Impact of Delirium on Outcomes After Intracerebral Hemorrhage

Stroke ◽  
2021 ◽  
Author(s):  
Michael E. Reznik ◽  
Seth A. Margolis ◽  
Ali Mahta ◽  
Linda C. Wendell ◽  
Bradford B. Thompson ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Hospital Discharge ◽  
Inpatient Rehabilitation ◽  
Nursing Facilities ◽  
Skilled Nursing ◽  
Logistic Regression Models ◽  
Mediating Role ◽  
Discharge Site ◽  
Postacute Care ◽  
The Impact

Background and Purpose: Delirium portends worse outcomes after intracerebral hemorrhage (ICH), but it is unclear if symptom resolution or postacute care intensity may mitigate its impact. We aimed to explore differences in outcome associated with delirium resolution before hospital discharge, as well as the potential mediating role of postacute discharge site. Methods: We performed a single-center cohort study on consecutive ICH patients over 2 years. Delirium was diagnosed according to DSM-5 criteria and further classified as persistent or resolved based on delirium status at hospital discharge. We determined the impact of delirium on unfavorable 3-month outcome (modified Rankin Scale score, 4–6) using logistic regression models adjusted for established ICH predictors, then used mediation analysis to examine the indirect effect of delirium via postacute discharge site. Results: Of 590 patients (mean age 70.5±15.5 years, 52% male, 83% White), 59% (n=348) developed delirium during hospitalization. Older age and higher ICH severity were delirium risk factors, but only younger age predicted delirium resolution, which occurred in 75% (161/215) of ICH survivors who had delirium. Delirium was strongly associated with unfavorable outcome, but patients with persistent delirium fared worse (adjusted odds ratio [OR], 7.3 [95% CI, 3.3–16.3]) than those whose delirium resolved (adjusted OR, 3.1 [95% CI, 1.8–5.5]). Patients with delirium were less likely to be discharged to inpatient rehabilitation than skilled nursing facilities (adjusted OR, 0.31 [95% CI, 0.17–0.59]), and postacute care site partially mediated the relationship between delirium and functional outcome in ICH survivors, leading to a 25% reduction in the effect of delirium (without mediator: adjusted OR, 3.0 [95% CI, 1.7–5.6]; with mediator: adjusted OR, 2.3 [95% CI, 1.2–4.3]). Conclusions: Acute delirium resolves in most patients with ICH by hospital discharge, which was associated with better outcomes than in patients with persistent delirium. The impact of delirium on outcomes may be further mitigated by postacute rehabilitation.

scholarly journals Comparison of Functional Status Improvements Among Patients With Stroke Receiving Postacute Care in Inpatient Rehabilitation vs Skilled Nursing Facilities

2019 ◽  
Vol 2 (12) ◽  
pp. e1916646 ◽  
Author(s):  
Ickpyo Hong ◽  
James S. Goodwin ◽  
Timothy A. Reistetter ◽  
Yong-Fang Kuo ◽  
Trudy Mallinson ◽  
...  
Keyword(s):  
Functional Status ◽  
Inpatient Rehabilitation ◽  
Skilled Nursing Facilities ◽  
Nursing Facilities ◽  
Skilled Nursing ◽  
Postacute Care

scholarly journals Divergent poststroke outcomes for black patients

Neurology ◽  
2019 ◽  
Vol 93 (18) ◽  
pp. e1664-e1674 ◽  
Author(s):  
James F. Burke ◽  
Chunyang Feng ◽  
Lesli E. Skolarus
Keyword(s):  
Racial Differences ◽  
Care Setting ◽  
Inpatient Rehabilitation ◽  
Functional Independence ◽  
Fee For Service ◽  
Primary Analysis ◽  
Skilled Nursing ◽  
Black Patients ◽  
Postacute Care ◽  
White Patients

