In-Hospital Stroke: Evaluation & Management

Podcast Transcript

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD:

In 2022, the American Heart Association issued a scientific statement laying out best practices for evaluating and managing patients who presented in-hospital with a stroke. In today's episode of Neuro Pathways, we're talking with the lead author of this statement, discussing how it was derived, what it means, and how it can be adopted into practice.

I'm your host Glen Stevens, neurologist/neuro-oncologist in Cleveland Clinic's Neurological Institute, and I am pleased to be joined by Dr. Amre Nouh. Dr. Nouh is a vascular neurologist and the Regional Chairman of the Department of Neurology in the Neuroscience Institute at Cleveland Clinic in Florida. Amre, welcome to Neuro Pathways.

Amre Nouh, MD, MBA:

Thank you for having me. I'm excited to be here.

Glen Stevens, DO, PhD:

So Amre, you're fairly new to the Cleveland Clinic. Tell me a bit about yourself and your role in Florida.

Amre Nouh, MD, MBA:

Yeah, so I'm a vascular neurologist, as you mentioned earlier. Over the past decade, I've held different positions in Connecticut, both at the University of Connecticut as a Core Faculty, Associate Professor of Neurology, a residency site director, and the Fellowship Director for Vascular Neurology at the University of Connecticut. And at Hartford HealthCare as a System and Regional Medical Director for Stroke and Cerebrovascular Disease.

Very excited about the growth in Florida for Cleveland Clinic and the opportunity to help lead an incredible team here to take the Cleveland Clinic care to the community in Florida and beyond.

Glen Stevens, DO, PhD:

Great. Well, welcome. So let's dive in today's topic. Transport us back in time and talk to us about the genesis for the best practices for evaluating and managing patients who present in-hospital with a stroke. And to be clear, we're not talking about patients who show up in the ED with the stroke, but we're talking about patients that are in the hospital and are suspected of having a stroke.

Amre Nouh, MD, MBA:

Well, that's right. And as you know as a practicing neurologist and many other caregivers even who are in the medical field, when patients are already hospitalized and have a catastrophic event or a change in their medical status, in their clinical status, that triggers an alarm. So analogous to someone with a rapid response or sudden alteration of consciousness. And when you experience that process on the medical side as a provider, as a clinician, it's very chaotic and disorganized. Depending on where you are, of course, there's different levels of resources, expertise and processes in place.

But if you contrast that with ER level of stroke care and those pathways, those have been so refined over the years because of the clinical trials and because of the checklists, methodology, and mentality for us to process quickly and make decisions about treatment. Even though they're the same pathology, they're very, very different processes, very different outcomes, very different patient population, even though it's the same exact type of pathology. Which has always intrigued myself, and I'm sure many others who practice in neurology.

Glen Stevens, DO, PhD:

So I'm sure your first steps when you looked into this was doing a literature review and determining what the current state of affairs were. What did you find when you looked into this, trying to evaluate in-hospital stroke?

Amre Nouh, MD, MBA:

That's a great question. So when I continued to grow some interest here, we did some preliminary QI work with our teams to look at this and found that there's a paucity in the literature. In fact, there's very little in the literature outside of some case series and some quality improvement initiatives that address this patient population.

So that fueled the desire to work with the American Heart and Stroke Association and propose what are some next steps from the AHA to move forward with identifying some of these best practices. And that led to the proposal to work with the AHA and lead the Scientific Committee with the team that we have there to put forth the best practices.

Glen Stevens, DO, PhD:

So I know that I was recently on the hospital service and saw a number of patients that were suspected of having a stroke. And I'm not sure what they do in Florida, but I believe here they call the two clot and that initiates a very rapid response on the neurologic service.

But what does the data show ... or do you have any data looking at the percentage of patients that are thought to have had an inpatient stroke. How many of them actually have a stroke versus the blood sugar's low, they're encephalopathic, some other process?

Amre Nouh, MD, MBA:

So when you look at the literature, it varies. And what is consistent across a lot of the case series that publish this is the rule of thirds. A third of the time there is some pathology, some case series are up to the 40s and 50s percent, and the majority are mimics. And that's not unsurprising.

Perhaps the mimic rate in the hospital is a little higher than in the emergency department only because of the comorbidities and other types of iatrogenic interventions including medication use and sedatives and other things like that, that can really drive up the quote, unquote "mimic rate" as compared to someone coming from the field.

