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

Current Concepts and Controversies in Stroke Recovery: Rehabilitation Implications

This paper summarises the stroke incidence crude rate as 3.02 per 1000 people of 25 years and over and that of ‘mini-strokes’ as 2.89 per 1000 people. Many people with a mini-stroke may develop a full stroke within one year. Occupational therapists therefore need to shift their attention first to primary prevention to alter original organic pathology and then to restitution of hemiplegia.

A number of issues in neurological recovery following hemiplegia are then highlighted. These include ‘penumbra’, a metabolic disorder, the understanding of which helps to know if a hemiplegic lesion is able to tolerate the loss of oxygen and whether it can adapt to the ischaemia, early mortality and implications of regional cerebral circulation changes for treatment of hemiplegia and for prognosis. In the treatment of hemiplegia, there is a need to understand the role of ipsilateral brain, that is, brain plasticity in stroke recovery, the role of uncrossed pyramidal fibres, the parallel versus hierarchical operation of the descending cortical influences, and the interactions of the pre-motor systems with the primary cortex. In treatment, the paper explains the implications of the use of Bobath-type therapeutic procedures, the use of unilateral or bilateral tasks in occupational therapy and the learned non-use of the hemiplegic side.

Documentation for Measuring Stroke Rehabilitation Outcomes

Stroke is the third commonest cause of hospital admission in Australia. Approximately 71% of patients with an acute stroke are likely to be admitted to public and private hospitals. With no advanced clinical information system in place in Australia, it is difficult to determine who is likely to benefit, what type of inpatient care is efficient and effective in providing maximum potential to the stroke patients. This paper highlights some of the problems encountered with the current medical records, in conducting a prospective, multi-institutional, population based stroke rehabilitation outcome study in Brisbane. The paper also discusses how these deficiencies affect health professionals such as occupational therapists, and how one can work with the medical record administrators of today as key resource people in health information management. To illustrate this, a pro forma rectifying some of the current deficiencies in the medical records is provided as a guide. (AMRJ, 1991, 21(3), 88–95).

Investigation of the Transient Ischemia Workload and its Incidence: Implications for Occupational Therapy Research

With limited effectiveness of medical and surgical intervention following stroke, the focus has shifted to preventing stroke and the most important warning sign of an impending stroke, the Transient Ischemic Attack (TIA) or the “mini stroke.” We found that the incidence of hospital admissions for the TIA patients in a population of slightly more than 1 million (660,598 people 25 years and older) was 1.18 per 1,000 men, or a total of 386 men, and 0.73 per 1,000 women, or a total of 258 women. The overall admission rate was 0.95 per 1,000 people 25 and older. For those hospitalized, the mean age was 67.9 years for men, and 71.3 years for women. Our epidemiological study of hospital admissions and the cases reported and managed by the general medical practitioners in the community showed the crude incidence rate of 2.89 per 1,000 people 25 years and older, while the adjustment for the world standardized population rate yielded a value of 1.26 per 1,000, or 44% of the crude rate that was actually observed. There appeared to be a marked disparity between the reported female and male cases of TIA. The research discussion focuses on two equally important thrusts: 1) development of strategies to reduce identified risk factors for stroke, and 2) establishment of a premorbid patient profile by occupational therapists that will have widespread implications for identifying changes for the potential prevention and treatment of stroke.

The Mobility Scale for Acute Stroke Patients: intra-rater and inter-rater reliability

Objective: With increasing pressure for accountability in the Australian health service, clinicians require reliable and valid measurement tools for assessing the physical status of stroke patients in the acute setting prior to entering rehabilitation, so that predictions can be made about the potential length of stay in rehabilitation and level of outcome. In response to the lack of suitable measures of physical disability for acute stroke patients, the Mobility Scale for Acute Stroke Patients was developed. The aim of this paper was to investigate the intra-rater and inter-rater reliability of the scale.

Method: Five tasks, which incorporate functional movements from lying to walking, were assessed using a six-point scale based on the level of assis tance. Stroke patients were filmed while being assessed by an experienced examiner using the Mobility Scale. Twenty-one clinicians viewed 10 video- taped performances of each activity.

Results: The intra-rater reliability from the viewing sessions one month apart was excellent for 92% of the judgements (weighted kappa >0.75). The weighted kappa values for inter-rater reliability were all in the excellent agreement range above 0.75.

Conclusion: The results of this study showed that the Mobility Scale has a high degree of reliability using this testing procedure. The reliability of the Mobility Scale in the clinical setting and its validity in predicting length of stay and outcome are being investigated.

