Stroke linked to accelerated decline in cognition

Stroke survivors experience declines in cognitive function both acutely and over the long term, says a US study that suggests survivors should be monitored for cognitive impairment in the years after a stroke. Researchers studied cognitive changes in 23,572 stroke survivors without baseline cognitive impairment over six years.
			Stroke survivors had faster declines in global cognition compared with those without stroke, and compared with their pre-stroke rate of decline

Increased mortality, morbidity and costs 

Stroke was associated with a decline in global cognition, new learning and verbal memory, they found. Stroke survivors had faster declines in global cognition compared with those without stroke, and compared with their pre-stroke rate of decline, according to findings in JAMA.

The authors said the decline in global cognition and executive function significantly increased the risks of mortality, dementia, depression and accelerated functional decline, which in turn was associated with patients being institutionalised and extra burden on caregivers.

The finding had implications for clinical practice, research and healthcare policy, they wrote. They suggested cognitive assessments be performed before stroke patients were discharged from hospital and in post-acute settings. Long-term monitoring of survivors’ cognitive function was also warranted.

“As adults increasingly survive stroke, cases of post-stroke cognitive impairment will multiply,” the authors said. “Given that post-stroke cognitive impairment increases mortality, morbidity and health care costs, health systems and payers will need to develop cost-effective systems of care that will best manage the long-term needs and cognitive problems of this increasing and vulnerable stroke survivor population.”

Study urges rethink on early mobilisation after stroke

The practice of getting patients out of bed and mobilised as soon as possible after acute stroke has been thrown into doubt by a study that finds early mobilisation may actually reduce patients’ chances of a favourable outcome.

Early mobilisation – comprising out-of-bed sitting, standing and walking ‒ was thought to contribute to stroke care and recovery and was recommended by many guidelines, the researchers said.

In the AVERT study, 2104 patients were randomised to receive either very early mobilisation or usual care within 24 hours of onset of acute stroke.

In findings that surprised the researchers, fewer patients in the early mobilisation group (median time to mobilisation 18 hours after stroke onset) had a favourable outcome after three months than those in usual care (median time to mobilisation 22 hours after stroke onset).

Patients in the early mobilisation group had a 27% reduced chance of a good overall functional outcome at three months, as measured by the Rankin Scale that rates level of disability, according to findings in The Lancet.

The authors said future research priorities included looking at who responds to post-stroke treatment, who doesn’t and why.
And they said the findings should prompt a rethink of many guidelines on post-stroke care.

Data reveals stroke readmission risks

A picture has emerged of which patients are most likely to be readmitted to hospital within a year of having a stroke or transient ischaemic attack (TIA), after researchers linked data from the Australian Stroke Clinical Registry (AuSCR) and hospital databases.

Previous estimates of the frequency of readmission to hospital within the first year of stroke onset varied widely from 13% to 62%, the researchers said. They used linked data from the AuSCR at one Victorian hospital and datasets for admissions and emergency presentations in Victorian patients over an 18-month period to analyse the Australian readmission rate.

Data were successfully linked for 782 of 788 patients registered with AuSCR. Within one year of their stroke or TIA, the study found that 42% of patients were readmitted, 12% of whom went back to hospital due to stroke.

Patients who had initially had a TIA had twice the risk of being readmitted within one year, compared with patients with stroke, the study showed.

Findings in the MJA also revealed that patients were significantly more likely to be readmitted if they had presented to an emergency department two or more times before the index event, and if they had a high level of co-morbidities.

The researchers said the study showed that data linkage between the AuSCR and routine hospital datasets was feasible, and that it could identify determinants of hospital readmission for patients who had stroke or TIA.

Meanwhile, an editorial in the MJA suggested that promising recent findings on neurointervention to treat ischaemic stroke ‒ involving using advanced imaging to identify patients who were most likely to benefit from endovascular reperfusion ‒ were set to drive a revolution in stroke care.

The authors said the challenge was working out how to redesign Australian stroke services and how best to build capacity in the neurointerventional workforce.

GPs in the dark on abbreviations used in discharge letters

GPs do not understand many of the abbreviations commonly used in hospital discharge letters, according to an Australian study that calls for urgent strategies to clear up discharge letter miscommunication.

