Monday, February 15, 2016

Missed a Stroke? You’re Not Alone

It’s easy to fall prey to the quality assurance shaming associated with your hospital’s stroke team.  It’s nearly impossible to find the right balance between over-triage of any remotely neurologic complaint, and getting the inevitable nastygram follow-ups resulting from unexpected downstream stroke diagnoses.

Take heart: it’s not just you.

This retrospective review of evaluated patients discharged with a diagnosis of acute stroke at two hospitals – one an academic teaching institution, and one a non-teaching community hospital.  All patients discharged with such a diagnosis were reviewed manually by a neurologist, and charts were analyzed specifically to quantify the frequency with which an Emergency Physician did not initially document acute stroke as a possible diagnosis, or a consultant neurologist did not make a timely diagnosis of stroke when asked.

Out of 465 patients included in their one-year review period, 103 of strokes were missed – 22% of those at the academic institution and 26% of those at the community hospital.  And, again, take heart – 20 of 55 patients missed at the academic institution were neurology consults for acute stroke, but were initially misdiagnosed by our neurology consultants, as well.  Posterior strokes were twice as likely to be missed as anterior strokes, and symptoms such as dizziness and nausea and vomiting were more frequent in missed presentations.  Focal weakness, neglect, gaze preference, and vision changes were less frequently missed.

Entertainingly, these authors are mostly verklempt over the fact half of missed stroke diagnoses presented within time windows for tPA or endovascular intervention – although, no other accounting of potential eligibility is presented other than timeliness.

“Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services"
http://www.ncbi.nlm.nih.gov/pubmed/26846858

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