Abstract 46: An Innovative Approach to the Bedside Nursing Swallow Screening Tool: Can Be Used as a Trigger for an Inpatient Cognitive Evaluation to Improve Timeliness of Post-Discharge Cognitive Therapy Referrals

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Lorina Punsalang ◽  
Brenda Rojas ◽  
Chriselda Manalo ◽  
Denise Gaffney ◽  
Katherine Lapsys ◽  
...  
Keyword(s):  
Cognitive Therapy ◽  
Heart Association ◽  
Healthcare Facility ◽  
Inpatient Setting ◽  
Stroke Patients ◽  
Post Discharge ◽  
Cognitive Evaluation ◽  
Swallow Screening ◽  
Bedside Nursing ◽  
Level I

Background: According to the American Heart Association, a formal assessment of cognitive dysfunction caused by stroke is a level I recommendation. However, cognitive evaluation is often missed or overlooked in the inpatient setting. When and who performs the assessment is not well-defined. Stroke nurses can corroborate with clinicians in completing the Montreal Cognitive Assessment (MoCA) 8.1, a validated tool for assessing cognitive function in stroke patients. Purpose: The purpose of this study was to evaluate the process of using the bedside nursing swallow screen (NSS) as a trigger for an inpatient cognitive evaluation by the Speech Therapist (ST). This study was also used to determine if post-discharge cognitive therapy referrals were placed based on the MoCA scores. Methods: All STs completed the required MoCA certification. The new process was implemented in October 2019. Data were analyzed from October 2019 through March 2020. NSS was performed on newly admitted stroke patients. If failed, an ST consult was ordered for a dysphagia evaluation. However, if passed, a cognitive evaluation consult was triggered by the RN. MoCA was completed within 24 hours. The total possible score is 30; a score of 26 or above is considered normal. A MoCA score of 25 or less, prompted a post-discharge cognitive therapy referral. Results: 229 patients were assessed, all of whom had an NSS completed. 120 (52.4%) passed the NSS, of which 85 (71%) completed a MoCA evaluation. 42 (49.4%) scored 25 or less, of which 35 (83.3%) were referred for a post-discharge cognitive therapy. 7 (17%) had no referral, of which 4 (57%) were discharged home to self-care; 2 (29%) discharged to other healthcare facility; and 1 (14%) left against medical advice. Conclusions: Repurposing the NSS as a standardized tool to trigger an inpatient MoCA evaluation was innovative, practical and efficient. Timely post-discharge cognitive therapy referrals were also evident on MoCA scores of 25 or less.

The shift from inpatient to outpatient hysterectomy for endometrial cancer in the United States: trends, enabling factors, cost, and safety

2021 ◽  
pp. ijgc-2020-002192
Author(s):  
Serena Cappuccio ◽  
Yanli Li ◽  
Chao Song ◽  
Emeline Liu ◽  
Gretchen Glaser ◽  
...  
Keyword(s):  
Endometrial Cancer ◽  
Abdominal Hysterectomy ◽  
The United States ◽  
Inpatient Setting ◽  
Significant Shift ◽  
Robotic Hysterectomy ◽  
Post Discharge ◽  
Enabling Factors ◽  
Healthcare Database ◽  
The Impact

ObjectiveTo evaluate trends in outpatient versus inpatient hysterectomy for endometrial cancer and assess enabling factors, cost and safety.MethodsIn this retrospective cohort study, patients aged 18 years or older who underwent hysterectomy for endometrial cancer between January 2008 and September 2015 were identified in the Premier Healthcare Database. The surgical approach for hysterectomy was classified as open/abdominal, vaginal, laparoscopic or robotic assisted. We described trends in surgical setting, perioperative costs and safety. The impact of patient, provider and hospital characteristics on outpatient migration was assessed using multivariate logistic regression.ResultsWe identified 41 246 patients who met inclusion criteria. During the time period studied, we observed a 41.3% shift from inpatient to outpatient hysterectomy (p<0.0001), an increase in robotic hysterectomy, and a decrease in abdominal hysterectomy. The robotic hysterectomy approach, more recent procedure (year), and mid-sized hospital were factors that enabled outpatient hysterectomies; while abdominal hysterectomy, older age, Medicare insurance, black ethnicity, higher number of comorbidities, and concomitant procedures were associated with an inpatient setting. The shift towards outpatient hysterectomy led to a $2500 savings per case during the study period, in parallel to the increased robotic hysterectomy rates (p<0.001). The post-discharge 30-day readmission and complications rate after outpatient hysterectomy remained stable at around 2%.ConclusionsA significant shift from inpatient to outpatient setting was observed for hysterectomies performed for endometrial cancer over time. Minimally invasive surgery, particularly the robotic approach, facilitated this migration, preserving clinical outcomes and leading to reduction in costs.

