Is length of time in a stroke unit associated with better outcomes for patients with stroke in Australia? An observational study

Fever, Hyperglycemia, and Swallowing Management in Stroke Unit and Non-Stroke-Unit European Hospitals: A Quality in Acute Stroke Care (QASC) Europe Substudy

ABSTRACT

BACKGROUND: Stroke unit care reduces patient morbidity and mortality. The Quality in Acute Stroke Care Europe Study achieved significant large-scale translation of nurse-initiated protocols to manage Fever, hyperglycemia (Sugar), and Swallowing (FeSS) in 64 hospitals across 17 European countries. However, not all hospitals had stroke units. Our study aimed to compare FeSS protocol adherence in stroke unit versus non-stroke-unit hospitals. METHODS: An observational study using Quality in Acute Stroke Care Europe Study postimplementation data was undertaken. Hospitals were categorized using 4 evidence-based characteristics for defining a stroke unit, collected from an organizational survey of participating hospitals. Differences in FeSS Protocol adherence between stroke unit and non-stroke-unit hospitals were investigated using mixed-effects logistic regression, adjusting for age, sex, and National Institutes of Health Stroke Scale. RESULTS: Of the 56 hospitals from 16 countries providing organizational data, 34 (61%) met all 4 stroke unit characteristics, contributing data for 1825 of 2871 patients (64%) (stroke unit hospitals). Of the remaining 22 hospitals (39%), 17 (77%) met 3 of the 4 stroke unit characteristics (non-stroke-unit hospitals). There were no differences between hospitals with a stroke unit and those without for postimplementation adherence to fever (49% stroke unit vs 57% non-stroke unit; odds ratio [OR], 0.400; 95% confidence interval [CI], 0.087-1.844; P = .240), hyperglycemia (50% stroke unit vs 57% non-stroke unit; OR, 0.403; 95% CI, 0.087-1.856; P = .243), swallowing (75% stroke unit vs 60% non-stroke unit; OR, 1.702; 95% CI, 0.643-4.502; P = .284), or overall FeSS Protocol adherence (36% stroke unit vs 36% non-stroke unit; OR, 0.466; 95% CI, 0.106-2.043; P = .311). CONCLUSION: Our results demonstrate that the nurse-initiated FeSS Protocols can be implemented by hospitals regardless of stroke unit status. This is noteworthy because hospitals without stroke unit resources that care for acute stroke patients can potentially implement these protocols. Further effort is needed to ensure better adherence to the FeSS Protocols.

Costs of acute hospitalisation for stroke and transient ischaemic attack in Australia

BACKGROUND

Stroke is a high-cost condition. Detailed patient-level assessments of the costs of care received and outcomes achieved provide useful information for organisation and optimisation of the health system.

OBJECTIVES

To describe the costs of hospital care for stroke and transient ischaemic attack (TIA) and investigate factors associated with costs.

METHODS

Retrospective cohort study using data from the Australian Stroke Clinical Registry (AuSCR) collected between 2009 and 2013 linked to hospital administrative data and clinical costing data in Queensland. Clinical costing data include standardised assignment of costs from hospitals that contribute to the National Hospital Costing programme. Patient-level costs for each hospital admission were described according to the demographic, clinical and treatment characteristics of patients. Multivariable median regression with clustering by hospital was used to determine factors associated with greater costs.

RESULTS

Among 22 hospitals, clinical costing data were available for 3909 of 5522 patient admissions in the AuSCR (71%). Compared to those without clinical costing data, patients with clinical costing data were more often aged <65 years (30% with cost data vs 24% without cost data, p < 0.001) and male (56% with cost data vs 49% without cost data, p < 0.001). Median cost of an acute episode was $7945 (interquartile range $4176 to $14970) and the median length of stay was 5 days (interquartile range 2 to 10 days). The most expensive cost buckets were related to medical (n = 3897, median cost $1577), nursing (n = 3908, median cost $2478) and critical care (n = 434, median cost $3064). Factors associated with greater total costs were a diagnosis of intracerebral haemorrhage, greater socioeconomic position, in-hospital stroke and prior history of stroke.

