Early access to a neurologist reduces the rate of missed diagnosis in young strokes

Abstract

Background: We hypothesized that the presence of an in-house neurologist or a neurology or emergency medicine (EM) residency is associated with a lower rate of missed stroke diagnosis and a greater use of thrombolytic therapy.

Methods: The outpatient Young Stroke registry from our academic medical center was reviewed. Patients 16 to 50 years of age who presented with ischemic stroke were included. Information on presentation, acute therapy, and missed diagnosis was obtained. The presence of an EM or neurology residency at the presenting hospital was recorded. We also assessed whether hospital teaching status in these fields affected missed diagnosis rates, the use of thrombolysis, or stroke intervention.

Results: Ninety-three patients were included. Thirteen patients were misdiagnosed. In hospitals with and without a neurology residency, the missed diagnosis rate was 6.3% versus 18.0%, respectively (P=.21). Two patients were misdiagnosed in hospitals with a neurology residency, but neither had neurology consultations in the emergency department. If these cases are removed from our analysis, the rate of missed diagnosis with and without a neurology residency is 0% versus 20.6%, respectively (P=.008). Acute stroke therapy was administered in 17.9% of patients seen with an EM residency, compared to 2.7% without an EM residency (P=.046). With and without a neurology residency, acute stroke therapy was administered in 25% versus 8.2% of cases, respectively (P=.055).

Conclusions: Young adults with ischemic stroke seen at hospitals with a neurology residency had a lower missed diagnosis rate. The presence of an EM resident or a neurology teaching program was associated with a greater use of acute stroke therapies. These results support initiatives to triage young adults with suspected acute stroke to hospitals with access to neurologic expertise in the emergency department.

Keywords: Missed diagnosis; patient safety; stroke; young adults.