ObjectiveTo explore racial differences in disability at the time of first postdischarge disability assessment.MethodsThis was a retrospective cohort study of all Medicare fee-for-service beneficiaries hospitalized with primary ischemic stroke (ICD-9,433.x1, 434.x1, 436) or intracerebral hemorrhage (431) diagnosed from 2011 to 2014. Racial differences in poststroke disability were measured in the initial postacute care setting (inpatient rehabilitation facility, skilled nursing facility, or home health) with the Pseudo-Functional Independence Measure. Given that assignment into postacute care setting may be nonrandom, patient location during the first year after stroke admission was explored.ResultsA total of 390,251 functional outcome assessments (white = 339,253, 87% vs black = 50,998, 13%) were included in the primary analysis. At the initial functional assessment, black patients with stroke had greater disability than white patients with stroke across all 3 postacute care settings. The difference between white and black patients with stroke was largest in skilled nursing facilities (black patients 1.8 points lower than white patients, 11% lower) compared to the other 2 settings. Conversely, 30-day mortality was greater in white patients with stroke compared to black patients with stroke (18.4% vs 12.6% [p < 0.001]) and a 3 percentage point difference in mortality persisted at 1 year. Black patients with stroke were more likely to be in each postacute care setting at 30 days, but only very small differences existed at 1 year.ConclusionsBlack patients with stroke have 30% lower 30-day mortality than white patients with stroke, but greater short-term disability. The reasons for this disconnect are uncertain, but the pattern of reduced mortality coupled with increased disability suggests that racial differences in care preferences may play a role.

Abstract NS8: Increasing Discharges to Acute Rehabilitation With a Multidisciplinary Task Force

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Melissa M Mortin ◽  
Emily Perrinez ◽  
Simpson Sharp ◽  
Sarah Donnelly ◽  
Thomas Hemmen ◽  
...  
Keyword(s):  
Case Management ◽  
Task Force ◽  
Inpatient Rehabilitation ◽  
Admission Criteria ◽  
Nursing Facilities ◽  
Provider Education ◽  
Skilled Nursing ◽  
Team Meetings ◽  
Admission Rates ◽  
Family Social Support

Background: Patients with Acute Ischemic Stroke recover function better when discharged to inpatient rehabilitation (IRF) over skilled nursing facilities (SNF). We aimed to increase discharge to IRF over SNF at two Comprehensive Stroke Centers (CSC) within our care network. Methods: We reviewed the discharge pattern at our CSCs compared to comparable centers using GWTG benchmarking and designated a multidisciplinary task force aiming to meet discharge patterns at our centers to nationwide trends. The task force used Lean Methodology to identify barriers for IRF discharge recognition and placement. Results: The taskforce identified non-modifiable barriers such as socioeconomic determinants, insurance status, family/social support; and modifiable barriers such as inconsistencies in therapist recommendations and notations, limited access to case management, and lack of provider knowledge about IRF admission criteria. Beginning November 1, 2018, the following interventions were used to achieve increased IRF referral and admission rates: educating therapists to provide more specific and consistent documentation; thorough therapist, case management, and provider education on IRF admission criteria; cohorting patients on dedicated neurology units; and daily multidisciplinary team meetings (consisting of a therapist, case management, and the primary provider) on the neurology units. IRF admission rates were then collected retrospectively. Between Novembers 1, 2018 to April 30, 2019, the rate of admissions to IRF for the UCSD Health System increased from 7.7% to 13.5% (see Table). Conclusions: Using Lean Methodology we identified and reduced barriers for IRF referral after stroke. This suggests IRFs are underutilized when disposition is not effectively streamlined. Further studies are needed to understand which interventions had the highest impact of increasing IRF admission and referral rate.

Does Investor-Ownership of Nursing Homes Compromise the Quality of Care?