The Barthel Index and ADL Evaluation in Stroke Rehabilitation in Australia, Japan, the UK and the USA

At present many of the activities of daily living indices used in Australia lack essential characteristics of an index yielding desirable results. This study argues that the Barthel Index as modified by Shah, Vanclay and Cooper (1989a) is robust and has the required biometric and psychometric qualities. It presents evidence in support of the use of the Barthel Index as a preferred measure of the activities of daily living function to report therapeutically meaningful and valid information of patient care and stroke rehabilitation outcomes in Australia. It also presents the functional performance on the modified Barthel Index and the outcome of all 258 first stroke patients admitted for inpatient rehabilitation in Brisbane, Australia. Using the Barthel Index as a measure of activities of daily living functions, the study then compares the performances and outcomes of stroke patients between Australia, Japan, the United Kingdom and the United States of America.

Family carers in stroke care: examining the relationship between problem-solving, depression and general health

AIMS AND OBJECTIVES

The purpose of this article is to describe the problem-solving abilities of Hong Kong family carers looking after a stroke patients at home and report the relationships between their perceived problem-solving abilities with their depression level, general health status, and the functional recovery of stroke patients.

BACKGROUND

Previous research on supportive interventions for caregiving in stroke care suggests that enhancing carers' problem-solving abilities is useful. Nevertheless, not much is known about the relationship between carers' problem-solving abilities and their physical and psychosocial health and there is notably little work that has been done with the Chinese population.

DESIGN

A cross-sectional and correlational design was used.

METHODS

A convenience sample of 70 family carers, who were the main carers of stroke patients at home, during the first three months poststroke was recruited to complete a self-report questionnaire.

RESULT

Significant correlations were found between the family carers' global perceived problem-solving abilities and higher level of depressive symptoms (r = 0.35, P = 0.01) and poorer perceived health (r = 0.50, P = 0.01) as measured using the Center for Epidemiological Studies - Depression Scale and General Health Questionnaire. Among the three subscales of the Problem-Solving Inventory, problem-solving confidence showed the highest correlation with these variables. The functional ability of the stroke patients as measured using the Modified Barthel Index (MBI) was not associated with any variables.

CONCLUSION

Findings of this study suggest that perception of confidence is a key factor in appraisal of problem-solving among Chinese family carers, which raises questions for future research about the impact of cultural influences on designing and measuring interventions.

RELEVANCE TO CLINICAL PRACTICE

The study has implications for nursing and health care practice and for developing interventions targeted at building self-confidence among Chinese carers.

Balance and mobility outcomes for stroke patients: a comprehensive audit

This paper reports the in-patient rehabilitation admission and discharge scores on a comprehensive series of balance and mobility measures for 109 stroke patients (49.5 per cent female) with a mean (SD) age of 72.9 (10.4). The results reflect good outcomes regarding discharge destination (77 per cent discharged to own or families' home), and all balance and mobility measures improved significantly during rehabilitation (p<0.05). However, when performance at discharge was compared with values reported for healthy older people, the dynamic balance and mobility measures identified marked residual problems. Only 7 per cent of patients met all four criteria defined for independent community ambulation. These results are discussed in the context of modifying clinical practice to improve community ambulation outcomes for stroke patients.

Stroke rehabilitation: patient activity during non-therapy time

Since practice is a crucial variable in motor learning, this study aimed to quantify the level of motor activity during inpatient stroke rehabilitation and to investigate the relationship between level of motor ability with performance of motor activity. Seventeen stroke patients were observed on nine weekdays in a fast-stream rehabilitation hospital. The results showed that for two-thirds of the day, patients were not involved in structured therapy and that for half of these observations, the patients were not engaged in motor activities. There was a positive correlation (rho=0.68, p<0.05) between patients' performance of motor activity and a total Functional Independence Measure score. It appears that strategies are required so that, regardless of the level of disability, patients can be practising at an appropriate level.

Social issues in the rehabilitation of younger stroke patients

OBJECTIVES

To study social factors and outcomes in stroke rehabilitation patients under the age of 50.

STUDY DESIGN

Retrospective chart review examining (1) martial status and employment status on admission and at 3 months post discharge, (2) discharge destination, (3) the presence of absence of children under the age of 16, and (4) psychosocial difficulties as recorded by staff during hospitalization.

SUBJECTS AND SETTING

Eighty-three consecutive stroke patients under the age of 50 admitted to a Canadian tertiary-care hospital rehabilitation unit.

MAIN OUTCOME MEASURES

Discharge destination and primary caregiver at discharge, and return to work and marital separation 3 months after rehabilitation discharge.

