagnosis, timing and risk factors as part of a departmental quality improvement project aimed at improving policy in light of new acute stroke treatment guidelines. Methods: We analyzed all stroke codes in our urban, multi-hospital healthcare system by reviewing all cases where an acute stroke code head CT was ordered from January 2017 to April 2018. Patients for whom >1 stroke code was called during the period of interest were analyzed for final diagnosis, timing between stroke codes, and underlying medical and vascular risk factors. A diagnosis of stroke was confirmed by imaging with either CT or MRI. Results: There were 651 stroke codes in total, of which 51 were called on the same patient, representing 8% of all codes. 68.3% of all codes had a confirmed stroke or TIA, and 49% had a history of prior stroke or TIA. These 51 codes were represented by just 25 patients, one of whom triggered 3 stroke codes in one year, and the rest triggering 2. 61% were found to have a stroke the first time as well as the second time the code was called. Among these repeat strokes, 34.1% had atrial fibrillation, 31.4% had critical vascular stenosis and 14.3% had underlying malignancy. Patients without an acute stroke included those with toxic metabolic encephalopathy (21.6%) and seizure/post-ictal state (9.8%). 45.5% of toxic-metabolic patients had ESRD with an equal percentage having uncontrolled blood sugar. The average time between repeat stroke codes was 61.3 days. The average time between repeat stroke codes in patients who had a stroke both times was 17.67 days. Conclusions: We found that patients with a history of stroke remain at high risk for a repeat stroke in a short period of time, reflected by a time to repeat stroke code on confirmed patients of less than 3 weeks. Of these, a large proportion (65.5%), were found to have either atrial fibrillation or critical vascular stenosis. These patients may merit closer monitoring during the first month as they remain at high risk of further vascular events.