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Original research
DHOW2 score leads to significant improvement in acute stroke care management emergency department: a prospective analysis
  1. Naveed Akhtar1,
  2. Abdul Salam1,
  3. Paula Bourke2,
  4. Saadat Kamran1,
  5. Zain Bhutta2,
  6. Sujatha Joseph2,
  7. Mark Santos2,
  8. Deborah Morgan2,
  9. Stephen Thomas3,
  10. Adeel Ajwad Butt2,
  11. Ashfaq Shuaib1,4
  1. 1 The Neuroscience Institute, Hamad Medical Corp, Doha, Ad Dawhah, Qatar
  2. 2 Advanced Clinical Nurse Specialist, Neurology, Hamad General Hospital, Doha, Ad Dawhah, Qatar
  3. 3 Accident and Emergency, Hamad Medical Corporation, Doha, Qatar
  4. 4 Medicine, University of Alberta, Edmonton, Alberta, Canada
  1. Correspondence to Professor Ashfaq Shuaib, Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada; shuaib{at}


Background Delays in transfer of patients from emergency department (ED) to stroke ward increases medical complications. We evaluate if a new risk-score ‘DHOW2’ (dysphagia, hemiplegia, observation-required, wet (incontinence) and weight) will identify high-risk patients and whether expedited admission of ‘high-DHOW2’ score patients to SW will result in fewer complications.

Methods The DHOW2 score was designed to determine risk of complications following acute stroke. Phase I (279 patients) tested rates of complications with increasing DHOW2. Phase II (1091 patients), evaluated if early admission to the SW of high-DHOW2 patients will lead to fewer complications. Phase III (1257 patients) monitored implementation of the DHOW2 following completion of the study.

Findings Medical complications increased with higher-DHOW2 scores during all three phases; 0%–0.8% with DHOW2 of ≤3, 3.1%–6.5% with DHOW2 of 4–5 and 10.9%–14.1% with DHOW2 of ≥6 (p=<0.001). In phase II, more high-DHOW2 patients were admitted expeditiously to the SW from ED resulting in fewer complications, and fewer deaths. The odds of medical complications with DHOW2 of ≥6 was 36.8–58.3 compared with DHOW2 of ≤3. Expedited SW admission of ‘high-DHOW2 patients’ to within 8 hours reduced the development of complications to odds of 19.18–30.17 (p<0.001).

Interpretations The DHOW2 score detects patients at risk of AS related medical complications. It is easy to implement in busy EDs where nurses can use the score to identify such patients. The risk stratification by DHOW2 and early transfer of high-scoring patients to SW is associated with significantly fewer complications.

  • stroke management
  • medical complications
  • stroke care
  • stroke ward
  • DHOW2 score

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  • Contributors NA—Concept/design, analysis/interpretation, writing/reviewing. AbS—Statistical analysis, designing tables/figures. PB—Concept/designing, data collection. SK, ST, AAB—Critical revision. ZB—literature search, data collection. SJ, DM, MS—Data collection/entry, coordinating study. AsS—Concept/design, writing, overall responsibility and final approval.

  • Funding This research was funded by a generous grant from the MRC of the HMC, Qatar.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study has been approved by both the Institutional Review Board at the Medical Research Centre (MRC) (file #16016/16), and HGH Research Committee, Hamad Medical Corporation (HMC), Qatar.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.