Discovery is crucial.

Informants unanimously emphasized identifying the IHS patient as crucial in the stroke care chain and agreed that delayed discovery was the primary cause of treatment delays.

“…that is the critical part, if no one realises that the patient had a stroke on the ward. That would certainly result in a huge delay.” (Inf1)

They described scenarios contributing to delayed patient discovery, including patients waking up with stroke symptoms, experiencing symptoms post-anesthesia, or becoming symptomatic between staff rounds.

“Some patients are identified after waking up from anaesthesia… or the patient is not under constant observation at night and symptoms are observed in the morning.” (Inf4)

Some informants recounted incidents where staff were hesitant about whether symptoms indicated a stroke, potentially impeding the alert process. They explained that the individual who identified the patient could consult with a nearby colleague to discuss their findings before informing the ward physician, who would then assess the patient to determine if a stroke was suspected and initiate the stroke alert by calling the “key player”.

“I felt as if they had thought about calling me for some time before they actually did.” (Inf6)

If a nurse assistant suspects an IHS, they would inform the nurse, who, in turn, pages the doctor… The doctor then assesses the patient to determine if a stroke alert is warranted.”(Inf6)

The “key player”.

All informants described the first step in initiating a stroke alert as a telephone call, typically made by the ward physician, to a person with stroke expertise who has the authority to proceed with the stroke alert to immediate radiology. This individual, referred to as the “key player”, could be the on-call neurologist or internist, a stroke-specialized nurse, or an emergency physician. At sites with a written IHS protocol, the appropriate person to contact when suspecting a stroke in a hospitalized patient was clearly defined. At the one site without a written routine, most staff reported calling the on-call internist, as it was considered the most reasonable approach in that context.

When the “key player” was notified of a suspected IHS patient, various scenarios were described. Some informants reported that the “key player” did not physically assess the patient before deciding to proceed with the stroke alert, particularly in cases where revascularization therapy might be indicated.

“The more skilled the on-call neurologist and the more obvious the stroke symptoms, the greater the possibility of managing the situation over the phone.” (Inf2)

“When there’s suspicion of IHS, you contact the stroke coordinator, a nurse specialized in stroke care. They will ask you standardized questions based on a survey, and if the criteria are met, a stroke alert is initiated.” (Inf4)

If the symptoms suggested a stroke, a stroke alert was initiated to notify radiology, and the patient was transported to the CT scan by the ward staff, where the physical examination would take place later. Informants emphasized that the “key player” could gather valuable information over the phone, guiding the caller through a screening evaluation if the symptoms were unclear. They underscored the crucial role of the “key player” in providing clear instructions to the ward staff regarding the urgency of the situation.

“When you receive a phone call from someone who believes their patient had a stroke, especially from a ward you suspect is not accustomed to managing stroke patients, it’s crucial to be explicit: “This is really urgent. Drop everything you’re doing, bring a nurse, and meet me as soon as possible at the CT scan”.” (Inf1)

In cases where symptoms did not suggest stroke, or if revascularisation therapy was unlikely, the “key player” could examine the patient in the ward before making further recommendations. Some informants mentioned that the “key player” always assessed the patient in the ward before deciding to proceed with the stroke alert. In such cases, the “key player” played a role in expediting patient transport to radiology alongside the ward staff and initiated the physical examination that would otherwise occurr performed at the CT scan.

The in-hospital stroke alert.

Most informants explained that their hospitals used the same infrastructure for IHS alerts as for COS alerts. The stroke alert for a COS typically consists of a page sent to all relevant staff (on-call neurologist/internist, radiologist, stroke nurse) and departments (radiology, emergency department, intensive care unit, stroke department). This alert is usually initiated by the emergency department’s head nurse after receiving a call from paramedics regarding a suspected COS patient. Since the step where paramedics call the emergency department is absent in the care chain for IHS patients, informants described various ways to initiate the stroke alert from within the hospital.

The most common practice was for the “key player” to call the head nurse at the emergency department and request that they activate a stroke alert page. One informant described a system where the “key player” initiated the alert by calling the hospital switchboard, and the operator triggered the stroke alert via the pager system. This practice was established for all stroke alerts at that site. Another informant shared an alternative approach where the ward nurse was responsible for alerting relevant departments through phone calls, deviating from the standard practice for COS patients at that site. This highlights the variability in alert initiation procedures for IHS cases across different sites.

“…then we call the nurse at the main desk of the emergency department and inform them to go to the CT-scan […] and they are supposed to activate the stroke alert by pushing a button, so radiology and ICU are alerted.” (Inf5)

The unknown in-hospital stroke routine.

