Different utilization of intensive care services (ICSs) for patients dying of hemorrhagic and ischemic stroke, a hospital-based survey

Patient and hospital characteristics associated with do-not-resuscitate/do-not-intubate orders: a cross-sectional study based on the Taiwan stroke registry

BACKGROUND

Previous studies of do-not-resuscitate (DNR) or do-not-intubate (DNI) orders in stroke patients have primarily been conducted in North America or Europe. However, characteristics associated with DNR/DNI orders in stroke patients in Asia have not been reported.

METHODS

Based on the Taiwan Stroke Registry, this nationwide cross-sectional study enrolled hospitalized stroke patients from 64 hospitals between 2006 and 2020. We identified characteristics associated with DNR/DNI orders using a two-level random effects model.

RESULTS

Among the 114,825 patients, 5531 (4.82%) had DNR/DNI orders. Patients with acute ischemic stroke (AIS) had the highest likelihood of having DNR/DNI orders (adjusted odds ratio [aOR] 1.76, 95% confidence interval [CI] 1.61-1.93), followed by patients with intracerebral hemorrhage (ICH), and patients with subarachnoid hemorrhage (SAH) had the lowest likelihood (aOR 0.53, 95% CI 0.43-0.66). From 2006 to 2020, DNR/DNI orders increased in all three types of stroke. In patients with AIS, women were significantly more likely to have DNR/DNI orders (aOR 1.23, 95% CI 1.15-1.32), while patients who received intravenous alteplase had a lower likelihood (aOR 0.74, 95% CI 0.65-0.84). Patients with AIS who were cared for by religious hospitals (aOR 0.55, 95% CI 0.35-0.87) and patients with SAH who were cared for by medical centers (aOR 0.40, 95% CI 0.17-0.96) were significantly less likely to have DNR/DNI orders.

CONCLUSIONS

In Taiwan, DNR/DNI orders increased in stroke patients between 2006 and 2020. Hospital characteristics were found to play a significant role in the use of DNR/DNI orders.

Developing and testing inter-rater reliability of a data collection tool for patient health records on end-of-life care of neurological patients in an acute hospital ward

AIM

Develop and test a data collection tool-Neurological End-Of-Life Care Assessment Tool (NEOLCAT)-for extracting data from patient health records (PHRs) on end-of-life care of neurological patients in an acute hospital ward.

DESIGN

Instrument development and inter-rater reliability (IRR) assessment.

METHOD

NEOLCAT was constructed from patient care items obtained from clinical guidelines and literature on end-of-life care. Expert clinicians reviewed the items. Using percentage agreement and Fleiss' kappa we calculated IRR on 32 nominal items, out of 76 items.

RESULTS

IRR of NEOLCAT showed 89% (range 83%-95%) overall categorical percentage agreement. The Fleiss' kappa categorical coefficient was 0.84 (range 0.71-0.91). There was fair or moderate agreement on six items, and moderate or almost perfect agreement on 26 items.

CONCLUSION

The NEOLCAT shows promising psychometric properties for studying clinical components of care of neurological patients at the end-of-life on an acute hospital ward but could be further developed in future studies.

Effects of delay to stroke unit admission in patients with ischemic and hemorrhagic stroke

OBJECTIVE

To determine the association between delay in transfer to a central stroke unit from peripheral institutions and outcomes.

METHODS

We conducted a retrospective cohort study of all patients with acute stroke, admitted to a comprehensive stroke center (CSC) from three emergency departments (EDs), between 2016 and 2018. The primary outcomes were length of stay, functional status at 3 months, discharge destination, and time to stroke investigations.