RESULTS

Of the 55 patients with spouses, 8 (14.5%) separated within 3 months of hospital discharge. Fifteen of the 83 patients (18.1%) were not able to return to their premorbid place of residence; 4 (4.8%) required institutionalization. Of the 64 patients employed outside the home or studying at the time of their stroke, only 13 (20.3%) were able to return to work within 3 months of their discharge to home. Only 9.4% of those working full-time were able to return to full-time employment.

CONCLUSIONS

Rehabilitation of young stroke patients is associated with a variety of social problems, including marital breakup, child care responsibilities, and return to employment, which are uniquely important in this age group.

Prediction of gait velocity in ambulatory stroke patients during rehabilitation

OBJECTIVE

To quantify prediction of gait velocity in ambulatory stroke patients during rehabilitation.

DESIGN

Single group (n = 42) at the beginning of rehabilitation (Test 1) and 8 weeks later (Test 2).

SETTING

Inpatient rehabilitation.

PATIENTS

Unilateral first stroke; informed consent; able to walk 10 meters.

MEASURES

INDEPENDENT VARIABLES

Gait velocity at Test 1, age, time from stroke to Test 1, side of lesion, neglect.

DEPENDENT VARIABLES

Gait velocity at Test 2, gait velocity change.

RESULTS

The correlation between initial gait velocity and gait velocity outcome at Test 2 was of moderate strength (r2 = .62, p<.05). However, even at its lowest, the standard error of prediction for an individual patient was 9.4 m/min, with 95% confidence intervals extending over a range of 36.8 m/min. Age was a weak predictor of gait velocity at Test 2 (r2 = -.10, p<.05). Gait velocity change was poorly predicted. The only significant correlations were initial gait velocity (r2 = .10, p<.05) and age (r2 = .10, p<.05).

CONCLUSION

While the prediction of gait velocity at Test 2 was of moderate strength on a group basis, the error surrounding predicted values of gait velocity for a single patient was relatively high, indicating that this simple approach was imprecise on an individual basis. The prediction of gait velocity change was poor. A wide range of change scores was possible for patients, irrespective of their gait velocity score on admission to rehabilitation.

Identification of stroke prone patients by panoramic radiography

Stroke (cerebrovascular accident, CVA) is the third leading cause of death and an important cause of hospital admission and long term disability in Australia. Atherosclerotic lesions at the bifurcation of the common carotid artery are the most common cause of stroke. On occasion these lesions are partially calcified and visible on a conventional panoramic dental radiograph. The atheroma may appear either as a nodular radiopaque mass or as two radiopaque vertical lines within the soft tissues of the neck at the level of the lower margin of the third cervical vertebra (C3). These opacities are separate and distinct from the hyoid bone and variably appear above or below it. Dentists should scrupulously review the panoramic radiographs of all individuals over age 55 with medical histories of hypertension, diabetes mellitus, hypercholesteraemia and coronary artery disease, or whose behaviour includes smoking, ethanol abuse, or dietary indiscretion coupled with overweight and a sedentary lifestyle which are known to be associated with atherosclerosis and stroke.

Nonmedical bed-days for stroke patients admitted to acute-care hospitals in Montreal, Canada

BACKGROUND AND PURPOSE

Reducing the amount of nonoptimal time stroke patients spend in the hospital should be a priority because prolonged hospitalization is not only costly but may be detrimental for persons with stroke through deconditioning, social isolation, and the fostering of dependent relationships. The purpose of this study was to determine the amount of time spent by stroke patients in acute-care hospitals that was not justified for medical reasons and to identify mechanisms contributing to nonmedical bed-days.

METHODS

A retrospective cohort study was performed with 2232 persons admitted for acute stroke to one of 13 hospitals in Montreal, Canada, during 1991. Information was collected on the patient, the stroke, functional status, course in hospital, services, and discharge. Nonmedical bed-days were calculated as the difference between the time to meet specified criteria and time of discharge. Associations with nonmedical bed-days were estimated with adjustment for patient mix.

RESULTS

Acute-care stay averaged 27 days, yielding 60,279 bed-days. Almost 50% of the cohort remained in the hospital after meeting criteria for medical discharge, resulting in 43% of total bed-days not accounted for medically. Fifty percent of persons with delayed discharge did not go home but were discharged to another acute-care hospital or to rehabilitation or long-term care, accounting for 66% of the nonmedical bed-days. Hospital and discharge destination remained strongly associated with nonmedical days, even after adjustment for patient mix.

CONCLUSIONS

The single greatest contributor to excessive nonmedical stay appeared to be the need in Quebec for increased access to alternate levels of care, including skilled nursing facilities and rehabilitation centers.

