Extended Delays in Recognition of Stroke Symptoms and Stroke Code Activation for In-Hospital Strokes: The DELAY Study

Abstract

Background: Patients with stroke while hospitalized experience important delays in symptom recognition. This study aims to describe the overall management of an in-hospital stroke population and how it compares with an out-of-hospital community-onset stroke population.

Methods: In this retrospective observational study, we included consecutive patients with in-hospital and out-of-hospital strokes (both ischemic and hemorrhagic) over a period of one year treated at a comprehensive stroke center. Demographic and clinical data were extracted, and patient groups were compared with regard to stroke treatment time metrics.

Results: A total of 362 patients diagnosed with acute stroke were included, of whom 38 (10.5%) had in-hospital and 324 (89.5%) had out-of-hospital strokes. The median delay to stroke recognition (time between the last time seen well and first time seen symptomatic) was significantly longer in in-hospital compared to out-of-hospital strokes (77.5 [0-334.8] vs. 0 [0-138.5] min, p = 0.04). The median time interval from stroke code activation to the arrival of the stroke team at the bedside was significantly shorter in in-hospital versus out-of-hospital cases (10 [6-15] vs. 15 [8-24.8] min, p = 0.01). In-hospital strokes were less likely to receive thrombolysis (12.8% vs. 45.4%, p < 0.01) with significantly higher mortality (18.2% versus 2.6%, p < 0.01) and longer overall median hospital stay (3 [1-7] vs. 12 days [7-23], p < 0.01) compared to out-of-hospital strokes.

Conclusion: This study showed significant delays in stroke symptom recognition and stroke code activation for in-hospital stroke patients despite comparable overall stroke time metrics. Development of in-hospital stroke protocols and systematic staff training on stroke symptom recognition should be implemented to improve care for hospitalized patients.

Keywords: hemorrhagic stroke; in-hospital stroke; ischemic stroke; quality improvement; thrombectomy; thrombolysis.