All but one site had a written IHS routine outlining how to initiate a stroke alert for a hospitalized patient with stroke symptoms. While some informants considered the IHS routines effective, conflicting information emerged during interviews. Some described doubt among staff about who to contact when suspecting stroke in a hospitalized patient. Others noted hesitancy in recognizing whether the symptoms indicated stroke and whether a stroke alert was indicated. Additionally, trust issues arose among the receivers of the page when the alert originated from a hospital ward rather than the emergency department. As a result, they concluded that stroke protocols designed for COS may not be universally recognized or trusted for IHS. Simplified protocols for when to suspect stroke in hospitalized patients and initiating the stroke alert were suggested, along with increased staff education to ensure adherence to existing routines.

“The one thing you absolutely should not do is call the hospital switchboard and initiate the stroke alert. The stroke ward and radiology will not trust this stroke alert as it reaches them through a different channel. They are supposed to receive a phone call and a briefing; that is when they take action.” (Inf2)

“There is a stroke alert, it is initiated from the emergency department, but it was not established to be used from a ward.” (Inf3)

At the hospital without an established routine, IHS management varied depending on the physician assuming the role of the "key player." While contacting the "key player" to initiate the stroke alert was common practice, subsequent steps in the care pathway often differed due to the absence of a standardized system known to all staff. However, the hospital’s relatively small size allowed the "key player" to leverage local knowledge of clinics and personnel to devise tailored solutions for each IHS case.

“We know most phone numbers by heart, I know my colleagues by their first name and recognize their voices on the phone. Therefore, it is possible to “reinvent the wheel” for each IHS case. But of course it is negative that we do not have an established routine.” (Inf3)

Lack of confidence.

Some informants described hesitancy among staff to initiate a stroke alert for a hospitalized patient, fearing they might be wrong about the symptoms indicating a stroke.

“Then there’s this threshold to initiate a stroke alert in a fairly well patient. So you find yourself thinking, “He is 82 years old and was quite tired yesterday too. Is there truly something happening or will someone just think that I’m embarrassing?” (Inf5)

They noted that staff tended to seek confirmation from colleagues before contacting the “key player”, which could lead to multiple evaluations within the ward before the stroke alert was initiated by calling the “key player”. This hesitation was attributed to a lack of experience in managing stroke among those discovering the patient with suspected IHS.

“A nurse assistant informs the nurse about a suspected IHS, who then checks on the patient and feels uncomfortable because the doctor is at lunch. Should we disturb because of this? Nevertheless, you inform the doctor, who should recognize the urgency of the situation. Subsequently, the doctor should see the patient and understand that this requires immediate alerting… These steps before initiating the stroke alert are the most challenging.” (Inf5)

"For wards other than stroke wards, it is crucial that the person who identifies a patient with unusual symptoms dares to act fast. By this, I mean calling the doctor immediately without thinking twice." (Inf6)

“The first steps are truly the hardest ones–to discover the patient, trust yourself, and dare to pursue the case.” (Inf5)

This contrasts with COS, where the decision to activate the stroke alert is made in the prehospital setting. Ambulance staff, who manage patients with suspected stroke more frequently than hospital ward staff, are accustomed to using stroke screening protocols and benefit from the transport time to the hospital, which allows for a structured initial evaluation. If deemed necessary, they can contact the "key player" to discuss whether a stroke alert should be activated. Consequently, upon arrival at the hospital, the patient can proceed directly from the emergency department to the CT scan, as all relevant parties have had time to prepare in advance. Some informants emphasized that maintaining a high pace of management is easier than being the one responsible for escalating urgency, as in the case when ward staff must decide to call a stroke alert for a hospitalized patient without certainty about the symptoms. Simple protocols for when to call the "key player" when stroke is suspected in a hospitalized patient were suggested to encourage prompt action by staff.

“We are all in the right mindset in the emergency department, and the appropriate staff are present. Therefore, you can simply rush…” (Inf2)

A robust general stroke alert facilitates IHS management.

All informants described the radiology department as the natural meeting point for all involved parties, emphasizing that patient management for IHS should only deviate from COS management before arriving at the CT scan.

However, some informants highlighted challenges in IHS management that occurred after CT arrival, overlapping with the general stroke alert. Issues included suboptimal preparation for thrombolytic treatment (e.g., absence of IV lines, lack of weight information), delays at the CT-scan (routine CT-angiography preceding thrombolytics), and post-CT administration of thrombolytics in locations other than at the CT scan. Informants also noted staffing challenges during off-hours and perceived IHS patients as more medically complex.