Deficit and change in gait velocity during rehabilitation after stroke

OBJECTIVE

To quantify the initial deficit, change, and outcome in gait velocity during inpatient rehabilitation following stroke.

DESIGN

The initial deficit on admission to rehabilitation was quantified by comparing 42 stroke patients with 42 controls matched by gender and age. The change in the stroke patients during the next 8 weeks was quantified and gait outcome was compared with functional and normal criteria.

SETTING

Patients were referred from four inpatient rehabilitation centers at the time of admission following a median of 16.5 days in the acute hospital.

PATIENTS

SELECTION CRITERIA

ability to give informed consent; unilateral first stroke; ability to walk 10 meters.

INTERVENTION

Patients participated in a median of 17.38 hours of individual physical therapy including a median of 6.92 hours of gait training during the 8 weeks.

MAIN OUTCOME MEASURE

Gait velocity.

RESULTS

Gait velocity was initially 38.6% (26.7m/min SD = 14.9) of the performance of controls and improved to 55.1% (38.1m/min). At outcome only 24% exceeded the 5th percentile of controls (48.1m/min) or the velocity required to cross the typical signalled intersection (46.2m/min). The change was only 26% of the initial deficit. Fifty-five percent of the patients improved beyond the 95% confidence intervals surrounding the error of measuring change. Indices of responsiveness indicated that there was a high signal-to-noise ratio and a robust effect size.

CONCLUSION

Gait velocity discriminated the effect of stroke and the change during rehabilitation.

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.

The Western Sydney Stroke Risk in the Elderly Study. A 5-year prospective study

Aging of the Australian population, as in other developed nations, will ensure that stroke remains one of the most important causes of death and disability. The Stroke Risk in the Elderly (SITE) study aims to measure prospectively the independent contribution of dietary, sociodemographic, blood lipid, blood pressure, and hemostatic factors to risk of stroke and other cardiovascular outcomes. The target population included all independently living men and women aged 65 years and over, residents in several retirement villages in western metropolitan Sydney, New South Wales, Australia. The study cohort consists of 225 men and 787 women, selected as a convenience sample from all eligible residents in the local government areas (LGAs) adjacent to Westmead Hospital. Participants attended a baseline session to complete dietary, life-style, medical, and sociodemographic questionnaires. Anthropomorphic variables and blood pressure were measured. Blood was taken for measurement of serum lipid, glucose, and hemostatic factors. Questionnaire results were compared with an age/sex-stratified, randomly selected sample drawn from the community (in the same LGAs), in order to quantify potential sampling and selection biases. The study cohort will be followed for a minimum of 5 years. The attendance rate of eligible residents for a baseline medical, dietary, life-style, and sociodemographic assessment was 72% for males and 69% for females. The study cohort was older, better educated, less ethnically diverse, and among women, less likely to have ever been married compared to people aged over 65 years in the comparison group. The baseline results suggest that hemostatic factors may be of importance in assessing risk of cardiovascular disease, (CVD), particularly in older men.(ABSTRACT TRUNCATED AT 250 WORDS)

A model for management of patients with stroke during the acute phase. Outcome and economic implications

BACKGROUND AND PURPOSE

The purpose of the study was to develop a clinical pathway for patients with nonhemorrhagic stroke during the acute hospital phase to improve the quality of care and reduce costs.

METHODS

The pathway included standard admission orders and a swallow screen on day 1 of hospitalization. Physical therapy, occupational therapy, speech therapy, and social worker assessments were done on day 2. A physiatry consult was performed on day 3 if indicated, and by day 4 a discharge target date and disposition were addressed.

RESULTS

Outcomes for 121 patients during the first year of pathway implementation are reported. The average length of stay on the acute service decreased from 10.9 days to 7.3 days (P < .05), reducing the charges per patient by 14.6%. Complications in the form of urinary tract infections and aspiration pneumonia rates decreased by 63.2% (P < .05) and 38.7%, respectively.

CONCLUSIONS

We conclude that the implementation of a clinical pathway for patients with acute, nonhemorrhagic stroke resulted in a significant reduction in length of stay, charges, and complications while improving the quality of care.

Ascertaining the true incidence of stroke: experience from the Perth Community Stroke Study, 1989-1990

OBJECTIVE

To determine the age and sex specific incidence, and case fatality of stroke in Perth, Western Australia.

DESIGN AND SETTING

A population-based descriptive epidemiological study.

SUBJECTS

All residents of a geographically defined segment of the Perth metropolitan area (population 138,708) who had a stroke or transient ischaemic attack between 20 February 1989 and 19 August 1990, inclusive.

