In-Patient Code Stroke

A Quality Improvement Strategy to Overcome Knowledge-to-Action

Gaps in Response Time
Charles D. Kassardjian, MD, MSc, FRCPC; Jacqueline D. Willems, MN;
Krystyna Skrabka, MA; Rosane Nisenbaum, PhD; Judith Barnaby, MEd; Pawel Kostyrko, MD;
Daniel Selchen, MD, FRCPC; Gustavo Saposnik, MD, MSc, FAHA, FRCPC

Background and Purpose—Stroke is a relatively common and challenging condition in hospitalized patients. Previous
studies have shown delays in recognition and assessment of inpatient strokes leading to poor outcomes. The goal of this
quality improvement initiative was to evaluate an in-hospital code stroke algorithm and educational program aimed at
reducing the response times for inpatient stroke.
Methods—An inpatient code stroke algorithm was developed, and an educational intervention was implemented over 5
months. Data were recorded and compared between the 36-month period before and the 15-month period after the
intervention was implemented. Outcome measures included time from last seen normal to initial assessment and from
last seen normal to brain imaging.
Results—During the study period, there were 218 inpatient strokes (131 before the intervention and 87 after the intervention).
Inpatient strokes were more common on cardiovascular wards (45% of cases) and occurred mainly during the perioperative
period (60% of cases). After implementation of an inpatient code stroke intervention and educational initiative, there were
consistent reductions in all timed outcome measures (median time to initial assessment fell from 600 [109–1460] to 160
[35–630] minutes and time to computed tomographic scan fell from 925 [213–1965] to 348.5 [128–1587] minutes).
Conclusions—Our study reveals the efficacy of an inpatient code stroke algorithm and educational intervention directed at
nurses and allied health personnel to optimize the prompt management of inpatient strokes. Prompt assessment may lead
to faster stroke interventions, which are associated with better outcomes.   (Stroke. 2017;48:2176-2183. DOI: 10.1161/
STROKEAHA.117.017622.)
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Key Words: algorithm ◼ hospitalization ◼ inpatients ◼ quality improvement ◼ stroke

I n-hospital acute strokes account for 7% to 15% of all

acute cerebrovascular events and represent a challenge for
healthcare systems.1–4 Special characteristics make this group
more susceptible to a higher incident risk of stroke and poorer
outcomes compared with patients arriving from outside the
hospital. For example, in-hospital stroke patients are usually
older, have higher prevalence of comorbid conditions,2,4–6
and many occur during the perioperative period, often
among patients undergoing cardiac procedures.1–3,5 Others
occur on cardiology, general medicine, or surgical wards
while receiving care for other medical conditions requiring
hospitalization.5,7
More recently, there has been a focus on educating the gen-
eral public to recognize the cardinal features of stroke and
to create rapid triage systems so that patients with suspected
acute stroke in the community setting can be routed to the
nearest stroke center.8–10 The same degree of effort has not
been spent on in-hospital strokes.
On first consideration, patients who have a stroke while
admitted to hospital should be at an advantage compared
with out-of-hospital strokes. Inpatients already are in a moni-
tored environment, have rapid access to nurses and physi-
cians, are in close proximity to imaging facilities, and often
have recent laboratory testing. Together, these factors should
facilitate prompt recognition, investigation, and manage-
ment of acute stroke in hospital. However, numerous stud-
ies revealed greater delays in the care of in-hospital stroke
patients compared with out-of-hospital stroke patients.5,7,9,11,12
Some identified causes include lack of education about iden-
tifying stroke on inpatient wards, delayed notification of the

Received February 20, 2017; final revision received May 9, 2017; accepted May 23, 2017.
From the Division of Neurology, Department of Medicine (C.D.K., J.D.W., K.S., P.K., D.S., G.S.) and Applied Health Research Centre, Li Ka Shing
Knowledge Institute (R.N.), St. Michael’s Hospital, Toronto, Ontario, Canada; Division of Neurology (C.D.K., D.S., G.S.) and Dalla Lana School of Public
Health (R.N.), University of Toronto, Ontario, Canada; and Ryerson University, Toronto, Ontario, Canada (J.B.).
Guest Editor for this article was Eric Smith, MD, MPH.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.
117.017622/-/DC1.
Correspondence to Gustavo Saposnik, MD, MSc, Stroke Outcomes and Decision Neuroscience Research, St Michael’s Hospital, University of Toronto,
55 Queen St, Suite 931, Toronto, Ontario M5C 1R6, Canada. E-mail saposnikg@smh.ca
© 2017 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.117.017622