Abstract WP178: Acute Stroke Ischemic Symptom Onset-to-Arrival Time in Michigan Hospitals

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Muhammad U Farooq ◽  
Kathie Thomas
Keyword(s):  
African American ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Patient Outcomes ◽  
Symptom Onset ◽  
Arrival Time ◽  
Heart Association ◽  
The United States ◽  
Stroke Patients ◽  
White Patients

Objectives: Stroke is the fifth-leading cause of death and the leading cause of disability in the United States. One of the primary goals of the American Heart Association/American Stroke Association is to increase the number of acute stroke patients arriving at emergency departments (EDs) within 1-hour of symptom onset. Earlier treatment with thrombolysis in patients with acute ischemic stroke translates into improved patient outcomes. The objective of this abstract is to examine the association between the use of emergency medical services (EMS) and symptom onset-to-arrival time in patients with ischemic stroke. Methods: A retrospective review of ischemic stroke patients (n = 8873) from 25 Michigan hospitals from January 2012-December 2014 using Get With the Guidelines databases was conducted. Symptom onset-to-ED arrival time and arrival mode were examined. Results: It was found that 17.4% of ischemic stroke patients arrived at the hospitals within 1-hour of symptom onset. EMS transported 69.1% of patients who arrived within 1-hour of symptom onset. During this 1-hour period African American patients (22%) were less likely to use EMS transportation as compared to White patients (72%). The majority of patients, 41.8%, arrived after 6-hours of symptom onset. EMS transported only 40% of patients who arrived after 6-hours of symptom onset. As before, during this 6-hour period African American patients (20%) were also less likely to use EMS transportation as compared to White patients (75%). Symptom onset-to-ED arrival time was shorter for those patients who used EMS. The median pre-hospital delay time was 2.6 hours for those who used EMS versus 6.2 hours for those who did not use EMS. Conclusions: The use of EMS is associated with a decreased pre-hospital delay, early treatment with thrombolysis and improved patient outcomes in ischemic stroke patients. Community interventions should focus on creating awareness especially in minority populations about stroke as a neurological emergency and encourage EMS use amongst stroke patients.

Abstract 2848: Medication Knowledge And Assistance In Older Chronic Heart Failure Patients.

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Robyn Gallagher ◽  
Judith Donoghue ◽  
Lynn Chenoweth ◽  
Jane Stein-Parbury
Keyword(s):  
Heart Failure ◽  
New York ◽  
Chronic Heart Failure ◽  
Self Efficacy ◽  
Heart Association ◽  
Post Discharge ◽  
Medication Knowledge ◽  
Moderate Heart Failure ◽  
Association Class ◽  
New York Heart Association

Medication knowledge and assistance in older chronic heart failure (CHF) patients. Medication adherence is central to the optimal management of CHF. Little is known about older patients’ knowledge of their medications or the factors that contribute to this knowledge. Aim: To describe and identify the predictors of medication knowledge in older CHF patients. Method: Subjects ( n = 62) aged over 55 years with moderate heart failure (New York Heart Association Class II and III) who identified as self-managing were recruited from hospital or rehabilitation. Interviews occurred at home four weeks post-discharge using a medication checklist and the Self-Efficacy in Chronic Illness Scale (Lorig et al, 2001). Multiple regression analysis determined the predictors of medication knowledge. Results: Patients were aged mean 78.4 years (sd 8.54 years), mostly male (57%) and had an average 8 (median, range 3–22) medications to take daily, of which 6 (median, range 3–14) were for CHF. Most managed their own medications (54%) but more than a quarter (28%) were assisted by reminding, dispensing and supervision. Compliance with medications was high (84%), although only half (53%) knew the name, main purpose and side effect of their medications. Patients with better self-efficacy (β = 2.88) and no help with medication (β = -21.05) had better medication knowledge (model F = 13.6, p = .000, R = .61, r 2 = .37). Conclusion: Older CHF patients have poor knowledge of their medications, which may be improved by promoting overall self-efficacy for disease management. Less knowledgeable patients received appropriate assistance with medications, but the consequence may be less knowledge and thus warrants further investigation.

