Results achieved with the implementation of a Stroke Code System in a large hospital: role of emergency department and analysis of the learning curve

Gómez-Angelats E, Bragulat E, Obach Baurier V, Gómez-Choco M, Sánchez M, Miró O

Objective: To analyze the implementation of a stroke code protocol and the results

obtained in an initial phase inside a hospital and in a second phase during which the

stroke code was also used for attending emergencies outside the hospital.

Methods: Retrospective analysis of 20 months’ application of the stroke code protocol.

Two periods were defined for analysis. During the first period of 8 months, the code was

used inside the hospital. In a second period of 12 months the code was used both inside

and outside the hospital. Data collected for analysis of each period were the numbers of

strokes diagnosed according to the stroke code criteria, the number of times the protocol

was activated, the number of code procedures finalized, and the number of patients who

received fibrinolytic therapy. The results obtained during the 2 periods were compared.

Results: The stroke code protocol was activated in 397 patients. More patients were

identified as meeting the stroke code criteria in the second period (P < .001); likewise, the number of times the code was activated as patients met the criteria was also higher in the second period (P < .001). More stroke code-activated study protocols were completed in the second period than in the first (P < .001). These results were accompanied by a larger number of patients who underwent fibrinolysis in the second period (P < .01), although only 46 patients (21%) who completed the study protocol received fibrinolytic therapy, whereas 30 patients (40%) had received such therapy in the first period (P < .001). The overall percentage of patients with stroke who came to the emergency department and received fibrinolytic therapy was similar in the 2 periods (5.3% in the first and 6.8% in the second). Of the 104 patients in whom the stroke protocol was activated and who did not complete the study, the main reason in the first period was that the window of opportunity had closed (P < .001) whereas in the second period the main reason was the presence of concomitant disease (P < .001). When fibrinolysis was not provided it was because the stroke had caused few symptoms or the event was finally considered a transient ischemic attack, which was significantly more common in the later period (P < .01). Conclusions: These results show that providing care to stroke patients within 3 hours of onset according to a protocol based on consensus between staff working inside the hospital and external emergency caregivers led to a rate of fibrinolytic therapy around 6%. The percentage was not higher in the later period than when the code was followed only inside the hospital. The study also shows that the main reasons why this percentage did not rise are the delay in reaching the emergency department and the presence of alternative diagnoses.

Bragulat E, Gómez Angelats E, Gómez-Choco M, Miró O, Obach Baurier V, Sánchez M