MAIN OUTCOME MEASURES

Definite acute "first-ever-in-a-lifetime" (first-ever) and recurrent stroke classified according to standard definitions and criteria.

RESULTS

During the 18-month study period, 536 stroke events occurred among 492 patients, 69% of which were first-ever strokes. The crude annual event rate for all strokes was 258 (95% confidence interval 231-285) per 100,000, and the overall case fatality at 28 days was 24% (95% CI, 20%-28%). The crude annual incidence for first-ever strokes was 178 (95% CI, 156-200) per 100,000; 189 (95% CI, 157-221) per 100,000 in males and 166 (95% CI, 136-196) per 100,000 in females. The corresponding rates, age-adjusted to the "world" population, were 132 (95% CI, 109-155) for males and 77 (95% CI, 60-94) for females.

CONCLUSIONS

In contrast to mortality rates for ischaemic heart disease, the incidence of stroke in Australia appears little different from that for several other Western countries. For both males and females the incidence of stroke rises exponentially with increasing age. Although the sex-dependent difference in the risk of stroke is greatest in middle age, males are at greater risk of stroke even among the most elderly. To determine the incidence of stroke accurately, population-based studies of stroke need exhaustive and overlapping sources of case ascertainment. If only cases admitted to hospital had been used, we would have underestimated the rate of stroke among the most elderly by almost 40%. We estimate that approximately 37,000 people, about 50% of whom are over the age of 75, suffer a stroke each year in Australia.

Acute stroke outcome: effects of stroke type and risk factors

We studied 925 consecutive patients hospitalised with acute stroke to determine how stroke type, age, gender and risk factors influence acute, in-hospital outcome. Stroke types included carotid territory cortical or large subcortical infarction (52%), vertebrobasilar infarction (12%), lacunar infarction (11%), intracerebral haemorrhage (16%), and subarachnoid haemorrhage (9%). Mean age (mean +/- 1 SD) was 66 +/- 15 years, but patients with cerebral infarction were older than those with cerebral haemorrhage. The prevalence of hypertension, diabetes mellitus and cardiac disease increased with age across all stroke types, while the prevalence of smoking decreased with age. Mortality was 19% overall, but varied significantly between stroke types, highest in intracerebral haemorrhage (34%), and lowest in lacunar infarction (1%). Age had a marked adverse effect on mortality, independent of stroke type, the probability of death increasing by 3 +/- 0.5% per year from 20-92 years, whereas gender had no effect. Cardiac disease and diabetes were independent adverse prognostic factors (Odds Ratios 1.6 and 1.5 respectively). Cerebral haemorrhage, age, cardiac disease and diabetes all independently worsen acute stroke outcome.

Stroke rehabilitation: Australian patient profile and functional outcome

A prospective, multi-institutional, population based study identified 1274 non-surgical stroke admissions to all hospitals in a major Australian city during 1984. The demographic and diagnostic profile and the nature of functional recovery of all 258 first stroke survivors who were referred for inpatient rehabilitation are presented. The median duration of rehabilitation stay was 49 days. The mean functional independence score, as measured on a modified Barthel Index at admission was 44, compared with 78 on discharge, a mean improvement of 34. Stair climbing had the lowest mean value on admission (12), while bowel control had the lowest residual deficit on discharge (95). The stroke study group was representative of the unimpaired aged population in all respects except ethnicity, where differences are attributed to age. The variables identified as significant are; side and severity of paralysis, age and sex, marital status and ethnicity. Stroke rehabilitation outcome was not influenced by etiology, site of lesion, arterial distribution, occupation or education.

Efficiency, effectiveness, and duration of stroke rehabilitation

This prospective multicenter study identifies the variables significant in the prediction of rehabilitation efficiency, achievement of rehabilitation potential and duration of rehabilitation stay in 258 persons with a first stroke admitted to comprehensive inpatient rehabilitation in Brisbane, Australia, during 1984. All three dependent variables were poorly predicted, with only 17% of the variance in rehabilitation efficiency, only 30% of the variance in achievement of rehabilitation potential, and only 22% of the variance in duration of rehabilitation stay explained. Unlike other reports, we considered most of the major medical (side of paralysis, stroke etiology, site of the lesion, arterial distribution affected, etc.), rehabilitative (initial Barthel Index score, interval from stroke onset to acute-care hospital admission, interval from hospital admission to rehabilitation commencement, neurologic measures, etc.), and demographic (age, years of education, occupation, ethnicity, etc.) variables. The high proportion of unexplained variance is likely to be due to nonmedical factors influencing the selection of patients for rehabilitation.