2002 ◽  
Vol 32 (2) ◽  
pp. 315-325 ◽  
Author(s):  
Charlene Harrington ◽  
Steffie Woolhandler ◽  
Joseph Mullan ◽  
Helen Carrillo ◽  
David U. Himmelstein
Keyword(s):  
Quality Of Care ◽  
Nursing Homes ◽  
Skilled Nursing Facility ◽  
Nurse Staffing ◽  
Care Quality ◽  
Nursing Facilities ◽  
Skilled Nursing ◽  
Staffing Ratios ◽  
The Impact

Quality problems have long plagued the nursing home industry. While two-thirds of U.S. nursing homes are investor-owned, few studies have examined the impact of investor-ownership on the quality of care. The authors analyzed 1998 data from inspections of 13,693 nursing facilities representing virtually all U.S. nursing homes. They grouped deficiency citations issued by inspectors into three categories (“quality of care,” “quality of life,” and “other”) and compared deficiency rates in investor-owned, nonprofit, and public nursing homes. A multivariate model was used to control for case mix, percentage of residents covered by Medicaid, whether the facility was hospital-based, whether it was a skilled nursing facility for Medicare only, chain ownership, and location by state. The study also assessed nurse staffing. The authors found that investor-owned nursing homes provide worse care and less nursing care than nonprofit or public homes. Investor-owned facilities averaged 5.89 deficiencies per home, 46.5 percent higher than nonprofit and 43.0 percent higher than public facilities, and also had more of each category of deficiency. In the multivariate analysis, investor-ownership predicted 0.679 additional deficiencies per home; chain-ownership predicted an additional 0.633 deficiencies per home. Nurse staffing ratios were markedly lower at investor-owned homes.

scholarly journals The Role of Rehabilitation in Cancer Treatment

2016 ◽  
Author(s):  
Jennifer Smith
Keyword(s):  
Survival Rate ◽  
Cancer Survivors ◽  
Cancer Patients ◽  
Inpatient Rehabilitation ◽  
Nursing Facilities ◽  
Skilled Nursing ◽  
Rehabilitation Professionals ◽  
Care Services ◽  
Physical Dysfunction ◽  
Therapy Services

In the past, persons diagnosed with cancer were thought to need to prepare for death. Currently, the five-year survival rate for all cancers has increased to 66.2% from 2005 to 2011 as compared to 49% from 1975 to 1977. This increased survival rate can be attributed to earlier diagnosis, improved treatments, and the supportive care provided today. Cancer has become one of the most disabling and costly conditions affecting Americans today. A prevalent cause of disability and emotional distress in cancer survivors is physical dysfunction, and cancer survivors frequently report many unmet needs. This information suggests potential opportunities for rehabilitation professionals to help meet the needs of cancer patients. Rehabilitation for cancer patients may occur along the continuum of care including acute care services, inpatient rehabilitation facilities, skilled nursing facilities, home- health and outpatient therapy services. This editorial describes how rehabilitation professionals could become involved in the care of patients dealing with a diagnosis of cancer.

Abstract P440: Inpatient Blood Pressure Variability is Associated With Mortality and Poor Functional Outcome in Patients With Intracerebral Hemorrhage

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Evangelos Pavlos Myserlis ◽  
Jessica R Abramson ◽  
Haitham Alabsi ◽  
Christopher D Anderson ◽  
Alessandro Biffi ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Intracerebral Hemorrhage ◽  
Functional Outcome ◽  
Blood Pressure Variability ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Poor Functional Outcome ◽  
Logistic Regression Models ◽  
Established Risk Factor ◽  
The Impact

