Qualidade do cuidado ao acidente vascular cerebral isquêmico no SUS

Effect of implementing care protocols on acute ischemic stroke outcomes: a systematic review

BACKGROUND

Implementing stroke care protocols has intended to provide better care quality, favor early functional recovery, and achieving long-term results for the rehabilitation of the patient.

OBJECTIVE

To analyze the effect of implementing care protocols on the outcomes of acute ischemic stroke.

METHODS

Primary studies published from 2011 to 2020 and which met the following criteria were included: population should be people with acute ischemic stroke; studies should present results on the outcomes of using protocols in the therapeutic approach to acute ischemic stroke. The bibliographic search was carried out in June 2020 in 7 databases. The article selection was conducted by two independent reviewers and the results were narratively synthesized.

RESULTS

A total of 11,226 publications were retrieved in the databases, of which 30 were included in the study. After implementing the protocol, 70.8% of the publications found an increase in the rate of performing reperfusion therapy, such as thrombolysis and thrombectomy; 45.5% identified an improvement in the clinical prognosis of the patient; and 25.0% of the studies identified a decrease in the length of hospital stay. Out of 19 studies that addressed the rate of symptomatic intracranial hemorrhage, 2 (10.5%) identified a decrease. A decrease in mortality was mentioned in 3 (25.0%) articles out of 12 that evaluated this outcome.

CONCLUSIONS

We have identified the importance of implementing protocols in increasing the performance of reperfusion therapies, and a good functional outcome with improved prognosis after discharge. However, there is still a need to invest in reducing post-thrombolysis complications and mortality.

Public hospitalizations for stroke in Brazil from 2009 to 2016

Background

Stroke is the third major cause of death in the world and the second in Brazil. The purpose of this work was to assess the stroke-related hospitalization, in-hospital mortality, and case fatality rates under the Brazilian Unified Health System (SUS) from 2009 to 2016.

Methods

We evaluated the hospital admissions for stroke and their associated outcomes using data from the Hospital Information available at the Informatics Department of SUS. We selected hospitalization registries according to stroke diagnosis codes from the International Statistical Classification of Diseases and Related Health Problems (ICD-10). We identified the association of age and sex with patient death through multiple logistic regression and calculated the rates of hospitalization, mortality and case-fatality per 100,000 inhabitants using age-adjustment methodology.

Results

We analyzed 1,113,599 stroke hospitalizations. From 2009 to 2016, the number of admissions increased from 131,122 to 146,950 and the absolute number of in-hospital deaths increased from 28,731 to 31,937. Younger age and male sex were significantly associated with patient survival. Our results showed that the annual age-adjusted hospitalization and in-hospital mortality rates decreased by 11.8% and 12.6%, respectively, but the case fatality rate increased for patients older than 70 years.

Conclusions

Although the age-adjusted hospitalization and in-hospital mortality rates declined, the total number of hospitalization and deaths have increased. It is expected a continuous increase over the next years of stroke admissions with the rapid aging of the Brazilian population. Efforts should be renewed targeting risk factors, access to hospital and rehabilitation in particular for the elderly population.

AVALIAÇÃO DOS INDICADORES DE ÓBITO E INCAPACIDADE DOS PACIENTES ATENDIDOS EM UMA UNIDADE DE ACIDENTE VASCULAR CEREBRAL

RESUMO Objetivo: avaliar indicadores de resultado para mortalidade e grau de incapacidade dos pacientes na alta antes e após implantação da unidade de acidente vascular cerebral. Método: um estudo quantitativo, retrospectivo e transversal, realizado em um hospital público, que teve a unidade de acidente vascular cerebral implantada em 2011. Foram analisados 245 prontuários de pacientes admitidos de 29 de janeiro de 2011 a 28 de janeiro de 2012. Foram 63 pacientes nos seis meses antes da implantação da unidade de acidente vascular cerebral e 182 pacientes nos seis meses após. Utilizou-se na alta hospitalar pelos registros no prontuário a escala de Rankin modificada, possui sete graus (0 a 6) que mensura o comprometimento funcional, variando de "sem incapacidade" até "óbito". Para análise dos dados foi utilizado um software de análise estatística (SAS para Windows®, versão 9.3). Resultados: somando os indicadores 0 e 1 (sem incapacidade e ausência de incapacidade significativa) da escala de Rankin modificada, encontramos 6,72% antes e 42,86% depois da implantação, indicando condição de menor incapacidade na alta após a implantação. A mortalidade foi de 20,69% antes da implantação e 12,73% depois. Conclusão: houve redução do grau de incapacidade dos pacientes e da mortalidade após implantação da unidade de acidente vascular cerebral.

