ResearchMissed Opportunities for Recognition of Ischemic Stroke in the Emergency Department
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.
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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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