Introduction: Although elevated blood pressure (BP) is an established risk factor for intracerebral hemorrhage (ICH), the impact of acute BP fluctuations on ICH outcomes remains unclear. In this study, we sought to investigate the effect of acute BP variability (BPV) on mortality and functional outcome in ICH survivors. Methods: Subjects were consecutive ICH patients ≥ 18 years with available inpatient BP data, who survived hospitalization. Four measures of systolic BPV were calculated: standard deviation (SD), coefficient of variation (CoV), average real variability (ARV), and successive variation (SV). Our outcomes were (1) death and (2) poor functional outcome, defined as a modified Rankin Score (mRS) of 3-6 in a period between 60-120 days after discharge. We assessed the effect of hyperacute (ICH event-72 hours) and acute/subacute (72 hours-discharge) BPV on outcomes. We constructed Cox proportional hazards and logistic regression models to investigate the associations of BPV (per 10 mmHg increase) with mortality and poor functional outcome, respectively, after adjustment for potential confounders. Results: We included 345 patients, 120 of whom had available mRS data. 151 (43.8%) patients were female and 280 (81.2%) were white; mean age was 71 (±13) years. SBP ARV and SBP SV were the strongest predictors of mortality (HR 2.53-2.91 per 10 mmHg increase), while SBP SD, CoV, and SV were the strongest predictors of poor functional outcome (OR 2.89-5.14 per 10 mmHg increase) (Table) . These associations remained significant when analyzing both hyperacute as well as acute/subacute BPV. Compared to hyperacute BPV, acute/subacute BPV was more strongly associated with both mortality and poor functional outcome. Conclusion: Inpatient blood pressure variability is an important determinant of mortality and poor functional outcome in ICH survivors. Further studies are needed to investigate the role of addressing BPV as a potential target for intervention.

Abstract 12097: The Impact of a High-Performance Cardiopulmonary Resuscitation Protocol on Survival From Out-of-Hospital Cardiac Arrests Witnessed by Paramedics

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Ziad Nehme ◽  
Jocasta Ball ◽  
Melanie Villani ◽  
Michael Stephenson ◽  
Tony Walker ◽  
...  
Keyword(s):  
Cardiopulmonary Resuscitation ◽  
Hospital Discharge ◽  
High Performance ◽  
Population Based ◽  
Quality Improvement Intervention ◽  
Intervention Period ◽  
Logistic Regression Models ◽  
Improvement In Survival ◽  
Population Based Registry ◽  
The Impact

Introduction: Some emergency medical services (EMS) have shown increases in survival from out-of-hospital cardiac arrest (OHCA) following the implementation of a high-performance cardiopulmonary resuscitation (CPR) protocol. Despite this, little is known about the effect of high-performance CPR on OHCA witnessed by EMS personnel. Methods: We performed a retrospective cohort study of adult, EMS-witnessed OHCA patients of medical etiology from a population-based registry in Victoria, Australia. Patients treated after the introduction of a high-performance CPR protocol and training program between February 2019 and January 2020 were compared to historical controls between January 2015 and January 2019. The effect of the intervention on survival to hospital discharge was examined using logistic regression models adjusted for temporal and arrest factors. Results: A total of 1,561 and 420 EMS-witnessed OHCA patients were treated in the control and intervention periods, respectively. Baseline characteristics were similar across control and intervention periods, including the median age of cases (69 vs. 69 years, p=0.97), male sex (65.2% vs. 60.5%, p=0.08) and initial shockable arrests (33.7% vs. 29.3%, p=0.09). Resuscitation interventions were similar across groups, except for the use of mechanical CPR which declined during the intervention period (17.0% vs. 10.7%, p<0.001). Unadjusted survival to hospital discharge was similar across control and intervention periods for the overall population (29.4% vs. 32.1%, p=0.27), but significantly higher during the intervention period for initial shockable arrests (66.6% vs. 76.9%, p=0.03). After adjustment for confounders, cases in the intervention period were associated with a 43% increase (adjusted odds ratio [AOR] 1.43; 95% CI: 1.05, 1.94; p=0.02) in the risk-adjusted odds of survival to hospital discharge or a 79% increase (AOR 1.79, 95% CI: 1.09, 2.95; p=0.02) for initial shockable arrests. Conclusions: The implementation of a high-performance CPR quality improvement intervention was associated with significant improvement in survival from EMS witnessed OHCA. Efforts to monitor and improve CPR performance could yield further improvements in patient outcomes.

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