scholarly journals Emergency Medical Service Transport Times for Acute Stroke and Myocardial Infarction

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 373-373
Author(s):  
Kelly R Evenson ◽  
Trent B Legare ◽  
Emily B Schroeder ◽  
Jane H Brice ◽  
Wayne D Rosamond ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Medical Service ◽  
American Heart ◽  
Heart Association ◽  
Discharge Diagnosis ◽  
Diagnosis Code ◽  
Stroke Patients ◽  
Delivery Of Care ◽  
Emergency Medical ◽  
Wilcoxon Rank Sum Test

P188 It is currently recommended by the American Heart Association that both stroke and myocardial infarction (MI) patients be treated with urgency, as time dependent medical therapies are available for both conditions. Since stroke symptoms are often vague, it has been hypothesized that stroke patients may not be treated with the same urgency as MI patients by emergency medical services (EMS). To examine this hypothesis, EMS transport times were examined for both stroke and MI patients who used a paramedic-level, county based EMS system for transportation to a single hospital during 1999. Patients were identified by their hospital discharge diagnosis as stroke (ICD-9 430–438) or MI (ICD-9 410–414). Trip sheets with the corresponding transport times were retrospectively obtained from the 911 center. Thirteen patients with both a stroke and MI discharge diagnosis code were excluded from these analyses, leaving 75 stroke and 127 MI patients. While stroke patients were older than MI patients (median 81.1 vs. 73.3 years, p=0.01), the distribution of gender (56.9% women) and ethnicity (68.3% white) was not significantly different between stroke and MI patients. The use of lights and sirens to the scene (84.4%) and to the hospital (10.6%) also was not significantly different between stroke and MI patients. Mean EMS transport times are presented below in minutes, with the corresponding Wilcoxon rank sum test. In this study, all components of EMS transport times were similar for stroke and MI patients. Multiple linear regression predicting transport times confirmed these results. In this single county, EMS urgency for delivery of care was not different for stroke and MI patients.

Barriers to Providing Prehospital Care to Ischemic Stroke Patients: Predictors and Impact on Care

2018 ◽  
Vol 33 (5) ◽  
pp. 501-507 ◽  
Author(s):  
Timmy Li ◽  
Jeremy T. Cushman ◽  
Manish N. Shah ◽  
Adam G. Kelly ◽  
David Q. Rich ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Barriers To Care ◽  
Prehospital Care ◽  
Heart Association ◽  
Living Alone ◽  
Stroke Patients ◽  
Publication Type ◽  
Stroke Treatment ◽  
Significant Difference ◽  
The Impact

AbstractIntroductionIschemic stroke treatment is time-sensitive, and barriers to providing prehospital care encountered by Emergency Medical Services (EMS) providers have been under-studied.Hypothesis/ProblemThis study described barriers to providing prehospital care, identified predictors of these barriers, and assessed the impact of these barriers on EMS on-scene time and administration of tissue plasminogen activator (tPA) in the emergency department (ED).MethodsA retrospective cohort study was performed using the Get With The Guidelines-Stroke (GWTG-S; American Heart Association [AHA]; Dallas, Texas USA) registry at two hospitals to identify ischemic stroke patients arriving by EMS. Variables were abstracted from prehospital and hospital medical records and merged with registry data. Barriers to care were grouped into themes. Logistic regression was used to identify predictors of barriers to care, and bi-variate tests were used to assess differences in EMS on-scene time and the proportion of patients receiving tPA between patients with and without barriers.ResultsBarriers to providing prehospital care were documented for 15.5% of patients: 29.6% related to access, 26.7% communication, 23.0% extrication and transportation, 20.0% refusal, and 14.1% assessment/management. Non-white and non-black race (OR: 3.69; 95% CI, 1.63-8.36) and living alone (OR: 1.53; 95% CI, 1.05-2.23) were associated with greater odds of barriers to providing care. The EMS on-scene time was ≥15 minutes for 70.4% of patients who had a barrier to care, compared with 49.0% of patients who did not (P<.001). There was no significant difference in the proportion of patients who were administered tPA between those with and without barriers to care (14.1% vs 19.2%; P=.159).ConclusionsBarriers to providing prehospital care were documented for a sizable proportion of ischemic stroke patients, with the majority related to patient access and communication, and occurred more frequently among non-white and non-black patients and those living alone. Although EMS on-scene time was longer for patients with barriers to care, the proportion of patients receiving tPA in the ED did not differ.LiT, CushmanJT, ShahMN, KellyAG, RichDQ, JonesCMC. Barriers to providing prehospital care to ischemic stroke patients: predictors and impact on care. Prehosp Disaster Med.2018;33(5):501–507.