Glen Stevens, DO, PhD:

And do you know what percentage of patients in-house would actually get TPA or something like that?

Amre Nouh, MD, MBA:

Yeah. When you look at the data across the case series, it ranges from two to 20%. I think those numbers change as the time window and therapeutic windows are changing. We're seeing more interventional treatments, as you know, with the changes of the extended time window to 24. So like I said earlier, I independently looked at ... just a literature search, looking at PubMed. To look at the words in-hospital stroke or inpatient stroke, specifically for patients who have a stroke during their hospitalization compared to the body of the literature on the topic of stroke. And it's probably around two or three percent.

So the overwhelming majority of the data that we have in the world of stroke is really not looking at this patient population. But those numbers will continue to change, I think, as we continue to see evolutions in who meets criteria for treatment and expansion of the time window.

Glen Stevens, DO, PhD:

As a little sidebar, I was treating a patient about two years ago for Gamma Knife. And the patient lived quite some distance away, so they stayed overnight at a hotel, close, and drove in because we always start early in the morning. And pulled into the cancer center, and as they pulled into the cancer center, they became hemiparetic and couldn't speak. And the red coat came out to get the patient out of the car and the wife goes, he's not able to talk. So they put him in a chair, brought him down to Gamma Knife, and we had one look at him and thought, oh my goodness, he's having a stroke. So of course, we called right the rapid response team and sent him right over to the ED and they enacted the stroke protocol.

So he's kind of an in between case, I guess. He's not really brought to the ED and he's not really in the hospital. He's the in between patient. But he ended up having a proximal IAC stenosis. And it's really quite interesting because it was just before COVID, just in the early days of COVID. And I still wonder, since with COVID we saw some increased risk of thrombosis and some proximal ... you could probably speak to this better than I can. And I really wonder if he had a COVID related proximal clot. So they took him and actually did an intervention where they took the clot out, they sucked the clot out. And I ended up seeing him over in the hospital. He did great. He got discharged at the end of the week, had a very small infarct, and we ended up doing his Gamma Knife treatment. But for him, if he would've been an hour away, hard to imagine he would've survived.

Amre Nouh, MD, MBA:

Amazing. Yeah.

Glen Stevens, DO, PhD:

And he was just at the right place at the right time. While he wasn't actually in a bed in the hospital, it just shows how quickly we can move on some of these cases. And I like to say that Gamma Knife saved his life, even though the Gamma Knife was done for a completely separate reason as that goes along.

But it just shows the power of what you guys can do and how you can change people's lives. So I think it's very important that we treat all these patients that need to be treated.

Amre Nouh, MD, MBA:

And I think, Glen, that brings us to an important point, recognition and education.

Glen Stevens, DO, PhD:

Right. So I was going to get into the actual committee guidelines discussion, which you certainly know a lot about. So why don't you talk to us a little bit about the actual statement and how we should be managing patients in the hospital? What we should be looking out for, those types of things.

Amre Nouh, MD, MBA:

Yes. First and foremost, it was a pleasure working on this. And we had a fantastic multidisciplinary group of neurologists, neurointensivists, neurosurgeon, nursing, we had even internal medicine on there. So we really did quite a diligent effort to try to see what is in the literature. And this is by no means a guideline, it's a scientific statement. So it really just outlines evidence-based best practices. And I think the core elements that are captured here are five important points. The sentinel effort around education and recognition of symptoms is the beginning of everything.

I think one of the key opportunities across all hospitals ... and especially that this is something that is not a high occurrence. It's low frequency potentially as compared to many other things, but high impact. I would argue that it's moving out of that low frequency, high impact box and moving into the more frequency. Especially now with the complexity of patients we're seeing, expansion of services that are provided in-hospital, the workforce that is available, so we're seeing more and more alerts coming up. But the first and foremost is around education.

So the first summary recommendation was recognition of symptoms and identifying your high risk patient population. There are some key populations we found that tend to be high risk populations. And if you look at folks who get some form of vascular procedure, endovascular or open, either cerebrovascular or cardiovascular or vascular in general, that represents about almost half of the majority of the population at risk. If you add in the critically ill folks, ICU-based folks, I think you would hit almost about two thirds. So when you focus your education and your resources, the high risk population is going to matter.

