Inpatient Hospital Treatment For Strokes: How Many Get Treated?

Stroke treatment is a race against time. The faster a person receives treatment, the better their chances of recovery. The first few hours after a stroke are crucial and involve stabilising the patient, making a diagnosis, and providing early treatment. Ideally, stroke patients should be treated in a special stroke unit in the hospital.

Between 2.2% and 17% of strokes occur during hospitalisation for another diagnosis or procedure, and these in-hospital strokes represent a unique population with different risk factors and substantially worsened outcomes compared to community-onset strokes. The treatment for in-hospital strokes is the same as for strokes that occur in the community, but there are often delays in hospital-based evaluations.

The typical length of a hospital stay after a stroke is five to seven days. During this time, the stroke care team will evaluate the effects of the stroke and develop a rehabilitation plan. Patients with mild or moderate disabilities who are medically stable can continue their rehabilitation at home, while those with more severe disabilities may be transferred to an inpatient rehabilitation unit or independent rehabilitation facility.

Between 2.2% and 17% of strokes occur during hospitalisation for another diagnosis

Between 2.2% and 17% of strokes occur in patients who are already hospitalised for another diagnosis or procedure. This unique group of patients faces distinct challenges and substantially worsened outcomes compared to those who experience strokes outside of hospitalisation. The in-hospital strokes are often a result of the illness and comorbidities that led to the initial hospitalisation or an iatrogenic consequence of therapeutic interventions and withdrawal of protective therapy during hospitalisation.

The in-hospital strokes present a set of unique risk factors and more mimics, resulting in greater difficulty in recognising stroke symptoms. The symptoms can be misinterpreted as side effects of medications or attributed to other medical conditions. The delay in recognising stroke onset can lead to longer evaluation and treatment times, impacting the quality of care. Additionally, the in-hospital strokes have a greater severity, and the patients experience more disability on discharge compared to community-onset strokes.

The median age of patients with in-hospital strokes is 73 years, and about 53% of these strokes occur in women. The admitting diagnoses for these patients include cardiovascular issues, neurology/neurosurgery, hematology/oncology, orthopedic/trauma, gastrointestinal problems, and respiratory issues. Cardiac risk factors, such as atrial fibrillation and coronary artery disease, are more frequently observed in this group.

The in-hospital strokes pose a substantial societal burden. The 30-day cost of care for an in-hospital stroke of average severity is estimated to be US$17,500 in the United States. With an estimated 35,000 to 75,000 in-hospital strokes occurring in the US each year, the lifetime direct and indirect costs for these strokes are projected to be approximately $4.9 billion to $10.5 billion.

To improve the quality of care and outcomes for in-hospital strokes, it is crucial to have rapid evaluation systems and stroke response teams in place. Educating hospital staff about stroke signs and symptoms and creating acute inpatient stroke response systems can help expedite evaluation and treatment, ultimately improving patient outcomes.

In-hospital strokes have a 30-day cost of care of $17,500

The financial burden of in-hospital strokes is substantial. The 30-day cost of care for an in-hospital stroke of average severity is estimated at $17,500. This figure is based on the assumption that there are 35,000 to 75,000 in-hospital strokes in the United States each year, which would result in lifetime direct and indirect costs of approximately $4.9 billion to $10.5 billion.

The cost of stroke care can vary depending on several factors, including the type of stroke, diagnosis status, comorbidities, and demographic characteristics. Ischemic strokes, which are caused by blocked arteries, have a lower average cost per hospital admission than hemorrhagic strokes, which involve the rupture of a blood vessel. According to the Agency for Healthcare Research and Quality, the average hospital stay for ischemic stroke patients is 5.6 days, with a cost of $9,100 per stay. In contrast, hemorrhagic stroke patients have an average hospital stay of 8.4 days, with a cost of $19,500 per stay.

The cost of stroke treatment also depends on the specific procedures and medications used. For example, the use of thrombolytics or clot-busting drugs during hospitalization can add approximately $5,978 to the overall cost. Other procedures such as angioplasty and stent placement can cost between $11,000 and $41,000. The mechanical removal of blood clots typically costs around $7,718.

In addition to the direct medical costs, stroke can also result in indirect costs due to lost productivity and the need for long-term care or rehabilitation. The total economic burden of stroke is significant, and developing cost-effective strategies for prevention, treatment, and management is crucial.

In-hospital strokes are caused by a combination of factors including illness, comorbidity, and therapeutic interventions

In-Hospital Strokes: Causes and Treatment

In-hospital strokes refer to strokes that occur during a patient's hospitalisation for a different diagnosis or procedure. They account for between 2.2% and 17% of all strokes and present unique challenges due to their association with higher rates of thrombolytic contraindications and worsened outcomes. In-hospital strokes are caused by a combination of factors, including illness, comorbidity, and therapeutic interventions.