RESULTS

One thousand four hundred thirty-five patients were included, with a mean age of 72.9 years, and 92.4% ischemic stroke; 663 (46.2%) patients were female. Each additional day of delay was associated with 2.0 days of increase in length of stay (95% confidence interval [CI] 0.8-3.2, p = 0.001), 11.5 h of delay to vascular imaging (95% CI 9.6-13.4, p < 0.0001), 24.2 h of delay to Holter monitoring (95% CI 7.9-40.6, p = 0.004), and reduced odds of nondisabled functional status at 3 months (odds ratio 0.98, 95% CI 0.96-1.00, p = 0.01). Factors affecting delay included stroke onset within 6 h of ED arrival (605.9 min decrease in delay, 95% CI 407.9-803.9, p < 0.0001), delay to brain imaging (59.4 min increase in delay for each additional hour, 95% CI 48.0-71.4, p < 0.0001), admission from an alternative service (3918.7 min increase in delay, 95% CI 3621.2-4079.9, p < 0.0001), and transfer from a primary stroke center (PSC; 740.2 min increase in delay, 95% CI 456.2-1019.9, p < 0.0001).

CONCLUSION

Delay to stroke unit admission in a system involving transfer from PSCs to a CSC was associated with longer hospital stay and poorer functional outcomes.

An exploratory descriptive cohort study of 90-day prognosis after acute ischaemic stroke with mechanical thrombectomy

AIM

To evaluate the relationship between nursing assessment findings at discharge and acute ischaemic stroke (AIS) patient prognosis after mechanical thrombectomy (MT).

METHODS

We analysed the characteristics of 144 AIS patients with MT treatment admitted to a university affiliated teaching hospital in Chengdu, Sichuan Province China, from January 2020 to December 2020. The modified Rankin Scale (mRS) score was used to assess outcomes 90-days after discharge. Exploratory analyses were undertaken using IBM SPSS Statistics (Version 26.0).

RESULTS

At 90-days, 47.9% (n = 69) had a good prognosis (mRS ≤ 2) including 22.2%(n = 32) fully recovered patients. There were 5 (3.5%) deceased patients and 48.6% (n =70) of patients had a poor prognosis (mRS ≥ 3). In univariate analysis, clinical prognosis correlated with the need for inpatient endotracheal intubation (p = 0.02), nasogastric tube (p＜0.001), indwelling urinary catheter (p＜0.001), central venous catheter (p = 0.03), health knowledge needs of pressure injury prevention (p = 0.03), National Institute of Health Stroke Scale (NIHSS) score (p＜0.001) and Activities of Daily Living (ADL) score (p＜0.001) at the time of discharge from hospital. The average hospitalisation time of the 144 patients was 12[IQR, 9-25] days, and the average cost of hospitalisation was $Y$21291.93 (SD 9165.01).

CONCLUSION

Almost half of the surviving patients had a poor prognosis. In our country, this surgery and rehabilitation impose a significant financial burden that needs to be addressed. However, the longer length of hospital stay and higher costs at discharge may be contributing factors to worse outcomes. The outcomes of comprehensive nursing assessment of the patients, including nursing needs, activities of daily living, and neurological function, can predict their outcome.

IMPACT STATEMENT

We recommend a comprehensive nursing assessment at discharge that predicts patient outcomes and can be used for subsequent targeted interventions. The prognosis of patients with acute ischaemic stroke after mechanical thrombectomy is poor, and the financial burden needs to be considered.

End-of-Life Care Decision-Making in Stroke

Stroke is one of the leading causes of death and long-term disability in the United States. Though advances in interventions have improved patient survival after stroke, prognostication of long-term functional outcomes remains challenging, thereby complicating discussions of treatment goals. Stroke patients who require intensive care unit care often do not have the capacity themselves to participate in decision making processes, a fact that further complicates potential end-of-life care discussions after the immediate post-stroke period. Establishing clear, consistent communication with surrogates through shared decision-making represents best practice, as these surrogates face decisions regarding artificial nutrition, tracheostomy, code status changes, and withdrawal or withholding of life-sustaining therapies. Throughout decision-making, clinicians must be aware of a myriad of factors affecting both provider recommendations and surrogate concerns, such as cognitive biases. While decision aids have the potential to better frame these conversations within intensive care units, aids specific to goals-of-care decisions for stroke patients are currently lacking. This mini review highlights the difficulties in decision-making for critically ill ischemic stroke and intracerebral hemorrhage patients, beginning with limitations in current validated clinical scales and clinician subjectivity in prognostication. We outline processes for identifying patient preferences when possible and make recommendations for collaborating closely with surrogate decision-makers on end-of-life care decisions.