Why admit stroke patients to hospital?

Methodology of a stroke rehabilitation trial

The effectiveness of rehabilitation after stroke remains largely unproven. Attempts have been made to evalute domiciliary therapy,1 community stroke teams2 and the intensity of therapy,3 but much of the evidence is inconclusive. We have been engaged in a randomized comparison trial of day hospital and home physiotherapy for elderly stroke patients discharged from hospital. This paper describes the background to the study and the pilot work from which the methodology was determined.

Alternative strategies for stroke care: a prospective randomised controlled trial

BACKGROUND

Organised specialist care for stroke improves outcome, but the merits of different methods of organisation are in doubt. This study compares the efficacy of stroke unit with stroke team or domiciliary care.

METHODS

A single-blind, randomised, controlled trial was undertaken in 457 acute-stroke patients (average age 76 years, 48% women) randomly assigned to stroke unit, general wards with stroke team support, or domiciliary stroke care, within 72 h of stroke onset. Outcome was assessed at 3, 6, and 12 months. The primary outcome measure was death or institutionalisation at 12 months. Analyses were by intention to treat.

FINDINGS

152 patients were allocated to the stroke unit, 152 to stroke team, and 153 to domiciliary stroke care. 51 (34%) patients in the domiciliary group were admitted to hospital after randomisation. Mortality or institutionalisation at 1 year were lower in patients on a stroke unit than for those receiving care from a stroke team (21/152 [14%] vs 45/149 [30%]; p<0.001) or domiciliary care (21/152 [14%] vs 34/144 [24%]; p=0.03), mainly as a result of reduction in mortality. The proportion of patients alive without severe disability at 1 year was also significantly higher on the stroke unit compared with stroke team (129/152 [85%] vs 99/149 [66%]; p<0.001) or domiciliary care (129/152 [85%] vs 102/144 [71%]; p=0.002). These differences were present at 3 and 6 months after stroke.

INTERPRETATION

Stroke units are more effective than a specialist stroke team or specialist domiciliary care in reducing mortality, institutionalisation, and dependence after stroke.

The epidemiology of stroke and transient ischaemia in Brisbane, Australia

This study presents the crude and age-adjusted annual incidence rates and diagnostic classifications of acute strokes and identified transient ischaemia cases in persons 25 years and over in an urban population slightly over one million. Ot the total of 2676 hospital admissions 1244 were stroke patients (the other 89 were unsubstantiated, 144 were resident outside the incidence area, 555 were asymptomatic lesions and 644 were TIA admissions); 139 patients were in chronic care facilities; 134 were managed in their own homes by their medical practitioners, with 84 certified community and 455 medical practitioners' reported deaths giving a total of 2056 strokes. Including the TIAs treated at home and admissions to hospitals there were 1877 TIAs (population at risk 660,598). The overall age-adjusted incidence rate for stroke was 1.22 or 40 percent of the crude rate per 1000 persons at risk, while the overall TIA age-adjusted rate was 1.20 or 43 percent. Aetiological classifications revealed thrombosis 0.46, embolism 0.09, intracerebral haemorrhage 0.19, subaracnoid 0.14, and acute but ill-defined events were 0.34 per 1000 persons. Early mortality was 32 percent with a significant winter peak with incidence unrelated to mean ambient temperature.

Stroke patients' views on their admission to hospital

OBJECTIVE

To explore which components of care were valued by patients admitted to hospital following a stroke.

DESIGN

Qualitative study using in depth interviews 10 months after the stroke.

SETTING

Two adjacent districts in North Thames Regional Health Authority.

SUBJECTS

82 survivors of stroke taken consecutively from a stroke register, 40 of whom agreed to be interviewed.

RESULTS

Patients reported that during the acute stage of the stroke they wanted to put their faith in experienced and trusted experts who would help them make sense of the event, take all the actions necessary to ensure survival, and provide comfort and human warmth during the crisis. In addition to being reassured by the clinical tests and practical nursing help they received, patients valued feeling cared about by the staff. In most cases patients reported that their needs were met; however, the institutional nature of the hospital sometimes obstructed the fulfillment of their needs.

CONCLUSION

Patients have important psychosocial needs during the acute stage of the stroke, which are often met by hospital admission. Patients gained benefits from their admission over and above those measurable in terms of morbidity or function. They used a combination of criteria to evaluate their care, focusing on the process as well as the outcome of care. Researchers and clinicians should do likewise.

Is admission medically justified for all patients with acute stroke or transient ischemic attack?

STUDY OBJECTIVES

To determine whether admission to an acute care hospital is medically justified for all patients with acute stroke or transient ischemic attack (TIA) and whether those patients for whom admission is justified can be identified in the emergency department.

DESIGN

Retrospective descriptive study.

SETTING

Urban county teaching hospital.

PARTICIPANTS

Consecutive adult patients seen in an ED with nonhemorrhagic stroke, TIA, or hemorrhagic stroke.

METHODS

Admission to an acute care hospital was deemed medically justified when the patient had any of the following criteria: another diagnosis that warranted admission, an inadequate home situation, altered mental status, or an adverse event during hospitalization or if they underwent hospital-based treatment that could not be provided on an outpatient basis.