The second part of the education is adopting a standard tool to identify this. And we haven't found, at least as of yet, any superior methods in hospitals. I mean, I think all hospitals have different protocols, but nothing published as a head-to-head to see what's a better screening tool for the nursing staff or some of our colleagues to identify these things. But even at Cincinnati, like a BE-FAST or a NIH, or a modified NIH is reasonable. But identifying a standard process to identify if someone's having changes, and then having some standard cadence in defining the right audience to educate. So the education doesn't end there.

Also, the activation process. What are the protocols for activating? What is the availability? Who are the key individuals who can do that and what are the steps that we have? So education I think is one of the most important areas where we can really make a change and start controlling the narrative on identifying better and recognizing.

The second part is around rapid response teams. If you look at programs like the Cleveland Clinic and other academic medical centers, there's a different set of resources that are available to us. And you shared there's a two clot protocol in your on-service, there's probably residents in others. But when you look at 6,000 or so hospitals across the country, maybe 27, 28%, less than a third are certified stroke programs. The majority of our hospitals are community-based, so there may not be 24 seven neurology or that type of expertise.

So really as part of the rapid response team, we have to know that it's going to be coming down to what kind of resources are available, and then identifying where the gaps are per hospital and per system. I think that's going to be important. The standardization of the response was something we talked about. We shared this in the paper. What potential role the primary nurse would have, the charge nurse, and the response team. I think one of the take home points that comes up again and again ... and I had the opportunity to present this at the last stroke conference back in February. Is the primary team. You mentioned the mimic rate, and that's indeed high.

I think we spend a lot of time trying to figure out why the patient's there, what's the medical history, when they were admitted, what's the story, what meds they're on. There's a lot to decipher as you walk into a situation where someone is having a neurologic change. And the presence of the primary team at the bedside can help accelerate that process. And I think as part of the education, one of the recommendations would be if there's a high risk population and there's a high level of awareness involving the primary team, of course, as soon as they're available to aid in facilitating that information, is going to be critical.

The third part we talked about was standardizing evaluation. I think the fourth part, or the fourth key element is addressing the barriers to treatment. And we identified in the paper, there's a table summary about some of the common barriers that we've seen come up that include lack of expertise, for example, and how to mitigate that. We talked about some of the opportunities around education, perhaps case simulation. Uncertainty about what tests to order. So adopting a checklist approach similar to what you call the two clot or a brain attack or stroke code approach in the ED, adopting a same response in the hospital setting.

And then what you do with patients with nonfocal neurologic symptoms? I mean, this is a harder one. And I think it's going to depend on the resources available, the expertise available to be able to either adopt a liberal approach, or evaluate more targeted education for the high risk patient populations. And that, it's not painted all with one brush. I think depending on the hospital setting, the resources, and patient population, that should be tailored.

And then lastly, you can't change what you can't measure. So we really put forth some foundational work that I hope that the stroke community continues to build some literature on, is the quality and oversight. So looking at these individual events, especially the ones that are treatment cases or the ones that were strokes and identifying where the barriers are in terms of delays, what process improvements can happen to accelerate the things so we have similar stories like the one that you shared earlier about your patient.

And I think a lot of the hangup time is parallel processing not happening in the hospital setting. I think there's a lot of time being wasted ... this is just from personal experience. Potentially trying to decipher if this is a stroke or a mimic, and … out the history and reviewing the things, and then making a decision if you're going to proceed with imaging. We can parallel process and call the transport folks and get that information while we're evaluating a patient with that same level of certainty and acuity.

I think that's a synopsis of the five key elements and the takeaways from the paper. I hope that this continues to grow as an area of interest for some of our neurologists, and non-neurologists as well.

Glen Stevens, DO, PhD:

Excellent. So as follow up to that, unless I'm mistaken, I think that on a yearly basis I do a MyLearning module on identifying a stroke. I'm not sure if the nursing staff is doing that as well, but certainly on the physician level we do that on a yearly basis. So that's encouraging.

You mentioned that ... I think you said two-thirds of the hospitals don't have specific capabilities of in-house neurology for this. What about telemedicine for these groups? Are hospitals contracting out for telemedicine to try and help?

Amre Nouh, MD, MBA:

Yeah. So I think the two thirds is coming from the stroke certification. That's the data when you look at the percentage of hospitals in the United States that have a stroke certification by, for example, the Joint Commission or something. That may not mean if they have neurology expertise or not. But I will answer the teleneurology part, and I think we mentioned that in the paper and that's a great point you pick up adopting teleneurology opportunities to evaluate patients in the hospital and then establishing transfer protocols is going to be key.

