Elsevier

Journal of Emergency Nursing

Volume 39, Issue 5, September 2013, Pages 434-439
Journal of Emergency Nursing

Research
Missed Opportunities for Recognition of Ischemic Stroke in the Emergency Department

https://doi.org/10.1016/j.jen.2012.02.011Get rights and content

Introduction

Evidence suggests that a significant number of patients discharged from the hospital with a diagnosis of ischemic stroke are not identified as having a stroke on admission. Those presenting with “nontraditional” stroke symptoms may be less likely to be diagnosed correctly. We aimed to establish whether there was an association between symptom presentation and diagnostic accuracy and to identify the type and frequency of nontraditional symptoms that resulted in a missed diagnosis in the emergency department.

Methods

We reviewed the medical records of 189 patients discharged with a diagnosis of ischemic stroke from Yale-New Haven Hospital. We performed χ2 analysis to determine whether an association existed between symptom presentation and diagnostic accuracy. Descriptive statistics allowed us to identify symptom type and frequency in patients with a missed diagnosis.

Results

A diagnosis of suspected stroke was missed in 15.3% of patients who presented to the emergency department. We found a strong association (P < 0.0001) between symptom presentation and diagnostic accuracy. Of the patients presenting with any “traditional” symptom, 4% were missed. Of those presenting with only nontraditional symptoms, 64% were missed (odds ratio, 43.4; 95% confidence interval, 15.0-125.4). Nontraditional symptoms included generalized weakness, altered mental status, altered gait, and dizziness.

Discussion

In order to facilitate appropriate management of patients with ischemic stroke, emergency nurses must be aware that symptom presentation is highly variable. Patients presenting with nontraditional symptoms may benefit from an immediate and comprehensive neurological evaluation.

Section snippets

Methods

We collected data through a retrospective medical record review. Our population was all patients who were initially admitted to the hospital through the emergency department of the study institution and then later discharged with a diagnosis of ischemic stroke. Our sample included patients discharged between October 2008 and June 2009 (N = 189). We included patients in whom stroke was diagnosed by magnetic resonance imaging within the first 24 to 48 hours after admission. In several cases where

Results

The sample of 189 patients comprised 95 men and 94 women, and the majority of patients were white. There was a wide age range, from 20 to 99 years, with a mean age of 70.4 ± 16.3 years (Table 2). The diagnosis of suspected stroke was missed in 29 of 189 patients (15.3%) who presented to the emergency department and were ultimately diagnosed with an ischemic stroke.

We found a strong association between symptom presentation and diagnostic accuracy. In patients who presented with any traditional

Discussion

We found that more than 1 in 7 patients (15.3%) discharged from the hospital with a diagnosis of ischemic stroke presented with symptoms that were not considered indicative of a stroke in the emergency department. To our knowledge, there are no studies to date that have evaluated rates of missed stroke diagnosis, that is, providers failing to recognize symptoms indicative of a stroke and patients being given an incorrect diagnosis. However, studies examining stroke overdiagnosis report a rate

Limitations

The relatively small sample size was a limitation of our study. Because this was a retrospective study, we sometimes relied on incomplete documentation by multiple providers. As with all studies, there is the possibility of human error, particularly when entering data into a spreadsheet. To minimize this, we rechecked all data for each patient. If there was no documentation of a symptom, we assumed it was absent, unless the patient presented with altered mental status, in which case symptom

Implications for Emergency Nurses

Optimal management of patients with ischemic stroke, including the delivery of time-dependent treatment and secondary-prevention measures, requires a multidisciplinary approach with an emphasis on timely and accurate diagnosis. Emergency nurses play a key role in facilitating this process. This requires increased awareness among emergency nurses about the complexity of stroke symptom presentation including “atypical” and unusual symptom presentations. Triage nurses could include a specific

Conclusions

The diagnosis of suspected ischemic stroke is missed in a significant number of patients who are evaluated in the emergency department. A missed diagnosis is strongly associated with the presentation of nontraditional ischemic stroke symptoms. We found that generalized weakness and fatigue, altered mental status, altered gait, and dizziness occurred in more than 50% of the patients whose diagnosis was initially missed. These nontraditional symptoms are nonspecific and nonfocal and can be

Natasha M. Lever is Advanced Practice Registered Nurse, Yale-New Haven Hospital, New Haven, CT.

References (15)

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Natasha M. Lever is Advanced Practice Registered Nurse, Yale-New Haven Hospital, New Haven, CT.

Karin V. Nyström is Clinical Coordinator, Yale-New Haven Stroke Center, Yale-New Haven Hospital, New Haven, CT.

Joseph L. Schindler is Clinical Director, Yale-New Haven Stroke Center, and Assistant Professor, Department of Neurology and Neurosurgery, Yale University School of Medicine, New Haven, CT.

Janet Halliday is Clinical Research Coordinator, Yale-New Haven Stroke Center, and Department of Neurology, Yale University School of Medicine, New Haven, CT.

Charles Wira III is Assistant Professor, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.

Marjorie Funk is Professor, Yale University School of Nursing, New Haven, CT.

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