Abstract 146: Inpatient Rehabilitation Facility Care Reduces the Likelihood of Death and Rehospitalization After Stroke Compared with Skilled Nursing Facility Care

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Janet Prvu Bettger ◽  
Li Liang ◽  
Ying Xian ◽  
Eric D Peterson ◽  
Cheryl Bushnell ◽  
...  
Keyword(s):  
Proportional Hazards ◽  
Skilled Nursing Facility ◽  
Heart Association ◽  
Inpatient Rehabilitation ◽  
Sensitivity Analyses ◽  
Post Discharge ◽  
Skilled Nursing ◽  
Stroke Registry ◽  
Differential Outcomes ◽  
Variable Approach

Introduction: Accountable care and bundled payment initiatives have increased attention on inpatient post-acute care effectiveness. Empirical evidence for whether care at inpatient rehabilitation (IRF) or skilled nursing facilities (SNF) is associated with differential outcomes is limited. Methods: Data from the American Heart Association Get With The Guidelines-Stroke registry were linked with Medicare claims. We compared post-discharge mortality and a composite of all-cause rehospitalization or death for beneficiaries who received IRF or SNF care immediately after hospital discharge. Proportional hazards regression with inverse propensity weighting (IPW) was used to adjust for measured differences in demographic, clinical and hospital characteristics. Acknowledging the possibility of unmeasured differences between groups, an instrumental variable approach (IV=hospital-specific proportion of patients discharged to IRFs vs SNFs) was used to adjust for both measured and unmeasured confounding. Results: From 1,142 hospitals there were 34,574 AIS patients discharged to IRFs and 34,430 to SNFs. Patients receiving SNF vs IRF care were older (83 vs 79 years), had more comorbid illness, and higher unadjusted 7, 90, and 365 day mortality and rehospitalizations (Table). After IPW adjustment mortality and rehospitalization/mortality rates remained significantly better for patients with IRF vs SNF care (Table). Differences attenuated with IV analysis but IRF care continued to be associated with better outcomes (Table). Findings were similar in sensitivity analyses among patients with a NIHSS score. Conclusions: Receiving care at an IRF after AIS was associated with lower mortality and all-cause rehospitalization/death compared with SNF care even after rigorous adjustment for both measured and unmeasured differences in treatment selection. Further research is needed to discern the mechanisms for these potential differences between settings.

Abstract TP308: Transitional Care in Stroke Certified and Non-certified Hospitals: The Comprehensive Post-Acute Stroke Services (COMPASS) Study

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Janet Prvu Bettger ◽  
Sara Jones ◽  
Anna Kucharska-Newton ◽  
Janet Freburger ◽  
Walter Ambrosius ◽  
...  
Keyword(s):  
Transitional Care ◽  
Discharge Planning ◽  
Care Transitions ◽  
Cluster Randomized Trial ◽  
Stroke Patients ◽  
Care Needs ◽  
Post Discharge ◽  
Exact Test ◽  
Chi Squared

Background: Greater than 50% of stroke patients are discharged home from the hospital, most with continuing care needs. In the absence of evidence-based transitional care interventions for stroke patients, procedures likely vary by hospital even among stroke-certified hospitals with requirements for transitional care protocols. We examined the standard of transitional care among NC hospitals enrolled in the COMPASS study comparing stroke-certified and non-certified hospitals. Methods: Hospitals completed an online, self-administered, web-based questionnaire to assess usual care related to hospitals’ transitional care strategy, stroke program structural components, discharge planning processes, and post-discharge patient management and follow-up. Response frequencies were compared between stroke certified versus non-certified hospitals using chi-squared statistics and Fisher’s exact test. Results: As of July 2016, the first 27 hospitals enrolled (of 40 expected) completed the survey (67% certified as a primary or comprehensive stroke center). On average, 54% of stroke patients were discharged home. Processes supporting hospital-to-home care transitions, such as timely follow-up calls and follow-up with neurology, were infrequent and overall less common for non-certified hospitals (Table). Assessment of post-discharge outcomes was particularly infrequent among non-certified sites (11%) compared with certified sites (56%). Uptake of transitional care management billing codes and quality metrics was low for both certified and non-certified hospitals. Conclusion: Significant variation exists in the infrastructure and processes supporting care transitions for stroke patients among COMPASS hospitals in NC. COMPASS as a pragmatic cluster-randomized trial will compare outcomes among hospitals that implement a CMS-directed model of transitional care with those hospitals that provide highly variable transitional care services.