Public-private settlement and hospital mortality per sources of payment

OBJECTIVE

To analyze if the adjusted hospital mortality varies according to source of payment of hospital admissions, legal nature, and financing settlement of hospitals.

METHODS

Cros-ssectional study with information source in administrative databases. Specific hospital admission reasons were selected considering the volume of hospital admissions and the list of quality indicators proposed by the North-American Agency for Healthcare Research and Quality (AHRQ). Were analyzed 852,864 hospital admissions of adults, occurred in 789 hospitals between 2008 and 2010, in Sao Paulo and Rio Grande do Sul, applying multilevel logistic regression.

RESULTS

At hospital admission level, showed higher chances of death male patients in more advanced age groups, with comorbidity, who used intensive care unit, and had the Brazilian Unified Health System as source of payment. At the level of hospitals, in those located in the mean of the distribution, the adjusted probability of death in hospital admissions financed by plan or private was 5.0%, against 9.0% when reimbursed by the Brazilian Unified Health System. This probability increased in hospital admissions financed by the Brazilian Unified Health System in hospitals to two standard deviations above the mean, reaching 29.0%.

CONCLUSIONS

In addition to structural characteristics of the hospitals and the profile of the patients, interventions aimed at improving care should also consider the coverage of the population by health plans, the network shared between beneficiaries of plans and users of the Brazilian Unified Health System, the standard of care to the various sources of payment by hospitals and, most importantly, how these factors influence the clinical performance.

Nursing diagnoses in patients with cerebral vascular accident: an integrative review

OBJECTIVE

to verify the nursing diagnoses in patients affected by CVAs.

METHOD

this is an integrative review of the literature. The search was conducted on LILACS, Scielo, Medline, CINAHL, and Scopus databases between February and March 2015, using the following keywords: "Enfermagem", "Acidente Vascular Cerebral", "Diagnóstico de Enfermagem"; and "Nursing", "Stroke", and "Nursing Diagnosis".

RESULTS

we found 9 articles published between 2009 and 2015; most of them were Brazilian, cross-sectional, and exploratory, with a level of evidence of 6. The evidence from the publications was classified as: "Evaluation and validation of specific nursing diagnoses for subjects affected by CVAs" and "Application of the nursing process on subjects affected by CVAs".

CONCLUSION

we noticed the publications focused on nursing diagnoses related to motor disorders, such as risk of falls and impaired physical mobility. Domains regarding safety/protection (domain 11) and sleep/resting (domain 4) were present in most evaluated publications.

Brazilian version of the Quality of Care Scale: the perspective of people with disabilities

OBJECTIVE

To analyze evidence of the validity and reliability of a Brazilian Portuguese version of the Quality of Care Scale from the perspective of people with physical and intellectual disabilities.

METHODS

There were 162 people with physical disabilities and 156 with intellectual disabilities from Porto Alegre and metropolitan region, who participated in the study in 2008. Classical psychometrics was used to independently analyze the two samples. Hypotheses for evidence of criterion validity (concurrent type) were tested with the Mann-Whitney test for non-normal distributions. Principal components analysis was used to explore factorial models. Evidence of reliability was calculated with Cronbach alpha for the scales and subscales. Test-retest reliability was analyzed for individuals with intellectual disabilities through intra-class correlation coefficient and the Willcoxon test.

RESULTS

The principal components in the group with physical disabilities replicated the original model presented as a solution to the international project data. Evidence of discriminant validity and test-retest reliability was found.

CONCLUSIONS

The transcultural factor model found within the international sample project seems appropriate for the samples investigated in this study, especially the physical disabilities group. Depression, pain, satisfaction with life and disability may play a mediating role in the evaluation of quality of care. Additional research is needed to add to evidence of the validity of the instruments.

Outcome determinants of stroke in a brazilian primary stroke center

Background. Stroke mortality in Brazil is one of the highest among Western countries. Nonetheless, stroke outcome determinants are still poorly known in this country. In this study we evaluate outcome determinants of stroke in a primary stroke center in São Paulo, Brazil. Methods. We evaluated demographic, clinical, and outcome data of patients with ischemic stroke (IS), transient ischemic attack (TIA), and intracerebral hemorrhage (ICH) admitted at “Hospital Paulistano,” São Paulo, Brazil. In-hospital mortality and functional outcome determinants were assessed. Univariate and binary logistic regression analysis were performed. Results. Three hundred forty-one patients were included in the study, 52.2% being male with 66.8 ± 15.7 years. The stroke type distribution was IS: 59.2%, TIA: 29.6%, and ICH: 11.1%. ICH was associated with greater severity and poorer functional outcome. The determinants of poorer functional outcome were higher NIHSS, lower Glasgow score, and lower oxygen saturation level. The most important mortality determinant was the presence of visual symptoms. Conclusions. The stroke mortality and stroke outcome determinants found in the present study do not remarkably differ from studies carried out in developed countries. Stroke prognosis studies are crucial to better understand the high burden of stroke in Brazil.

