Barriers to the use of intravenous tissue plasminogen activator for in-hospital strokes

Background: Patients who have ischemic strokes (ISs) while hospitalized for other conditions may be less likely to receive intravenous tissue plasminogen activator (IV tPA) when compared to patients who have strokes in the community. This study explored possible barriers to IV tPA use in these patients. Methods: Stroke diagnosis was confirmed by chart review for all adult patients admitted to Bellevue Hospital between January 1, 2004 and December 31, 2008 who were discharged with a primary or secondary International Classification of Diseases, 9th edition code for transient ischemic attack, intracerebral hemorrhage, or IS. Circumstances at stroke onset were recorded for all patients who had strokes while hospitalized for another reason. Results: Seventy-nine in-hospital IS cases were identified; 18 (23%) occurred <2 weeks after major surgery, and another 14 (18%) had a delayed diagnosis because signs were not readily detectable on clinical examination. Twenty-four patients (30%) were eligible for IV tPA, of whom 13 were identified within 3 hours of onset and 10 (13%) were treated with IV tPA. The median National Institutes of Health Stroke Scale score was higher in hospitalized patients (13) than in patients admitted through the emergency department (5; P <.001 using the Wilcoxon rank sum test). Conclusions: Seventy percent of in-hospital IS cases in our single hospital retrospective study were postoperative, clinically subtle, or had contraindications to IV tPA, preventing its use. Of the remaining untreated patients, the biggest barrier to IV tPA administration was delay in stroke discovery, which was largely dependent on observation by hospital staff or family rather than patient report.