RESULTS

One hundred sixty-eight patients were seen during a 1-year period: 120 had an ED diagnosis of nonhemorrhagic stroke, 22 had a diagnosis of TIA, and 26 had a diagnosis of hemorrhagic stroke. One hundred sixty-one patients (96%) were admitted to our hospital. Sixty-three of the 161 admissions (39%) were retrospectively categorized as medically justified. Seventeen of the 63 patients (27%) whose admissions were medically justified developed the criteria justifying their admission after leaving the ED.

CONCLUSION

The practice of admitting all patients with nonhemorrhagic stroke, TIA, or hemorrhagic stroke to an acute care hospital is medically justified because the ED evaluation cannot reliably identify patients whose condition will worsen.

Stereotypes of emotional caregivers and their capacity to absorb information: the views of nurses, stroke carers and the general public

This study examines the phenomenon of stereotyping informal caregivers' capacity to learn about the condition of stroke victims. Forty-nine nurses, 55 carers and 39 members of the general public gave their opinions on how emotional they considered six hypothetical wives of stroke patients to be and how much information they thought each wife would be able to absorb. Results indicated that nurses were more pessimistic than caregivers in their assessment of how much information could be absorbed, even though these two groups did not differ in their assessment of the emotionality of the wives. Nurses and the general public responded in accordance with the expected stereotype: those rated as being high in emotionality were less likely to absorb information. No such association emerged from the ratings of caregivers. The existence of the stereotype, particularly among health professionals, has serious implications for rehabilitation programmes and caregiver well-being, and provides an explanation for why caregivers sometimes feel neglected in medical settings.

Device for quantifying tactile neglect in stroke patients

Perceptual problems such as tactile neglect are important features of stroke and strong predictors of a poor outcome. Although new methods of treatment have been described, documentation of the effects of such treatment is inadequate, mainly because satisfactory methods of quantifying tactile neglect are unavailable. We describe a device for quantifying neglect based upon the principle of the Bender test which uses double or simultaneous bilateral stimulation to determine neglect. The device, which is computer driven to ensure uniformity of test protocols, determines the cutaneous perceptual threshold to controlled-current electrical stimulation using surface electrodes. The effect of rival contralateral stimulation on the perceptual thresholds on the affected side of the patient's body is a quantitative measure of tactile neglect. The device was evaluated in normal young and neurologically normal elderly subjects and in stroke patients with clinical evidence of tactile neglect. It was shown to distinguish reliably between normal subjects and those who had tactile neglect. The device will be suitable for use in trials of treatments for tactile neglect and in tracking the natural history of this symptom.

Admissions, patterns of utilization and disposition of cases of acute stroke in Brisbane hospitals

In a population of slightly-more than one million persons, all cases of acute admission to hospital for cerebrovascular disease during 1984 were studied. Of the 2676 hospital admissions, 91% were of public-hospital patients. Of the 1908 patients who were aged more than 25 years and whose conditions were assigned the International classification of diseases' (ICD-9) codes (430-437) for cerebrovascular accidents, 1264 (1.8 patients per 1000 population of older than 25 years of age) cases were completed strokes, and 644 (1.0 patients per 1000 population of older than 25 years of age) cases were transient ischaemic attacks. There was no significant difference between the specific aetiological types of stroke that were diagnosed neuroradiologically and those that were diagnosed clinically. Among the cases of completed strokes, 54% of cases were thrombotic, 11% of cases were embolic, and 15% of cases were haemorrhagic, while nearly 20% of cases were unclassified. Twenty-one per cent of patients who were admitted to hospital with completed strokes died within two weeks of their admission, 28% of such patients were discharged home, 8% of such patients were transferred to full-maintenance care, and the remaining 43% of such patients were transferred for inpatient rehabilitation. The median length of stay for patients with completed strokes was 11.8 days compared with 6.2 days for patients with transient ischaemic attacks.

The impact of new technologies in primary health care

This article surveys the gradual diffusion of diagnostic technologies into homes in Sweden. The author speculates on the advantages and prospective problems of home care. In addition, the article proposes some general guides to assure that new technologies provide genuine benefits for the patient.

An audit of follow-up services for stroke patients after discharge from hospital

A register was kept of all patients admitted to hospital in Nottingham with acute stroke, and survivors were followed up at 1 and 6 months. A quarter of the 183 survivors seen at home 6 months after their strokes were still unable to perform some everyday activities. Only 18% of discharged patients ever received outpatient occupational therapy but 42% received physiotherapy. Those attending outpatient rehabilitation were more likely to improve in functional ability between 1 and 6 months. A third of patients interviewed had not seen their GP since discharge and many with severe disabilities did not receive potentially useful therapy or aids.

Controlled trial of a home-care service for acute stroke patients

In a controlled trial of a home-care service available for the first 6 months after acute stroke, 440 patients received the new service and 417 patients were in the control group. The trial group used more hospital bed days, had a slightly higher admission rate, and did not show better emotional adjustment to stroke than the control group. There was no difference between the 2 groups in stress on relatives. Functional recovery was equal in the 2 groups. A quarter of patients managed at home in each group were severely disabled. Providing a new service does not necessarily alter clinical decisions in the short term, and care should be taken before expanding domiciliary services to reduce hospital use.