CONCLUSION

Medical and nursing costs were incurred by most patients admitted with stroke or TIA, and were relatively more expensive on average than other cost buckets such as imaging and allied health.

IMPLICATIONS

Scaling this data linkage to national data collections may provide valuable insights into activity-based funding at public hospitals. Regular report of these costs should be encouraged to optimise economic evaluations.

Quality metrics in the management of acute stroke in Greece during the first 5 years of Registry of Stroke Care Quality (RES-Q) implementation

Introduction

Establishment of a prospective stroke registry may promote the documentation and improvement of acute stroke care. We present the status of stroke management in Greece using the Registry of Stroke Care Quality (RES-Q) dataset.

Methods

Consecutive patients with acute stroke were prospectively registered in RES-Q registry by contributing sites in Greece during the years 2017-2021. Demographic and baseline characteristics, acute management, and clinical outcomes at discharge were recorded. Stroke quality metrics, with a specific interest in the association between acute reperfusion therapies and functional recovery in ischemic stroke patients are presented.

Results

A total of 3590 acute stroke patients were treated in 20 Greek sites (61% men, median age 64 years; median baseline NIHSS 4; 74% ischemic stroke). Acute reperfusion therapies were administered in almost 20% of acute ischemic stroke patients, with a door to needle and door to groin puncture times of 40 and 64 min, respectively. After adjustment for contributing sites, the rates of acute reperfusion therapies were higher during the time epoch 2020-2021 compared to 2017-2019 (adjusted OR 1.31; 95% CI 1.04-1.64; p < 0.022; Cochran-Mantel-Haenszel test). After propensity-score-matching, acute reperfusion therapies administration was independently associated with higher odds of reduced disability (one point reduction across all mRS scores) at hospital discharge (common OR 1.93; 95% CI 1.45-2.58; p < 0.001).

Conclusions

Implementation and maintenance of a nationwide stroke registry in Greece may guide the stroke management planning, so that prompt patient transportation, acute reperfusion therapies, and stroke unit hospitalization become more widely accessible, improving the functional outcomes of stroke patients.

Determinants of Prolonged Length of Hospital Stay in Patients with Severe Acute Ischemic Stroke

OBJECTIVE

Long hospitalizations are associated with a high comorbidity and considerable hospital cost. Admissions of severe acute ischemic stroke are prone to longer hospitalizations. We aimed to explore the issue and method for improving the length of stay.

METHODS

From the prospective Stroke Registry between January 2019 and June 2020, acute ischemic strokes with an admission National Institutes of Health Stroke Scale ≥ 15 were identified. Prolonged length-of-stay was defined as in-hospital-stay ≥ 30 days. All clinical characteristics were collected, and all do-not-resuscitate documentations were categorized if the order had been written within 7 days of onset.

RESULTS

A total of 212 patients were eligible for severe stroke. Of these, 42 (19.8%) had prolonged length-of-stay and 170 had non-prolonged length-of-stay (median 43 vs. 13 days). The prolonged group was younger, mostly men, and was more likely to be in an independent state and more likely to receive reperfusion therapy, and there was a higher frequency of late do-not-resuscitate orders if signed. Although there was a lower in-hospital mortality rate in the prolonged group (12% vs. 23%), there was a higher proportion with a severe functional state (Modified Rankin Scale = 4-5) among the survivors (97% vs. 87%).

CONCLUSIONS

Severe acute ischemic stroke patients with a prolonged length-of-stay were younger, mostly male, more likely to receive reperfusion therapy, less likely to have an early do-not-resuscitate order if signed, and more likely to have poor functional status at discharge, although there was a lower rate of in-hospital mortality.

Stroke systems of care in high-income countries: what is optimal?

Stroke is a complex, time-sensitive, medical emergency that requires well functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage, and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service. Many have now developed a role in the very early phase (hyperacute units) plus outreach for patients who return home (early supported discharge services). Different levels (comprehensive and primary) of stroke centre and telemedicine networks have been developed to coordinate the various service components with specialist investigations and interventions including rehabilitation. Major challenges include the harmonisation of resources for stroke across the whole patient journey (including the rapid, accurate triage of patients who require highly specialised treatment in comprehensive stroke centres) and the development of technology to improve communication across different parts of a service.