Lean: increase efficiency in stroke patient care

The early identification of performance in the five-repetition sit-to-stand test (5-STS) at discharge in stroke patients could be of interest because it can determine independence for community-based activities. This study aimed to determine whether the initial measurement of the 5-STS test can be a determinant of the performance level prediction and amount of change in the 5-STS test at discharge in stroke patients. A prospective cohort study was conducted with a sample of 56 patients aged ≤60 d post-stroke. The 5-STS test results, as well as changes in patient condition, were measured at admission (T0) to an outpatient rehabilitation program, after the first month (T1), and at discharge (T2). The mean age was 62.7 (SD = 13.0), 58.9% of the subjects were male, and 75% had suffered an ischemic stroke. A multivariate linear regression model using the 5-STS test at T0 explained 57.7% of the variance in the performance at discharge. Using the 5-STS at T1 increased the variance to 75.5% (p < 0.001). Only the time from stroke onset at T0 significantly contributed to the two models. The measurement of the 5-STS at T0 and the amount of change in its performance at T2 explained 60.2% (p < 0.001) of the variance, while reassessment at T1 explained only 19.3% (p < 0.001). The level of patient performance on the 5-STS test at discharge, as well as any potential change, can be predicted by the admission measure of 5-STS in stroke patients.

ObjectivesHome discharge is a crucial goal for stroke patients in convalescent rehabilitation wards. While previous studies have identified relationships between Functional Independence Measure (FIM) scores and home discharge outcomes using conventional statistical methods, these analyses have limitations in visualizing combinations of independent FIM items. This study aimed to identify combinations of independent motor FIM items associated with home discharge in stroke patients using UpSet plots.MethodsWe analyzed 205 stroke patients admitted to a convalescent rehabilitation ward between April 2018 and March 2021. Independence in motor FIM items was defined as a score of 6 or higher. We used UpSet plots to visualize combinations of independent motor FIM items at discharge and identified major combinations (occurring in >7% of cases) in the home discharge group.ResultsAmong 136 patients discharged to home, four major combinations of independent motor FIM items were identified: independence in all 13 items (22 patients, or 16.2%), independence in 12 items excluding stairs (18 patients, or 13.2%), independence in 10 items excluding bathing, tub transfer, and stairs (14 patients, or 10.3%), and dependence in all items (11 patients, or 8.1%). These combinations accounted for 47.8% of home discharge cases.ConclusionsThe visual analysis using UpSet plots revealed that, while higher levels of activities of daily living (ADL) independence increased the likelihood of home discharge, complete independence was not required. Dependence on specific items, such as bathing, tub transfer, and stairs, could be compensated through care services and environmental modifications. These findings provide practical insights for developing rehabilitation strategies and discharge planning.

In the United States, the incidence rate of new or recurrent stroke is approximately 795 000 per year, and stroke prevalence for individuals over the age of 20 years is estimated at 6.5 million.1 Mortality rates in the first 30 days after stroke have decreased because of advances in emergency medicine and acute stroke care. In addition, there is strong evidence that organized postacute, inpatient stroke care delivered within the first 4 weeks by an interdisciplinary healthcare team results in an absolute reduction in the number of deaths.2,3 Despite these positive achievements, stroke continues to represent the leading cause of long-term disability in Americans: An estimated 50 million stroke survivors worldwide currently cope with significant physical, cognitive, and emotional deficits, and 25% to 74% of these survivors require some assistance or are fully dependent on caregivers for activities of daily living (ADLs).4,5 Notwithstanding the substantial progress in acute stroke care over the past 15 years, the focus of stroke medical advances and healthcare resources has been on acute and subacute recovery phases, which has resulted in substantial health disparities in later phases of stroke care. Additionally, healthcare providers (HCPs) are often unaware of not only patients’ potential for improvement during more chronic recovery phases but also common issues that stroke survivors and their caregivers experience. Furthermore, even with evidence that documents neuroplasticity potential regardless of age and time after stroke,6 the mean lifetime cost of ischemic stroke (which accounts for 87% of all strokes) in the United States is an estimated $140 000 (for inpatient, rehabilitation, and follow-up costs), with 70% of first-year stroke costs attributed to acute inpatient hospital care1; therefore, fewer financial resources appear to be dedicated to providing optimal care during the later phases of stroke recovery. Because there remains a …