2176
 Kassardjian et al   Quality Improvement for In-Patient Stroke    2177
most appropriate personnel, and poor communication about
the need for urgent medical evaluation.
Consequently, there is an opportunity for improvement in
the care of patients who have an acute stroke while admitted
to hospital. We hypothesized that an educational intervention
targeting first responders (eg, nurses and physicians) would
improve initial response time for inpatient strokes, a critical
outcome determining access to new interventional treatment
for acute stroke.
Our aim was to develop an algorithm for the management
of inpatient strokes, implement an educational program as a
quality improvement intervention to be disseminated to inpa-
tient wards, and assess if this reduced delays in the manage-
ment of inpatient stroke.
Methods
St. Michael’s Hospital is a 500-bed tertiary care academic and teach-
ing hospital located in downtown Toronto, Canada. The hospital has
active general neurology, general internal medicine, cardiology, and
cardiovascular surgery wards, in addition to other medical and sur-
gery wards and intensive care units. There are ≈2 to 4 in-hospital
strokes per month, and many are identified beyond the time win-
dow for intervention. No protocol existed for managing in-hospital
strokes. Approval was obtained from our institutional research ethics
board for this study.
Development of the Intervention
Our initial step was to collect baseline data for inpatient strokes on
the time from last seen normal (LSN) to initial assessment and time
from initial assessment to brain imaging (eg, computed tomographic
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[CT] scan or magnetic resonance imaging), in order to confirm that
these times were not ideal and present these data to stakeholders. We
met with key stakeholders to determine perceived barriers to timely
and effective care of in-hospital stroke patients, including neurolo-
gists, the stroke medical director, stroke clinical nurse specialists,
regional education coordinators, nurse managers, nursing staff,
and allied health staff (physiotherapists, occupational therapists,
and speech-language pathologists). These interviews revealed that
there was a lack of knowledge about identifying strokes, the need
for timely evaluation of an acute stroke, and the availability of a
stroke team.
The medical education team discussed possible interventions
aimed at achieving a tangible change in behavior (eg, rapid in-hos-
pital stroke assessment and management). After the discussion with
stakeholders, an algorithm was developed for the identification and
initial management of in-hospital stroke (Figure 1). On the basis
of the algorithm, a 13-slide electronic presentation was developed,
which was presented at in-service education sessions lasting 60
minutes, on each of the targeted inpatient units (this presentation
is available in the online-only Data Supplement). The wards receiv-
ing this intervention included the following: cardiovascular surgery,
cardiology, the cardiovascular intensive care unit, the cardiac cathe-
terization laboratory, general internal medicine, respirology, neurol-
ogy, nephrology, orthopedic surgery, neurosurgery, trauma surgery,
vascular surgery, and general surgery. The in-service education
sessions contained information on stroke symptoms and signs, the
importance of speed because of a tight time window for thromboly-
sis, and the process of activating a code stroke and were delivered
to the nursing staff on each unit, as well as the unit managers and
the allied health staff (eg, physiotherapists, speech-language pathol-
ogists). These groups were targeted because they represent stable
staff members on each ward that most commonly identify stroke
symptoms. The learning objectives of the educational intervention
included the following: to be able to describe the different types of
strokes, to be able to recognize the common signs and symptoms of
an acute stroke, to understand why acute stroke is an emergency, to
be aware of the treatment options for an acute stroke, to describe the
role of different medical team members in activating a code stroke,
and to describe the procedure for activating a code stroke for an inpa-
tient. During each in-service educational session, a written log was
kept of questions that were asked or needed clarification, allowing
the presentation to adapt if there were gaps or portions that were
unclear. Laminated posters of the inpatient code stroke algorithm
were placed throughout the inpatient units, and pocket cards were
provided to nursing staff.
The algorithm was reviewed with key stakeholders (stroke nurse
practitioner and case manager, medical education team, neurology,
internal medicine, and stroke leaders) responsible for the manage-
ment of inpatients with an acute stroke. Because of the high turnover
of medical residents, our intervention was targeted at nurses, unit
managers, and allied health. However, the inpatient code stroke algo-
rithm was distributed to all residents starting rotations at St. Michael’s
Hospital and reviewed during their new staff orientation sessions.
Outcome Measures
The primary outcome was time from LSN to initial assessment.
Secondary outcomes included the following: time from LSN to
brain imaging, time from initial assessment to brain imaging, post-
stroke complications, neurological deficits, number of patients
receiving intravenous thrombolysis, or vascular interventional pro-
cedures. Time to acute stroke treatment was not chosen as a primary
outcome as most inpatient strokes would not be likely to receive
thrombolysis or interventional procedures. Timed variables were
collected prospectively for both the pre- and postintervention peri-
ods. Chart reviews were performed of all patients who had a stroke
while admitted to hospital for the study period, identified by review-
ing discharge summaries, consults to neurology, or activation of the
inpatient code stroke protocol. Data abstractors were trained on how
to collect the necessary information using a standardized data col-
lection form. Demographic features, presenting symptoms, stroke
severity, vascular risk factors, and complications after the stroke
were collected.
The preimplementation (baseline) study period was from April
2006 to April 2009. The implementation period was May 2009 to
October 2009 and then a postimplementation evaluation period went
from November 2009 to February 2011.
Statistics
Adjusted and unadjusted primary and secondary outcome mea-
sures were compared pre- and post-implementation of the interven-
tion (comparing the April 2006 to April 2009 time period with the
November 2009 to February 2011 time period). For the multivari-
ate analysis, data were adjusted for demographics, stroke severity as
defined by the number of neurological deficit at onset of stroke,13 and
baseline cardiovascular risk factors (eg, hypertension, coronary artery
disease).
Unadjusted comparisons between the preimplementation and post-
implementation groups with respect to categorical indicators were
performed using the χ2 test or the Fisher exact test. Continuous vari-
ables were compared between groups using the 2-sample t test or
the nonparametric Wilcoxon rank-sum test. We considered the expo-
nential, Weibull, generalized γ, log-normal, and log-logistic regres-
sion models to estimate time ratios and 95% confidence intervals to
measure the effect of post–Inpatient Code Stroke intervention on time
from LSN to initial assessment, time from LSN to brain imaging,
and time from initial assessment to brain imaging, adjusted for any
previous surgery, indicator of at least 2 neurological symptoms, and
coronary artery disease. The model that best fit the data was the one
with smaller Akaike information criterion. For times recorded as zero
minutes, we added 0.5 minutes to include them in the statistical mod-
els. We also included run charts, commonly used in quality improve-
ment studies, to display process performance over time.
All analyses were conducted using SAS 9.4 (SAS Institute, Inc,
Cary, NC), and statistical significance was defined as 2-sided P val-
ues <0.05.
 2178  Stroke  August 2017
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Figure 1. The algorithm developed for inpatient code strokes. *The time of initial assessment by the nurse, allied health member, or physician
(whichever came first). MRP indicates most responsible physician; NP, nurse practitioner; SMH, St. Michael’s Hospital; and STAT, immediately.