Researchers audited the use of abbreviations in 200 electronic discharge letters from Nepean Hospital in western Sydney to identify the 15 most commonly used abbreviations plus five less frequently used but clinically important abbreviations. They then surveyed 132 local GPs to determine their understanding of the abbreviations. 

Findings in the MJA showed that the following six abbreviations were misinterpreted by more than a quarter of GPs:

• SNP: soft non-tender ‒ interpreted incorrectly by 47% of GPs
• TTE: transthoracic echocardiogram ‒interpreted incorrectly by 33.3% of GPs
• EST: exercise stress test ‒ interpreted incorrectly by 33.3% of GPs
• NKDA: no known drug allergies ‒ interpreted incorrectly by 32.6% of GPs
• CTPA: computed tomography pulmonary angiogram ‒ interpreted incorrectly by 31.1%      of GPs
• ORIF: open reduction and internal fixation ‒ interpreted incorrectly by 28% of GPs

Misinterpretation of abbreviations by GPs could result in duplication of investigations or them failing to institute treatment based on investigation results or failing to follow up with recommended management, the authors warned.

One potential solution was to ban the use of abbreviations in electronic discharge letters, but that was impractical, they concluded.

Other solutions included creating a list of approved medical abbreviations for use in discharge letters and providing GPs with that list, or using medical software to auto-complete mutually exclusive abbreviations.

Weekend effect a “systematic phenomenon”

The heightened risk of death after admission to a hospital at the weekend ‒or “weekend effect” ‒ is a systematic phenomenon, according to a study which found it occurred across several developed countries’ healthcare systems.
			Risk of dying within 30 days after an emergency admission was between 8-20% higher if admitted at the weekend in three of the four countries

Impact on emergency admissions

The researchers used international data from the Global Comparators project to study almost 3 million admissions from 28 metropolitan teaching hospitals in Australia, England, the US and The Netherlands.

Findings in BMJ Quality and Safety showed that patients’ risk of dying within 30 days after an emergency admission was between 8% and 20% higher if they were admitted at the weekend in three of the four countries. While the Australian data showed no significant daily variation in the heightened risk of 30-day death for emergency admissions, it found patients admitted on a weekend had significantly higher odds of death seven days after emergency admission.

Patients who had elective surgery on a Friday, Saturday or Sunday had a higher risk of 30-day death compared with a Monday procedure, with Australian patients who had surgery on a Sunday facing twice the risk of 30-day death compared with those who had Monday surgery.

While the researchers cautioned that the findings were limited to a small number of hospitals, they said they suggested the ‘day-of-the-week’ effect was a systematic phenomenon affecting hospitals across international borders.

They surmised the weekend effect could be associated with reduced access to test results and diagnostics on weekends or perhaps to there being fewer and less experienced staff on weekends, but they urged further research into the factors behind the phenomenon.

The study was published as the UK NHS launched a controversial drive towards providing seven-day healthcare services. In an article on The Conversation,  Peter Silvey of LaTrobe University warned that evidence from overseas suggested forcing hospitals to provide all services equally distributed through the week was not the answer, with seven-day services coming at a high cost in relation to any health benefit.

Weekend discharge after major surgery doesn’t increase risk of readmission

While research shows that patients experience worse outcomes if they are admitted to hospital or have surgery on a weekend, those who are discharged on a Saturday or Sunday after major surgery do not have  an increased risk of readmission, a new study shows.

Researchers studied the “weekend-effect” on 30- and 90-day readmission rates among 128,057 Californian patients who had undergone abdominal aortic aneurysm (AAA) repair, colectomy, total hip arthroplasty and pancreatectomy. Overall, 23% of patients were discharged on a weekend.

Patients discharged on a weekend had shorter lengths of stay and were less often discharged to a skilled nursing facility than those discharged during the week.

However, hospital readmission rates were similar for those discharged on a weekend compared to those discharged on weekdays after AAA repair and pancreatectomy, and weekend discharge was associated with a lower 30-day readmission rate for patients undergoing colectomy and hip replacement.

“Contrary to our hypothesis, weekend discharge was not associated with an increased risk for hospital admission,” the authors wrote in JAMA Surgery.

They noted that a significant percentage of patients who were readmitted went to a different hospital than the discharging hospital.

The study concluded that hospitals with adequate staffing, appropriate coordination of care protocols and discharge systems in place could consider discharging postoperative patients on a weekend without concern that they would have a higher risk of being readmitted.