Background and Purpose: Transitions of care, specifically between inpatient and outpatient care settings can be a point of vulnerability in the care of stroke patients. As patients transfer from inpatient care facilities to outpatient clinics, information can become lost resulting in delays in care, a slower recovery, and patient and family frustration. The purpose of this program is to provide a link between the inpatient and outpatient care settings and improve the coordination of care along the continuum by communicating to the outpatient providers essential information about the stroke patients they will be seeing for follow up. Methods: In order to improve the transition of care between care settings, a two-part program was used. First, the Stroke Advanced Practice Nurse along with the inpatient Neurology team completes a discharge timeout to collect and verify essential information, such as the final diagnosis, suspected stroke etiology, discharge medications, follow up appointments, and transitional care issues such as pending studies. This information is then compiled into a transitional care matrix, which is shared on a weekly basis with the outpatient clinicians who will be seeing the patients that week, allowing them to anticipate and prepare for the follow ups and the patients’ needs. Since initiation in April 2018, 95 stroke patients’ plans of care have been reviewed using the above process. Results: Use of the discharge timeout and transitional care matrix has resulted in improved transitions of care. The process has resulted in more consistent and prompter scheduling of follow up appointments in the outpatient stroke clinic. Furthermore, the transitional care matrix that is shared with outpatient clinicians has helped them to be more prepared for appointments and has created an atmosphere of collaboration between different stroke providers. Conclusions: In conclusion, the discharge timeout and transitional care matrix process has shown to be a valuable tool in the transition of care for stroke patients between the inpatient and outpatient settings, resulting in fewer delays in care and improved anticipation of care needs.

Essential Workflow and Performance Measures for Optimizing Acute Ischemic Stroke Treatment in India.

PURPOSE: To create a model to predict independence in the activities of daily living at discharge in stroke patients in the convalescence stage. The study also examined whether the predictability of functional independence at discharge would be improved by creating a specific prediction model for each rehabilitation facility. METHODS: To create the prediction model, data of 65 first stroke patients were analyzed using stepwise multiple regression analysis. Age, time post-stroke, Functional Independence Measure motor subscale score, Functional Independence Measure cognitive subscale score, Stroke Impairment Assessment Set, Berg Balance Scale, and Vitality Index at admission were selected as predictor variables of Functional Independence Measure motor subscale score at discharge. The accuracy of this model was compared with an existing prognosis model using data from 98 first-stroke patients, comparing the difference between actual and predicted Functional Independence Measure motor subscale score at discharge for each model. RESULTS: The prediction formula created included admission Functional Independence Measure motor subscale score, Vitality Index, age, and Stroke Impairment Assessment Set score. The adjusted R square value was 0.60. The prediction errors of the new and previous models were −2.5 ± 10.8 and −18.3 ± 18.7, respectively, which were significantly different. CONCLUSION: Our results suggest that prediction accuracy may be improved by creating prediction formulas specifically for each institution.

Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge. Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988-1989. These diagnosis-related groups were chosen because patients were discharged to all three major types of Medicare-supported posthospital care. Patients were interviewed in-person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment. The impacts of discharge locations on the functional outcomes were examined by one-way analyses of variance (ANOVA). In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P<.01). Stroke patients discharged to home health had the lowest rehospitalization rates (P<.05). Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P<.05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement. The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.

Introduction: Stroke patients are the second highest post-acute rehabilitation users but there are few comparisons of inpatient rehabilitation (IRF) and skilled nursing facility (SNF) care on patient-reported outcomes. Methods: We compared 3 and 12 month dependence (modified Rankin Scale score=3-6), quality of life (QOL) (Euro-qol-5D continuous variable max=1; death=0), and institutionalization (residence recorded as nursing home, hospice or dead) for acute ischemic stroke (AIS) patients in GWTG-Stroke and the AVAIL (Adherence eValuation After Ischemic Stroke Longitudinal) study living at home pre-stroke and discharged to an IRF or SNF immediately after hospital discharge. Binary and continuous outcomes were modeled by logistic and linear regression, respectively. Inverse propensity weighting (IPW) was used to adjust for measured differences in demographic, clinical and hospital characteristics. Results: Of 473 AIS patients, 72% were discharged to IRFs vs 27% to SNFs. IRF compared with SNF patients were 73 vs. 77 years, with 23% vs. 18% ambulating independently at hospital discharge. After IPW adjustment patients who received IRF care reported better QOL and were less likely to be institutionalized at 3- and 12-months than those who received SNF care but the difference in dependence was not statistically significant (Table). In sensitivity analyses among patients with a NIHSS score, QOL at 3-months was significantly better for IRF compared with SNF patients with no other differences between groups. Conclusions: AIS patients referred to IRFs had higher QOL at 3-months and lower odds of institutionalization at 3 and 12 months post stroke compared with patients referred to SNFs. Further research is needed to discern the mechanisms for potential differences in patient reported outcomes between settings.