“…then we move the patient from the CT-scan to a nearby room to administer the thrombolytic agent. This final step has proven to cause a delay of a minute or so, and we are exploring alternative approaches for the future.” (Inf2)

Informants mentioned that revisions to their general stroke alert protocols positively impacted patient management, including IHS patients. These revisions included administering thrombolytics before CT angiography, preparing thrombolytic agents before patient arrival, and increasing the level of medical competence at stroke alerts.

“During off-hours, stroke alerts used to be managed by interns. They were insecure and uncomfortable handling acute stroke patients. Now we only have residents or attendings working off-hours, and given their years of experience there is usually little to discuss.” (Inf4)

Resignation.

Some informants found IHS management acceptable despite its challenges, acknowledging the difficulty of eliminating the chaotic environment surrounding IHS cases in wards with no stroke experience. They suggested that educating staff about something rare might not be worthwhile, as the individual discovering the patient would still likely be inexperienced in stroke management. Some considered the existing routines for initiating the IHS alert adequate, attributing any issues to staff non-adherence. One informant felt that IHS management was as effective as COS management, although this was contradicted by background data.

“How good could it possibly be when there is always someone inexperienced involved. It will never be any better than expected, it will never be good. It could be as good as expected, and I believe that is how good it is now.” (Inf2)

“However, the management of IHS patients is no less effective than for those with community-onset.” (Inf4)

Varying levels of knowledge about HIS.

All informants highlighted that there was insufficient education due to excessive administrative burdens and staff shortages. As a result, recent advances in acute stroke management, such as the possibility of performing thrombectomy within 24 hours, might not have been communicated to all staff.

“I definitely think that knowledge about this [thrombectomy within 24 h] is lagging behind, even among colleagues in internal medicine.” (Inf3)

Informants concurred that hospital staff lacked sufficient education on IHS, pointing out the absence of IHS-specific content in current education programs. They suggested that IHS education might be given a low priority due to the perception that it is rare, making the cost-benefit ratio seem unfavourable. Despite this, most informants agreed that regular education on IHS is essential to keep staff up to date.

“Of course, education of staff members at the wards could always be improved. But it is very resource-intensive, especially in a large hospital.” (Inf1)

“Especially those who do not work with stroke patients daily could use a reminder. It is easy to forget things you do not regularly encounter.” (Inf6)

Knowledge and experience improve IHS management.

The importance of knowledge and experience in stroke management was emphasized as crucial for successful IHS management. Wards with prior experience in stroke management were reported to handle suspected IHS cases more effectively compared to inexperienced wards. This was attributed to staff experience in recognizing stroke symptoms, understanding the urgency of treatment, and familiarity with stroke management protocols.

“When there is a stroke alert from the stroke ward, the staff naturally assume their positions. There is no need to assemble a separate stroke alert response team, you are the stroke alert response team.” (Inf2)

“You respond more easily to things you have heard about [IHS]. Then you have a strategy and a plan. Everything moves a bit faster when you are confident that this ward has a routine; you simply follow it and execute as instructed.” (Inf5)

In contrast, wards with limited experience in stroke management were seen as more prone to delays in recognizing symptoms and initiating the stroke alert by calling the "key player." This was attributed to insecurity about interpreting stroke symptoms and unfamiliarity with the IHS routine. The rotation of interns to hospital wards with less stroke experience was considered a positive factor for enhancing IHS management, as their recent experience from other wards could contribute to improved recognition of stroke symptoms and timely initiation of the stroke alert.

“I know our interns are very competent. As long as they are in the wards, […] I’m convinced they will identify the patients with IHS.” (Inf3)

Education is requested.

Several informants highlighted that staff were interested in stroke education, noting regular participation in stroke education sessions. Wards that had recently managed IHS patients expressed an interest in further improvement and actively sought additional IHS education. Constructive events were also described, including debriefing sessions held shortly after managing an IHS case. These sessions encouraged discussions of specific cases and emphasized the importance of following the IHS routine.

“After a recent IHS case, we decided to designate the IHS alert as the “routine of the month”… This way, we reminded each other about the routine, discussed it in workplace meetings and ensured everyone read it at least once.” (Inf6)

Informants expressed a preference for brief, concise IHS education that focuses on when to suspect stroke in hospitalized patients and provides clear guidelines on the necessary actions. This approach aligns with the education provided for other urgent conditions, such as cardiopulmonary resuscitation.

“In the best case scenario, calling an IHS alert should be common knowledge, just like I know how to manage urgent and dangerous conditions by heart, including some I’ve never seen, like anaphylactic shock […] Shouldn’t knowing how to initiate an IHS alert be a standard skill? Yes, I would like that!” (Inf2)