Abstract TP379: “Build It and They Will Come”: How Comprehensive Stroke Certification Increases the Number of Transfers

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Betty Robertson
Keyword(s):  
Research Question ◽  
Heart Association ◽  
Fold Increase ◽  
Joint Commission ◽  
Level Of Care ◽  
Stroke Patients ◽  
Full Spectrum ◽  
Specialized Care ◽  
High Level

Introduction/Background: Stroke is the leading cause of long-term disability affecting 800,000 people in the U.S. each year. In September 2012 The Joint Commission, in collaboration with the American Heart Association/American Stroke Association’s Brain Attack Coalition, launched the Advanced Certification for Comprehensive Stroke Centers (CSCs). This new level of certification recognizes the significant resources in staff and training that comprehensive stroke centers must have to treat complex stroke. Certification is available only to comprehensive stroke centers in Joint Commission-accredited acute care hospitals. For CSC eligibility, there are numerous requirements and volumes that must be met. The most complicated stroke cases should be treated at the centers best equipped to provide specialized care that lead to better outcomes. Cedar-Sinai became the 4 th program in the nation to receive this prestigious certification. By providing expert care, numerous clinical trials, and high level treatment and procedures, we have become the center of choice for patients in need of a higher level of care. Research Question: Does comprehensive stroke certification lead to an increased number of transfers for higher level of care? Methods: Retrospective analysis of the number of acute strokes transferred to Cedars-Sinai between the first years of Comprehensive Stroke Certification in 2012 through 2015. Results: 2012 yielded a total transfer of 97 patients. In 2015 the volume had risen to 194, a 50% increase in 4 years. It is important to note that in 2014, 4 patients were transferred post TPA infusion (Drip and Ship), the gold standard for treatment of ischemic stroke. 2015 resulted in 25 such transfers, a six fold increase. Conclusion: The full spectrum and coordination of services that a CSC is equipped to provide contributes to increased access of specialized care for complex stroke patients. This in turn leads to better outcomes. This not only translates to delivery of timely optimal treatment for stroke patients, but also increases our expertise in delivery of this care.

Potentially Preventable Hospital Readmissions After Patients’ First Stroke—A National Population-Based Study In Taiwan

2021 ◽  
Author(s):  
Ling-Jan Chiou ◽  
Hui-Chu Lang
Keyword(s):  
Hospital Readmission ◽  
Discharge Planning ◽  
Multinomial Logistic Regression ◽  
Hospital Readmissions ◽  
Care Program ◽  
Severity Index ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Post Discharge ◽  
Important Indicator

Abstract Readmission is an important indicator of the quality of care. The purpose of this study was to explore the probabilities and predictors of 30-day and 1-year potentially preventable hospital readmission (PPR) after a patient’s first stroke. We used claims data from the National Health Insurance (NHI) from 2010 to 2018. Multinomial logistic regression was used to assess the predictors of 30-day and 1-year PPR. A total of 41,921 discharged stroke patients was identified. We found that hospital readmission rates were 15.48% within 30-days and 47.25% within 1-year. The PPR and non-PPR were 9.84% (4,123) and 5.65% (2,367) within 30-days, and 30.65% (12,849) and 16.60% (6,959) within 1-year, respectively. The factors of older patients, type of stroke, shorter length of stay, higher Charlson Comorbidity Index (CCI), higher stroke severity index (SSI), hospital level, hospital ownership, and urbanization level were associated significantly with the 30-day PPR. In addition, the factors of gender, hospitalization year, and monthly income were associated significantly with 1-year PPR. The results showed that better discharge planning and post-discharge follow-up programs could reduce PPR substantially. Also, implementing a post-acute care program for stroke patients has helped reduce the long-term PPR in Taiwan.

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