Discharge from physiotherapy following stroke:: the management of disappointment

Background and Purpose: Systemic Inflammatory Response Syndrome (SIRS) is a predictor of poor functional outcome at discharge in stroke patients. We developed a prediction score to identify patients at greatest risk for developing SIRS after admission for an intracerebral hemorrhage (ICH). Methods: Retrospective review of consecutive patients presenting to our tertiary care center from 2008-2013 with primary ICH. Patients with a documented source of infection at any point during their hospitalization were excluded. SIRS was defined as having 2 or more of the following: 1) body temperature less than 36°C or greater than 38°C, 2) heart rate greater than 90, 3) respiratory rate greater than 20, or 4) white blood cell count less than 4000/mm or greater than 12,000/mm or more than 10% polymorphonuclear leukocytes for more than 24 hours. A prediction score was developed and adjusted for internal validation using Harrell’s Optimism method. Results: A total of 295 ICH patients met inclusion criteria. Sixty-eight (23.1%) patients developed SIRS during their hospital stay. On univariable analysis, patients with SIRS during hospitalization had a higher frequency of intubation (55.9% vs. 24.7%; p&lt;0.0001) and SIRS in the ED (42.7% vs. 9.7%; p&lt;0.0001), with higher median NIHSS at baseline (17 vs. 6; p&lt;0.0001), lower median GCS at baseline (10 vs. 15; p&lt;0.0001), higher median ICH score (2 vs. 1; p=0.0042), and greater ICH volume (18 vs. 9; p=0.0012). A score was developed ranging from 0-3 with 1 point for SIRS in the ED, 1 point for an ICH score of 2 or 3, and 2 points if the ICH score was 4 or more. The SIRS prediction score was predictive of developing SIRS during hospitalization (OR 2.86 per point from the score, 95%CI 1.94-4.21, p&lt;0.0001; adjusted AUC 0.701). A SIRS Score of 2 or more places a patient at a 3 fold increased odds of developing SIRS during hospitalization (OR 3.05, 95%CI 1.28-6.71, p=0.0056). Discussion: Approximately 20% of patients develop SIRS during their hospitalization for ICH, and a simple scoring system identifies those patients at highest odds of developing SIRS. Further research will determine whether the score can be used direct intervention to prevent the development of SIRS and improve outcomes after ICH.

Examining factors associated with pre-admission to discharge of stroke patients

Nursing personal in care of stroke

Stroke care is now managed in and out of dedicated stroke units. All agree that stroke units are worthwhile. But who should run them and who participate? Choice of physician personnel should depend on the type of unit, what participants need to know and to do, and who is available. The most advanced stroke units provide cutting edge care from arrival in the emergency room until rehabilitation. They have ready access to advanced diagnostic and therapeutic technologies and treatments and have physician coverage 24 hour a day, 7 days a week. These units require the following: (A) One or more physicians with intimate knowledge of brain anatomy, function, and cervicocranial blood supply. These physicians know the symptoms and signs found in stroke patients and the detailed differential diagnosis of stroke subtypes. They are very familiar with the symptoms, signs, and diagnosis of other neurological disorders. They are knowledgeable about stroke …

Post-emergency department management of stroke

Introduction: Weakness among stroke patients causes obstacles when fulfilling their activities in daily living (ADL). This condition also has an impact on the caregivers who provide daily care at home. The purpose of this study was to analyze the effect of independent ADL among the stroke patients on caregiver burden.Methods: The study used an analytical design through a cross-sectional approach. The variables included independent ADL and caregiver burden. A sample of 120 caregivers was taken from 2 community health centers in Surabaya through simple random sampling. The instruments used were Zarit Burden's Interview Schedule and the Katz Index of Independent for ADL. Regression ordinal was used to analyze the influence of independent ADL among stroke patients on caregiver burden.Results: The results showed that the caregiver who take care of stroke patients with severe functional impairment will feel burdened 3 times more than no burden. Post-stroke care at home through a rehabilitation program plays an important role in improving the condition of patients and their families at home, especially the caregivers.Conclusion: Nurses in a community health center through the family health care pathway provide comprehensive bio-psycho-socio-spiritual care in the rehabilitation period as expected. They are expected to improve and maintain the fulfillment of human needs comprehensively for stroke patients and their caregivers, so the quality of life of stroke patients, caregivers and their families remains optimal.