SAH has a 30-day readmission rate of 7.8% which continues to rise into the intermediate-term. A low but constant proportion of readmissions are potentially preventable. Several chronic medical comorbidities were associated with readmissions. Prospective studies are warranted to clarify causal relationships.
-In this large, nationally representative retrospective cohort study, migraine admission with aura was independently associated with TIA readmission, and status migrainosus was independently associated with subarachnoid hemorrhage. Further research would clarify the role of misdiagnosis and causal relationships underlying these strong associations.
Objective: To assess for changes in stroke code volume and yield after implementation of an extended 24-hour acute stroke code window (ASCW). Background: The DAWN and DEFUSE-3 trials showed that extended time windows of 16 to 24 hours benefit select patients with confirmed large vessel occlusion (LVO) of the anterior circulation. The Mount Sinai Hospital emergency department (MSH ED) extended its ASCW from 12 to 24 hours in anticipation of those results. Methods: We retrospectively analyzed de-identified data collected for patients presenting to the MSH ED as stroke codes, estimated by the number of acute stroke non-contrast head CT scans performed. We compared last known well (LKW)-to-arrival time, door-to-CT time, ancillary imaging, and intervention status seven months prior to (baseline cohort), and following (intervention cohort), implementation of the 24-hour ASCW. This work was part of a departmental quality improvement project to optimize local policy in the context of new acute stroke treatment guidelines. Results: Baseline cohort: 197 stroke codes were called. Median NIHSS was 7. 27 (14%) presented after 12 hours. Median LKW-to-arrival was 212 minutes and median door-to-CT was 22 minutes. 136 (69%) received a CT angiogram (CTA) and 32 (16%) received CT perfusion (CTP). 25 (13%) were treated with intravenous alteplase (IV tPA). 44 (22%) underwent mechanical thrombectomy (MT) with a median LKW-to-arrival of 209 minutes. Intervention cohort: 200 acute stroke codes were called. Median NIHSS was 6. 58 (29%) presented after 12 hours. Median LKW-to-arrival was 280 minutes, and median door-to-CT was 19 minutes. 135 (68%) received CTA and 27 (14%) received CTP. 36 (18%) were treated with IV tPA. 43 (22%) underwent MT with a median LKW-to-arrival of 283 minutes. Conclusions: The number of stroke codes called with an extended 24-hour ASCW remained stable. Although the number of patients presenting after 12 hours more than doubled, there was no increase in the number of patients who underwent MT. This likely reflects the practice that stroke codes are called whenever there is a high suspicion for LVO regardless of the determined ASCW, so that the change to 24-hour ASCW did not significantly impact demand and work flow.
Objective: To identify factors associated with readmission after aneurysmal subarachnoid hemorrhage (SAH) using nationally representative data Background: Readmission rate is a common metric linked to hospital compensation and as a proxy to quality of care. Prior studies in SAH have reported higher risk of readmission among those with longer length of stay (LOS) and discharge to skilled nursing facility. These studies were limited by small sample sizes and single-center design. Methods: The Nationwide Readmissions Database is a de-identified national database of readmissions with data on 49% of U.S. admissions in 2013. We used International Classification of Disease, Ninth Revision, Clinical Modification codes to identify index SAH admissions, comorbidities, and outcomes. Unadjusted and adjusted Poisson models were used to identify factors associated with increase readmission rate up to 1 year after discharge. Results: Out of 14464 index admissions for SAH, 8587 (59.4%) were female, average age was 61.2±16.1 years, with an even distribution of socioeconomic status. Among 11035 who survived to discharge, there were 2765 readmissions (25.1%) up to 1 year. In univariate analysis, variables associated with increased readmission rate included age, atrial fibrillation, CHF, diabetes, renal impairment, COPD, tracheostomy, percutaneous endoscopic gastrostomy, discharge not to home, and greater LOS. In multivariable analysis, significant predictors of higher readmission rate included LOS (0.001 greater rate per day increase, 95% CI 0.0001-0.002), CHF (rate ratio [RR] 1.08, 1.02-1.14), diabetes (RR 1.09, 1.05-1.14), renal impairment (RR 1.15, 1.09-1.2), COPD (RR 1.08, 1.02-1.14). Factors associated with lower readmission rate were age (0.0013 lower rate per year increase, -0.003, 0.0001) and discharge home (RR 0.92, 0.88-0.95). Conclusions: In this nationwide database several medical comorbidities were associated with higher readmission rates after SAH, in addition to previously reported variables of discharge disposition and LOS. Given that 1 out of 4 SAH patients are readmitted within the year, prospective studies are warranted on the feasibility and efficacy of interventions tailored to high-risk subgroups.
Background/Objective: Higher volumes in the emergency department (ED) and lower staffing ratios exist during hospital “off hours,” outside of weekday business hours, but the impact of these factors on emergent acute stroke metrics is unknown. As part of a departmental quality improvement project to optimize local policy in the context of new acute stroke treatment guidelines, we sought to assess the impact of time of day on acute stroke code process metrics. Methods: We retrospectively analyzed de-identified metrics for 646 stroke codes between January, 2017 and March, 2018. We calculated median times to neuroimaging, tPA administration, and preparation for endovascular therapy (ET) in the endovascular suite based on time of day (“on hours” = weekday business hours vs “off hours” = non-weekday business hours) and patient setting (ED, outside hospital transfer [OSH], inpatient). Results: Of all stroke codes, 57 (8.8%) received tPA and 98 (15.1%) received ET. Of these, 44 (77.2%) occurred during “off hours” for tPA and 69 (70.4%) for ET. Median door-to-needle (n=48) and door-to-groin puncture (n=84) time for ED presentations is higher during “off hours” (56 vs 44 min, 111 vs 92 min, respectively). Median door-to-groin puncture is similar for OSH transfers (n=64) regardless of arrival time (56 vs 60 min). For all groups, median time for preparation for ET in the endovascular suite is higher during “off hours” compared to “on hours” (ED 21 vs 19 min, OSH 20 vs 15 min, inpatient 26.5 vs 20 min). Conclusion: In our center, acute stroke codes during “off hours” have higher median times to tPA, groin puncture, and preparation for ET. Based on this data we are working to implement earlier activation of the endovascular team at triage for potential large vessel occlusion cases and increase staffing availability during “off hours.”
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.