I mean, we just learned of the select two trial results that were just published in the New England Journal that looked at ... I'm going to go a little off-topic, but it's relevant here. Identifying patients who are candidates for thrombectomy. And we found that patients with large cores, and what we would've thought wouldn't be treatment candidates, benefit from treatment. So another example where we're going to continue to see a more liberal approach on who we can take for treatment.

So I think teleneurology is going to play a big part in improving this area of stroke on the hospital side. And then hospitals identifying that folks like this who are hospitalized may perhaps need a higher level of care.

Glen Stevens, DO, PhD:

And around the country, are you seeing adoption of these statements that you mentioned?

Amre Nouh, MD, MBA:

Yeah, it's hard to say. I think this came out last year. COVID ... peaked and then was at the tail end. So the first time that the stroke conference was announced, it was a virtual conference. This year was the in-person, so we had the opportunity to present this in-person and we found a very large audience, a lot of insightful questions. And then, starting to see some traction. Just like with everything, there's going to be adoption curve of the early adopters and then the late adopters and so forth.

I think what the paper is trying to point out is that, A, there should be some best practices on this type of thing. Just raising some awareness. Just understanding that the process compared to the ER and hospitals are different. And just empowering clinicians and physicians from all specialties to have some sort of guidance for some best practices as a foundation. I think over the next few years, and I hope months and years as we see more and more treatment options, that we'll start to see more and more in-hospital stroke papers come out and best practices and studies that look at this statement.

Glen Stevens, DO, PhD:

Next phases, where do we go from here? Other than adopting to more centers.

Amre Nouh, MD, MBA:

That's something I think about. I think that as time goes on, we'll see what tools are available for us to identify stroke. Radiographic tools, clinical tools, and other monitoring tools for us to identify this. We know from the data consistently that morbidity and mortality is higher. We know the incidents, reported incidents is somewhere between 25 to 75,000 cases a year in the hospital. That might be an underrepresenation.

What I hope to see in the future is a little bit of innovation around creating opportunities to monitor folks who are high risk. Looking at best practices from the nursing colleagues, from our hospital colleagues outside of neurology as well, who have interest in this. I think the rapid response type model, being it cardiac, being it respiratory, being it neuro, something that is a strong quality driver for hospitals across the country. And what I'm hoping is just to make sure that for in-hospital stroke, this is an important quality driver that needs to have the same level of importance and attention, just like some of the other quality measures in hospitals.

Glen Stevens, DO, PhD:

Excellent. Before we conclude, any departing advice you'd like to share with our peers who might look to adopt some of the elements from the statement?

Amre Nouh, MD, MBA:

Yeah. Well, first and foremost, I appreciate the opportunity for our listeners to hopefully gain some of the insights here. I think one of the key things is I would love to encourage our listeners and others who read this and adopt some of these best practices to report back. I think we learn more when we see best practices being adopted and shared and tested. And then in nursing conferences, in the stroke conferences, in the literature, in the QI journals, really share best practices. If someone's out there doing this and doing this well, it would be great to share that for the larger community, the larger medical community. So my parting words of advice or wisdom would be for those who are in this space and have this interest to try to give back by sharing those best practices so we can build upon this body of literature and improve the outcomes for everybody we serve.

I think another area just to mention is the unknown unknowns. As the stroke world is evolving and we're seeing more adoption of liberal approaches to treating patients, I think one of the areas to look at, it would be interesting, is to see how we can do more with less. I think telemedicine point that you brought up is going to be key. So those in the telestroke space, in the teleneurology space, we don't have a lot of data on that. I think that will be something that would be great to see, how frequently is this happening across the country? And what is the role of teleneurology going to be moving forward, outside of just the acute phase in the ER, but in the hospital setting?

Glen Stevens, DO, PhD:

Well, Amre, I appreciate your joining me today, and I look forward to seeing how we all better serve these patients in the future. And hopefully this important initiative will be adopted across the country and will continue to save lives and decrease morbidity. Thank you for joining us today.

Amre Nouh, MD, MBA:

Thank you, Glen. Appreciate the opportunity.

Conclusion: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's consultqd.clevelandclinic.org/neuro, or follow us on Twitter @CleClinicMD, all one word. And thank you for listening.