Results
Overall, 245 inpatient strokes were identified during the 2
study periods. Twenty-seven patients were excluded as out-
liers because they were identified >72 hours from LSN and
could have represented preexisting or nonacute deficits. The
final sample size was 218 inpatient strokes (131 in the pre-
intervention period and 87 in the postintervention period).
Demographic characteristics of the cohort are shown in
Table 1. Coronary artery disease was more common in the
postintervention group (P=0.028), but other demographic
 Kassardjian et al   Quality Improvement for In-Patient Stroke    2179

Table 1.  Baseline Characteristics

Preimplementation Postimplementation P Value
No. of inpatient strokes 131 87
Mean (SD) age, y* 71.4 (12.7) 69.0 (14.0) 0.205
Age groups, n (%)*
 ≤60 25 (19.1) 22 (27.2) 0.872
 61–75 48 (36.6) 31 (38.3) 0.921
 ≥76 58 (44.3) 28 (34.6) 0.818
Male sex, n (%) 83 (63.3) 47 (54.0) 0.238
Setting, n (%)
 Perioperative 103 (78.6) 55 (63.2) 0.012
Clinical data, n (%)
 Hypertension 100 (76.3) 61 (70.1) 0.306
 Coronary artery disease 80 (61.1) 40 (46.0) 0.028
 Atrial fibrillation 45 (34.3) 20 (23.0) 0.073
 >2 neurological deficits observed at time of stroke 68 (51.9) 26 (29.9) 0.001
 Unilateral arm or leg weakness 116 (88.6) 72 (82.8) 0.224
 Speech disturbance 75 (57.3) 29 (33.3) 0.0005
 Unilateral facial droop 43 (32.8) 23 (26.4) 0.315
 Decreased level of consciousness 38 (29.0) 24 (27.6) 0.820
 Unilateral sensory loss 16 (12.2) 7 (8.1) 0.327
 Visual disturbance 18 (13.7) 7 (8.1) 0.196
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 Neglect 11 (8.4) 5 (5.8) 0.463

