A specialty without a disease: It was a major hangup for the field of hospital medicine in the early days. We’d hurdled many of the traditional barriers to specialty status—research fellowships, textbooks, an active society, a growing body of research, and thousands of practitioners focusing their practice on the hospital setting. However, despite several examples of site-defined specialties like emergency and critical-care medicine, cynics clung to the time-honored need for a specialty to own an organ, or at least a disease.
Early SHM efforts made a strong push to make VTE our disease—both its treatment and, more importantly, its prevention. It was a laudable effort, one that has saved many thousands of lives and limbs. It made sense for hospitalists to tackle VTE; it’s an incapacitating disease that affects many, is largely preventable, and had no strong inpatient advocate. While hematologists were the obvious “owner” of this disease, they were neither available nor able to redesign the inpatient systems of care necessary to thwart this illness. Hospitalists, invested in this issue by consequence of direct care of many at-risk patients and through commitment to improving hospital systems, came to own VTE prevention.
The Next Frontier: Stroke
It is time hospitalists apply this experience to the management of an even more incapacitating, largely preventable disease looking for an inpatient steward: stroke. A stroke occurs in the U.S. every 40 seconds, with disabling sequelae that often are avoidable with rapid detection and treatment. This is especially true when we are given the clarion call of a transient ischemic attack (TIA). The problem is that most American hospitals are not kingpins of efficiency—the key ingredient of the processes necessary to improve stroke outcomes. Furthermore, while our neurologic colleagues are the obvious group to lead the deployment of stroke QI programs, there just aren’t enough of them to do so.
Hospitalists provide a significant amount of neurologic care. One study notes that TIA and stroke were among the most commonly cared-for diseases by hospitalists.1 This places us in a prime position to take the lead and own this disease in collaboration with our neurology colleagues. Just as with reliable VTE prevention, the key to effective stroke care requires effective systems engineering in conjunction with disease-specific expertise.
CT scan of a human brain showing posterior temporal stroke.
Rapid Care for Acute Medical Crisis
EDs are equipped with stroke pathways to efficiently evaluate, triage, scan, and intervene for patients who present with stroke symptoms. While most hospitals have a long way to go to perfect these systems, some hospitals—mostly in large, urban centers—have achieved the appropriate level of ED efficiency. These hospitals are recognized by The Joint Commission accreditation as stroke centers. As a result, patients who present to these hospitals with stroke symptoms often receive thrombolytics—a disease- and life-altering therapy—within the appropriate, but very limited, time window for benefit.
But what happens if that same patient develops those same signs and symptoms in the hospital? Will they get the same level of efficient evaluation, triage, scanning, and intervention that occurs in the ED? This is more than an academic question. Fifteen percent of all strokes are heralded by transient neurologic deficits, so many of the estimated 300,000 annual TIA patients are admitted to the hospital. What’s the reason for the admission? To facilitate the diagnostic workup, monitor for stroke symptoms and apply timely interventions should this occur.
But are we equipped to provide this kind of timely care in the hospital?