Illness and Comorbidity

Illnesses and comorbidities that lead to hospitalisation can directly or indirectly increase the risk of in-hospital strokes. Conditions such as cancer, inflammatory states, and venous thromboembolism are associated with transient hypercoagulability, which can lead to in-hospital strokes. Additionally, certain illnesses can mask the early signs and symptoms of a stroke, making recognition and timely intervention more difficult.

Therapeutic Interventions

Therapeutic interventions, particularly those involving surgery or invasive procedures, can also contribute to in-hospital strokes. Iatrogenic complications, such as accidental ligation of arteries during surgery or arterial dissection, can directly cause strokes. Additionally, the withdrawal of antithrombotic or anticoagulant therapy, which may be necessary due to bleeding risks or the patient's inability to take oral medications, can further increase the risk of stroke.

Other Factors

Other factors that may contribute to in-hospital strokes include the patient's age and gender, with a median age of 73 years and a higher proportion of strokes occurring in women (53%). Additionally, cardiac risk factors, such as atrial fibrillation and congestive heart failure, are more commonly associated with in-hospital strokes than community-onset strokes.

The treatment of in-hospital strokes follows similar principles to community-onset strokes, focusing on rapid evaluation, ruling out stroke mimics, and timely administration of thrombolysis and other acute interventions. However, the presence of medical contraindications and delays in hospital-based evaluations can pose challenges in delivering timely and effective treatment.

In-hospital stroke patients have a longer length of stay, greater disability, and are less likely to return home

In-Hospital Stroke Patients: Longer Length of Stay, Greater Disability, and Less Likely to Return Home

In-hospital strokes, defined as acute infarction of central nervous system tissue, pose unique challenges due to their occurrence during hospitalization for another diagnosis or procedure. These strokes account for 2.2%-17% of all strokes and are associated with distinct risk factors, more mimics, and worsened outcomes compared to community-onset strokes. The presence of higher rates of thrombolytic contraindications further complicates their treatment.

Observational studies reveal that patients with in-hospital strokes face a longer length of stay, greater disability, and reduced likelihood of returning home upon discharge. In-hospital stroke patients experience delays in evaluation and treatment, with only 2.6%-11% receiving intravenous thrombolytic treatment. This delay contributes to worse prognoses, with in-hospital strokes resulting in higher mortality rates (14%-19%) than community-onset strokes.

The complexity of in-hospital strokes demands expertise in rapid evaluation and treatment. The creation of dedicated in-hospital stroke response teams is crucial to improving recognition and response times. However, it is important to distinguish stroke symptoms from those of systemic illnesses, side effects of medications, or stroke mimics.

Furthermore, in-hospital strokes are associated with higher rates of medical contraindications to intravenous thrombolysis, emphasizing the need for alternative treatment options such as intra-arterial thrombolysis or mechanical thrombolysis. While the benefits of thrombolysis for in-hospital strokes are evident, there is a "quality gap" in the timely evaluation and administration of treatment.

In summary, in-hospital stroke patients face prolonged hospital stays, greater disability, and reduced likelihood of returning home. This is attributed to delays in evaluation and treatment, higher medical contraindications, and the need for specialized stroke response teams. Addressing these challenges through quality improvement initiatives is essential to enhance the prognosis and outcomes for in-hospital stroke patients.

In-hospital stroke patients have a mortality rate 2-3x greater than community-onset strokes

In-hospital strokes refer to acute infarctions of the central nervous system that occur during a patient's hospitalisation for another diagnosis or procedure. These strokes represent a unique population with distinct challenges for treatment. The prognosis for in-hospital strokes is significantly worse than for community-onset strokes, with a mortality rate that is 2 to 3 times higher.

In-hospital strokes account for between 2.2% and 17% of all strokes, with an estimated 35,000 to 75,000 cases occurring annually in the United States. The 30-day cost of care for an in-hospital stroke of average severity is estimated at US$17,500, resulting in substantial financial burdens for patients and the healthcare system.

The higher mortality rate associated with in-hospital strokes can be attributed to several factors. Firstly, in-hospital strokes occur in patients with higher rates of thrombolytic contraindications, making treatment more complex. Secondly, there are often delays in the evaluation and treatment of in-hospital strokes, with longer in-hospital delays compared to community-onset strokes. This is partly due to the difficulty in recognising stroke symptoms in hospitalised patients, as they can be misinterpreted as side effects of medications or complications of the original illness. Additionally, in-hospital strokes may have more medical contraindications to intravenous thrombolysis, further complicating treatment options.

Furthermore, in-hospital strokes are associated with higher rates of disability on discharge. Studies have shown that patients with in-hospital strokes have a longer length of hospital stay, greater disability, and are less likely to return home directly from the hospital. They are also less likely to be able to walk independently or perform activities of daily living, such as bathing or preparing food, upon discharge.

To improve the outcomes for in-hospital stroke patients, there is a need for explicit quality improvement initiatives. This includes educating hospital staff about stroke symptoms, creating dedicated stroke response teams, and developing standardised stroke protocols to ensure timely and effective evaluation and treatment.

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