 Dysphagia 2 (1.5) 0 (0) 0.518
 Dizziness 4 (3.1) 5 (5.8) 0.489
*Sex and age data is shown for 81 patients (data for 6 patients in this group were missing).

features and comorbidities did not differ (Table 1). Overall,
60% of inpatient strokes occurred in the perioperative period
(defined as a stroke in which symptoms or signs were first
noted on the patient waking in the postanesthesia care unit),
and this was significantly more common in the preintervention
group (P=0.012).
The most commonly identified symptoms were unilateral
weakness (86%), speech disturbance (46%), decreased level
of consciousness (30%), and facial droop (29%). A larger
proportion of milder strokes were observed in the postinter-
vention group compared with preintervention (78.1% versus
48.1%; P=0.001), and more patients were identified with
speech disturbance after the intervention. The distribution of
inpatient strokes by type of ward is shown in Table 2, and
these did not differ statistically comparing the pre- and pos-
tintervention periods. The cardiovascular service accounted
for the largest proportion of inpatient strokes (42.9% overall).
After implementation of the inpatient code stroke protocol,
there were a total of 35 inpatient code stroke activations out
of 87 inpatient strokes. All of these were appropriate uses of
the code stroke protocol, since those 35 patients were within 4
hours of LSN and had signs or symptoms of stroke. The most
common reason for not activating the code stroke was that the
time from LSN was either unknown or >4 hours.
Outcome Measures
Table 3 compares the outcomes for the preintervention and
postintervention groups. For the entire cohort of in-hospital
strokes, the median time from LSN to initial assessment fell
from 600 minutes (109–1460 minutes) before implementation
of the educational code stroke intervention to 160 minutes (35–
630 minutes) after its implementation (P=0.0065; Figure 2).
Similarly, median time from LSN to brain imaging fell from
925 minutes (213–1965 minutes) to 348 minutes (128–1587
minutes; P=0.0288) and from initial assessment to brain imag-
ing scan fell from 135 minutes (43–480 minutes) to 110 min-
utes (51–331 minutes), although this difference did not reach
significance (P=0.5088; Figure 2). For the 35 patients in whom
a code stroke was activated, the median time from LSN to initial
assessment was 75 minutes and to CT scan was 125 minutes,
both significantly shorter than that during the preintervention
phase (P<0.0001 for both outcomes). Run charts were created
for the year before the implementation of the intervention and
the postintervention period, documenting the time from LSN
to initial assessment (Figure 3A) and from LSN to brain imag-
ing (Figure 3B) over time. Although there were fluctuations in
these times on a case-by-case basis, the overall trend for lower
time to initial physician assessment and brain imaging was sus-
tained throughout the postintervention period.
 2180  Stroke  August 2017

