In-Hospital Stroke Deaths Rise on Nights, Weekends

WEDNESDAY Feb. 20, 2008 -- The time of day and day of week a person has a stroke could mean the difference between life and death.

Two new studies find that stroke patients who enter the hospital at night and on weekends are more likely to die in the hospital than those who have strokes at more "regular" hours.

That's not acceptable, one researcher said. "We should not be treating patients differently because they had their stroke on a Saturday night," Dr. David S. Liebeskind, senior author of one of the studies and associate professor of neurology and associate director of the University of California, Los Angeles, Stroke Center. "The time of day and day of week shouldn't matter."

The study, slated for presentation Wednesday at the American Stroke Association's International Stroke Conference in New Orleans, is the first to address this topic in the United States and is also much larger than analyses undertaken in other countries.

"Data on really sick patients during off-hours is not new but the specifics to stroke are," said Dr. Jonathan Friedman associate dean of the Bryan-College Station campus at Texas A&M Health Science Center College of Medicine and assistant professor of surgery and neuroscience and experimental therapeutics at the Health Science Center College of Medicine.

"This is a lot of data and pretty convincing for stroke. It highlights how important systems and institutions are to get the best care 24 hours a day, seven days a week," said Friedman, who also directs the Texas Brain and Spine Institute.

Liebeskind and his team analyzed more than 2.4 million stroke cases across the United States. They found that the mortality rate for weekday admissions for all strokes was much lower than weekend admissions (7.9 percent versus 10.1 percent). For ischemic stroke (caused by a block in blood flow), mortality rates were 7.3 percent on weekdays versus 8.2 percent for nights and weekends.

Patients were also more likely to be routinely discharged if they were admitted on weekdays as compared to weekends (53.2 percent versus 43.8 percent for all strokes; 43.1 percent versus 38.9 percent for ischemic stroke). The two groups had a similar number of procedures done, but those coming in on weekends did not have their first procedure done as soon.

But the researchers noted that the study had already ended by 2004, when stroke care underwent major changes in the United States. Those changes include more hospitals being designated as "Primary Stroke Centers," where doctors have access to the emergency clot-busting drug tissue plasminogen activator (tPA).

"We don't have the most recent data, and we don't capture new developments," Liebeskind said. "This is stroke care data in the raw before any action was taken."

The second study addressing the same issue looked at data from 308,545 acute stroke admissions involved in the Get With The Guidelines (GWTG)-Stroke program between October 2001 and April 2007. The GWTG-Stroke program is an American Heart Association quality improvement program.

According to researchers at Michigan State University, East Lansing, patients presenting at the hospital with ischemic stroke during off-hours had an in-hospital mortality rate of 5.8 percent compared with 5.2 percent for on-hours. For hemorrhagic stroke (caused by excessive bleeding), the mortality rate was 27.2 percent for off-hour presentation and 24.1 percent for on-hour presentation.

The authors also found that the mortality difference decreased with the amount of time a hospital had been involved in the GWTG program.

Other studies being presented at the conference:

  • A random phone survey of U.S. primary care physicians' offices found that 100 percent of respondents (correctly) told callers to call 9-1-1 for a classic heart attack scenario. However, when confronted with a stroke scenario, 29 percent of office staff ignored the 9-1-1 recommendation and urged the patients to schedule an appointment with the doctor for later that day, instead.
  • Australian stroke patients who called and visited a doctor's office first (as opposed to an emergency number or ambulance) delayed the time it took for an ambulance to arrive and, consequently, the time it took to get to the hospital. Those who were advised over the phone to call an ambulance took a median time of 92 minutes to the time they got an ambulance versus almost seven hours for those who were examined first.
  • The use of a portable CT scanner (as opposed to the fixed scanners more often found at larger institutions) reduced the time needed to image the brains of emergency room patients with suspected stroke. The portable scanners may be useful for community hospitals, the U.S. researchers concluded.

Posted: February 2008


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