Increasing intensive care throughput

Simple changes to intensive care unit (ICU) processes for triaging and transferring patients can improve throughput without adversely affecting clinical outcomes, a study shows.

The researchers used process improvement methodology in an ICU which had 53 beds spread across four geographic locations in a 1400-bed tertiary care hospital.

A multidisciplinary working group of staff including ICU physicians, nurses, medical operations, transport administration, unit secretaries and chief internal medicine residents was tasked with creating a more efficient throughput process.

Changes they instituted included giving the ICU team the ultimate triaging authority for transferring patients, assigning patients moving out of ICU to any hospital bed if a bed on the respective services’ ward wasn’t immediately available, identifying patients suitable for transfer by 9am and giving the ICU team responsibility for writing transfer orders once a ward bed was assigned.

The findings, in the American Journal of Medical Quality, showed that the new processes reduced wait times for admissions, optimised the discharge of patients and reduced patients’ length of stay in both the ICU and the hospital.

The study estimated that the new processes saved an average of $US1947 per ICU admission, and the faster patient throughput translated into 157 additional admissions per year.

There was no increase in mortality or readmissions to the ICU.

“Though these processes might not apply to every hospital, this study has shown that interventions that decrease capacity can affect ICU LOS ([length of stay] and allow for the treatment of more critically ill patients,” the authors wrote.

Measures to halt spread of C. difficile fall short

A range of hospital-based strategies aimed at preventing the spread of the gastrointestinal infection Clostridium difficile are falling short, a new study finds, with patient-level factors found to be more significant.

C. difficile is the most common cause of healthcare-acquired infection, the Canadian researchers said, yet the real-world impacts of some of the prevention processes used by hospitals were unknown.

They analysed data on 650,000 patients admitted to Ontario’s 159 acute care hospitals over a year. C. difficile infection complicated 2341 admissions, and the hospitals’ implementation of prevention practices varied, they found.

The strategy of isolating all patients at onset of diarrhoea was adopted by 27% of hospitals, auditing of antibiotic stewardship compliance by 16%, auditing of cleaning practices by 72%, on-site diagnostic testing by 47%, use of vancomycin as first-line treatment by 15% and reporting infection rates to senior management by 33%, according to findings in BMJ Quality and Safety.

However, none of the prevention strategies were associated with significant reductions in the rate of C. difficile after adjustment for baseline infection rates.

The authors said patient characteristics, such as age, comorbidities and the patient’s type of admission (non-elective and medical admission) were the factors most strongly associated with the risk of acquiring the infection.

The researchers said the findings highlighted the need to better implement C. difficle prevention practices, as well as to assess the system-wide benefits of currently-used prevention processes. Research was needed to uncover other innovative ways of halting the spread of the infection, they added.

Coordinated care may not be the answer

A hospital-based coordinated care program for patients with chronic illness does not improve the quality of their life or reduce unplanned hospitalisations, despite it resulting in patients using almost twice as many community health services, an Australian study finds. In the study, 500 patients with chronic illness presenting to the emergency service at Nepean Hospital in Western Sydney were randomised to either standard care or to the Care Navigation (CN) program.
			Patients in the intervention group received almost twice as many community health services as those receiving standard care, mostly as a result of referrals from hospital, but there was no difference in their outcomes

Unplanned hospitalisations unchanged

Under the program, specialised nurses assessed the patients’ current health status and risk of readmission and directed them to the best method of care in the hospital or community. They also monitored the progress of the patients’ care in hospital and assessed their need for out-of-hospital care facilities, making   arrangements for the patients’ care after discharge.

Despite a growing body of evidence that the integration of patient care across primary, secondary and acute care could improve outcomes for people with chronic illness, the Care Navigation process failed to either improve the patients’ quality of life or reduce unplanned hospital presentations or admissions, according to findings in the MJA.

Patients in the intervention group received almost twice as many community health services (mainly nursing services) as those receiving standard care, mostly as a result of referrals from hospital, but there was no difference in their outcomes.

The researchers said that CN was an attempt to organise better coordination of the care for patients with chronic illness from a hospital base, but despite the patients receiving more community services, it was found to be no more effective than existing processes of care on any of the outcomes studied.

They concluded: “Future service development should explore potential benefits of linking navigated intrahospital care to ongoing, proactive care planning and delivery in the community.”