Table 2.  Distribution of Inpatient Strokes by Type of Ward Few patients received intravenous thrombolysis (n=12)
or endovascular intervention (n=2) to conduct an analysis
Preimplementation, Postimplementation,
Ward Service n (%) n (%) (Table 3).
Cardiology 14 (11) 13 (15)
Discussion
Cardiovascular surgery Inpatient strokes are medical emergencies and should be
60 (46) 37 (43)
(including cardiovascular ICU)
afforded the same high-quality care as strokes that occur
General surgery 9 (7) 6 (7) out of hospital. Numerous studies have documented delays
General internal medicine 17 (13) 14 (16) in the evaluation and management of strokes in hospitalized
patients.3,12,14 This may lead to poor outcomes for patients
Nephrology 3 (2) 2 (2)
experiencing inpatient strokes, including long hospitaliza-
Neurology 1 (<1) 1 (1) tion and greater disability.4,5 Although many institutions have
Neurosurgery 0 1 (1) protocols for stroke patients arriving through the emergency
Orthopedic surgery 7 (5) 3 (4)
department, such protocols do not always exist for in-hospital
strokes.
Trauma surgery 1 (<1) 1 (1) In this study, we have shown that the implementation of an
Vascular surgery 19 (15) 9 (10) inpatient code stroke algorithm combined with stroke educa-
tion targeting key stakeholders can improve the response times
(eg, LSN to initial assessment and brain imaging). These time
Reduction in times was also estimated after adjusting for periods are 2 key measures of access to class I-level evidence
the presence of cardiovascular risk factors, >2 neurological treatment options for acute stroke (eg, thrombolysis or endo-
deficits, and whether the stroke was perioperative. Using the vascular thrombectomy). The target of our intervention was
generalized γ regression model, the time from patient LSN the dissemination of knowledge and translation of knowl-
to initial assessment was significantly reduced by 35.4% edge-to-action gaps among key stakeholders who care for
(time ratio=0.646; 95% confidence interval, 0.455–0.918; inpatients, in order to change their conception of stroke as an
P=0.0147). Likewise, the time from patient LSN to brain emergency and to alter behavior (management of a suspected
imaging was significantly reduced by 38.4% (time ratio, inpatient stroke). The fact that there were significantly more
0.616; 95% confidence interval, 0.412–0.921; P=0.0182). mild strokes (with fewer neurological deficits) identified in
However, reduction in time from initial assessment to brain the postintervention phase suggests that the educational inter-
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imaging was not significant (log-logistic regression model, vention may have improved the recognition of early or mild
P=0.1894; time ratio=0.729; 95% confidence interval, 0.454– strokes. In addition, a larger percentage of inpatient strokes
1.169; reduction=27.1%). were perioperative in the preintervention phase, suggesting

Table 3.  Comparison of Outcome Measures Before and After Intervention

Preimplementation Postimplementation
Measure (n=131) (n=87) P Value
Primary outcome
 Median time from LSN to initial assessment, min (IQR) 600.0 (109–1460) 160 (35–630) 0.0065
Secondary outcomes
 Median time from LSN to brain imaging, min (IQR) 925.0 (213–1965) 348.5 (128–1587) 0.023
 Median time from initial assessment to brain imaging,
135.0 (43–480) 110.0 (51–331) 0.509
min (IQR)
 Number with complications of poststroke pneumonia
24 (18.3) 11 (12.6) 0.263
or urinary tract infection, n (%)
Discharge destination, n (%) 0.681
 Death 19 (14.5) 16 (18.6)
 Home 33 (25.2) 22 (25.6)
 Other acute care hospital 7 (5.3) 5 (5.8)
 Long-term care 6 (4.6) 1 (1.2)
 Rehabilitation 66 (50.4) 42 (48.8)
Acute care interventions, n (%)
 IV thrombolysis 9 (6.9) 3 (3.5) 0.370
 Endovascular procedure 2 (1.5) 0 (0) NA
IQR values are given as 25th and 75th quartiles. IQR indicates interquartile range; and LSN, last seen normal.
 Kassardjian et al   Quality Improvement for In-Patient Stroke    2181

Figure 2. Box plot of the effect of the

educational intervention on primary
and secondary outcomes, demonstrat-
ing median times, along with first and
third quartiles. CT indicates computed
tomography; IA, initial assessment; ICS,
Inpatient Code Stroke; and LSN, last seen
normal.

that the intervention may have had a larger impact on nonsur-
gical wards. This finding may be explained by improvements
in the detection of subtle signs of stroke; in the postopera-
tive period, patients are often closely monitored, whereas on
a medical floor where patients may have multiple comorbidi-
ties, subtle signs of stroke may be more easily overlooked.
There was strong consensus among stakeholders that
the inpatient code stroke protocol was an important step in
improving the quality of inpatient stroke care, as allied health
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felt better equipped to respond to a suspected stroke, and
found that physicians were more responsive to their request
for an urgent assessment for a suspected inpatient stroke (as
evidenced by the large number of code strokes activated by
physicians). This concept became more relevant with the
introduction of endovascular thrombectomy as part of the
standard of acute stroke care. In this study, the small number
of patients treated with intravenous thrombolysis is attribut-
able mainly to the presence of contraindications, including