Trends of the Incidence of Ischemic Stroke Thrombolysis over Seven Years and One-Year Outcome: A Population-Based Study in Joinville, Brazil

Background

In a population-based setting, we aimed to measure the incidence trends of ischemic stroke (IS) thrombolysis, thrombolysis times, proportion of symptomatic intracerebral hemorrhage (sICH), 30-day case fatality and functional outcomes. We also compared the 12-month functional status between thrombolyzed and nonthrombolyzed patients.

Methods

Using data from the Joinville Population-Based Stroke Registry, we prospectively ascertained a cohort of all thrombolyses done in Joinville citizens, Southern Brazil, from 2005 to 2011. For the definition of sICH we used European Cooperative Acute Stroke Study (ECASS) II criteria.

Results

Over 7 years, 6% (220/3,552) of all IS were thrombolyzed. The thrombolysis incidence increased from 1.4 [95% confidence interval (CI), 0.6-2.9] in 2005 to 9.8 (7.3-12.9) per 100,000 population in 2011 (p < 0.0001). The thrombolysis incidence age-adjusted to the world population in 2011 was 11 (8.2-14.3) per 100,000. Only 30% (50/165) were thrombolyzed within 1 h of arrival at hospital. In 7 days, 6.4% (14/220) had sICH and 57% (8/14) of those died. In the 2009-2011 period, a favorable functional outcome [modified Rankin scale (mRS) 0-1] at 12 months among patients who received thrombolysis was more frequent [mRS 0-1; 36% (38/107)] than among patients who did not receive thrombolysis [mRS 0-1; 24% (131/544); p = 0.016]. The logistic regression showed that thrombolyzed IS patients had a more favorable outcome (mRS 0-1; HR 2.13; 95% CI, 1.2-3.7; p < 0.016) than nonthrombolyzed patients.

Conclusion

In a population setting of a middle income country, the thrombolysis incidence and outcomes were similar to those of other well-structured services. After 1 year, patients thrombolyzed in the 4.5-hour time window had a better outcome. More than proportions, rates provide additional information and could be used to benchmark services against others.

[Experiencing acute stroke: the meaning of the illness for hospitalized patients]

The aim was to understand the meaning of the experience of the acute stroke patient. This was a qualitative study, based on the conceptual theory of symbolic interaction. It was conducted in a unit specialized in the treatment of stroke at a tertiary hospital in Fortaleza-CE and the ethical aspects were respected. The study included ten patients and data were collected through open interviews. The data were organized and analyzed according to enunciation techniques. The meaning of the illness experience was constructed based on the perception of the feelings that arose during the hospitalization and was characterized by fear of death and the sequelae of the disease; sorrow for the distance from home; relief, when a patient perceived an improved clinical course; and a desire to change one´s lifestyle. The experience of illness due to stroke is complex, as meanings are elaborated ​​from the feelings, actions and behaviors of the subjects.

Avaliação da qualidade do cuidado hospitalar no Brasil: uma revisão sistemática

A avaliação da qualidade de serviços hospitalares vem ganhando importância no mundo, sendo impulsionada pela demanda de financiadores, prestadores, profissionais e pacientes. O objetivo deste estudo é revisar a literatura sobre estudos de avaliação da qualidade hospitalar no Brasil e analisar as principais abordagens, metodologias e indicadores utilizados. Foi aplicada revisão sistemática de artigos científicos, dissertações e teses com análises empíricas sobre o tema, publicados entre 1990 e 2011. Foram identificados 2.169 documentos e incluídos 62 documentos na revisão, que representam 48 estudos distintos. Predominou o uso de fontes de dados secundárias com análise das dimensões efetividade, adequação, segurança e eficiência, destacando-se a aplicação da taxa de mortalidade, taxa de adequação, taxa de eventos adversos e tempo de permanência. Métodos que controlam diferenças de risco dos pacientes foram majoritariamente aplicados. Busca-se com esta revisão contribuir apontando elementos centrais para o desenvolvimento do tema no país e para a qualificação do cuidado prestado.