Figure 3. Run chart demonstrating (A) the time from last seen normal (LSN) to initial assessment and (B) the time from LSN to brain imag-
ing before and after the intervention. The horizontal red lines represent the median for the pre- and postimplementation period (A: prein-
tervention 600 min vs postintervention 160 min; P=0.006; B: preintervention 925 min vs postintervention 348.5 min; P=0.02).
 2182  Stroke  August 2017
recent surgery and medical comorbidities (eg, gastrointesti-
nal bleeding). Few patients were treated with endovascular
thrombectomy because this procedure was not yet standard of
care at the time of our study.
One recent study demonstrated that compared with out-of-
hospital strokes, patients with in-hospital strokes showed lon-
ger times to neuroimaging, lower rates of thrombolysis, and
left with greater poststroke disability.5 Similarly, in-hospital
strokes are less likely to meet various quality-of-care metrics,
such as the Get-With-the-Guidelines-Stroke achievement and
quality measures.4
Many factors lead to delayed recognition or assessment of
the hospitalized patient with an acute stroke, which may result
in delayed or missed treatment opportunities.7,15 Factors sug-
gested as leading to delays include the fact that neurological
deficits may be attributed to other general medical conditions;
medication effects; or delirium, lack of education on stroke
signs, the short time window for thrombolysis, and the lack of
a dedicated protocol for triaging acute stroke in hospitalized
patients.1,7,9,14–16
The disparity in the care of inpatient versus out-of-hospital
stroke should be amenable to improvement because inpatients
have the potential to be diligently monitored and are close to
resources such as CT scanners and stroke teams. In a study
by Cumbler et al,17 quality improvement methodology was
applied to reduce time to evaluation for inpatient strokes. In
that study, the quality improvement methodology focused
on creating a care pathway that included a checklist of ideal
practices and were able to reduce time to CT scan by 57%.17
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A unique feature of our study is that our primary interven-
tion addressed both gaps in knowledge and action gaps when
a stroke was identified, with emphasis on prompt action. This
was addressed through the education of ward personnel and
the creation of a formalized inpatient stroke protocol.
Our study has several limitations that deserve comment.
First, this is a single-center quality improvement study. As
such, we caution about the generalizability of our results.
On the contrary, our protocol was embedded into standard
practice targeting relevant time benchmarks reflecting care in
most stroke centers. Second, we cannot completely exclude
the effect of residual confounding from other variables. Third,
even after the intervention, the median time from LSN to brain
imaging was still 110 minutes, higher than recommended by
the current guidelines.18 There is, therefore, still room for fur-
ther systems-based quality improvement strategies to drive
this value lower. Fourth, this study was performed before the
publication of seminal trials demonstrating the effectiveness
of interventional thrombectomy for acute stroke, and thus
many of the patients ineligible for intravenous thrombolysis
may have been good candidates for endovascular therapy had
the study been performed more recently. Lastly, greater iden-
tification of perioperative strokes could have the unintended
consequences of increasing the reported complication rates
for surgical procedures at a given institution. However, this
is vastly outweighed by the potential benefits of identifying
and treating acute strokes. Despite these limitations, our study
demonstrates that a brief educational intervention consisting
of an in-service training conducted by members of the stroke
team, combined with a formalized pathway for managing
acute in-hospital stroke, can be successful at improving the
appropriate assessment and access to care (for which there is
class I evidence) for inpatient strokes.
Future improvements should focus on adapting this interven-
tion to more directly target medical and surgical residents who
spend time on the wards. Further emphasis of the urgency of
an acute stroke is also needed because some healthcare work-
ers continue to consider stroke a lesser emergency compared
with other hospital codes. In addition, it would be important
to have basic education around concepts of risk management
and decision making.19,20 Sustaining the improvement over the
long term will require continued commitment to educating
new staff members and commitment from ward managers to
emphasize the importance of the inpatient code stroke algo-
rithm. Other targets to further improve time to CT scanning
would include specific protocols for transportation of patients
to the scanner from the ward.
Conclusions
The timely assessment and imaging of inpatients with sus-
pected strokes is essential to provide parity in the care of in-
hospital and out-of-hospital stroke patients. An inpatient code
stroke algorithm and quality improvement educational strategy
aimed at overcoming knowledge-to-action gaps can be suc-
cessful in reducing most relevant initial times in acute stroke
care (LSN to assessment and LSN to brain imaging), which
have been associated with improved clinical outcomes.18
Acknowledgments
We appreciate the participation of nurses, allied health members, and
physicians involved in stroke care.
Sources of Funding
This project was founded by the Ontario Stroke Network and the
Heart and Stroke Foundation of Canada after an open peer-reviewed
competition. Dr Saposnik is supported by the Distinguished Clinician
Scientist and Mid-Career Awards from Heart and Stroke Foundation
of Canada after an open peer-reviewed competition.
Disclosures
None.
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