Causes of Mortality on a University Hospital Neurology Service

Jaren, Olav; Selwa, Linda M.

doi:10.1097/01.nrl.0000240859.97587.48

Cited by 8 publications

(6 citation statements)

References 26 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…In addition, the frequency of undetermined neuroinfection was less than 31% in Tan et al9 As reported by these authors, undetermined neuroinfection was frequently diagnosed in non-immunocompromised patients in our series. Indeed, our neuroinfection mortality was closer to rates in North America that ranged from 1.7% to 12% than the 47% reported by Chapp-Jumbo 8,9,11. Analogously to North-American NW results,9 prion and fungi were the more important lethal agents in our patients.…”

Section: Discussionsupporting

confidence: 75%

Neuroinfection survey at a neurological ward in a Brazilian tertiary teaching hospital

Marchiori

Lino

Machado

et al. 2011

Clinics

View full text Add to dashboard Cite

OBJECTIVES: This study was undertaken to characterize the neuroinfection profile in a tertiary neurological ward.INTRODUCTION:Neuroinfection is a worldwide concern and bacterial meningitis, tetanus and cerebral malaria have been reported as the commonest causes in developing countries.METHODS:From 1999 to 2007, all patients admitted to the Neurology Ward of Hospital das Clínicas, S�o Paulo University School of Medicine because of neuroinfection had their medical records reviewed. Age, gender, immunological status, neurological syndrome at presentation, infectious agent and clinical outcome were recorded.RESULTS:Three hundred and seventy four cases of neuroinfectious diseases accounted for 4.2% of ward admissions and the identification of infectious agent was successful in 81% of cases. Mean age was 40.5±13.4 years, 63.8% were male, 19.7% were immunocompromised patients and meningoencephalitis was the most common clinical presentation despite infectious agent. Viruses and bacteria were equally responsible for 29.4% of neuroinfectious diseases; parasitic, fungal and prion infections accounted for 28%, 9.6% and 3.5% respectively. Human immunodeficiency virus (HIV), herpes simplex virus 1 (HSV1), Mycobacterium tuberculosis, Treponema pallidum, Taenia solium, Schistosoma mansoni, Cryptococcus neoformans and Histoplasma capsulatum were the more common infectious pathogens in the patients. Infection mortality rate was 14.2%, of which 62.3% occurred in immunocompetent patients.CONCLUSION:Our institution appeared to share some results with developed and developing countries. Comparison with literature may be considered as quality control to health assistance.

show abstract

Section: Discussionsupporting

confidence: 75%

Neuroinfection survey at a neurological ward in a Brazilian tertiary teaching hospital

Marchiori

Lino

Machado

et al. 2011

Clinics

View full text Add to dashboard Cite

show abstract

“…This rationale may fail to adequately account for variation in patient preferences as most early deaths after ischemic stroke are related to patient or family preferences to withhold or withdraw potential life-sustaining interventions, such as artificial hydration and nutrition or mechanical ventilation. 2, 3 …”

Section: Introductionmentioning

confidence: 99%

Variation in Do-Not-Resuscitate Orders for Patients With Ischemic Stroke

Kelly

Zahuranec

Holloway

et al. 2014

Stroke

View full text Add to dashboard Cite

Background and purpose Decisions on life-sustaining treatments and the use of do-not-resuscitate (DNR) orders can affect early mortality after stroke. We investigated the variation in early DNR utilization after stroke among hospitals in California, and the impact of this variation on mortality-based hospital classifications. Methods Using the California State Inpatient Database from 2005–2011, ischemic stroke admissions for patients age ≥50 were identified. Cases were categorized by the presence/absence of DNR orders within the first 24 hours of admission. Multilevel logistic regression models with a random hospital intercept were used to predict inpatient mortality after adjusting for comorbidities, vascular risk factors and demographics. Hospital mortality rank order was assigned based on this model and compared to the results of a second model that included DNR status. Results From 355 hospitals, 252,368 cases were identified, including 33,672 (13.3%) with early DNR. Hospital-level adjusted utilization of DNR varied widely (quintile 1, 2.2% vs. quintile 5, 23.2%). Hospitals with higher early DNR utilization had higher inpatient mortality, as inpatient mortality more than doubled from quintile 1 (4.2%) to quintile 5 (8.7%). Failure to adjust for DNR orders resulted in substantial hospital reclassification across the rank spectrum, including among high mortality hospitals. Conclusions There is wide variation in the hospital-level proportion of ischemic stroke patients with early DNR orders; this variation affects hospital mortality estimates. Unless the circumstances of early DNR orders are better understood, mortality-based hospital comparisons may not reliably identify hospitals providing a lower quality of care.

show abstract

“…Research has shown that the majority of deaths on an inpatient neurology service resulted from withdrawal of life-sustaining support at the patient/family request. 2 In addition, involvement of palliative care services is common after stroke, 3 especially among higher educated patients. 4 We conducted a review of ischemic stroke mortalities at our institution to better describe the manner in which deaths occur after stroke, and estimate the potential impact that decisions to withhold/ withdraw treatments have on short-term ischemic stroke mortality.…”

mentioning

confidence: 99%

Early stroke mortality, patient preferences, and the withdrawal of care bias

2012

View full text Add to dashboard Cite

Objective: Early mortality is a potential measure of the quality of care provided to hospitalized stroke patients. Whether in-hospital stroke mortality is reflective of deviations from evidencebased practices or patient/family preferences on life-sustaining measures is unclear.Methods: All ischemic stroke mortalities at an academic medical center were reviewed to better understand the causes of inpatient stroke mortality.Results: Among 37 deaths or discharges to hospice in 2009, 36 occurred after a patient/family decision to withdraw/withhold potentially life-sustaining interventions. An independent survey of 3 vascular neurologists revealed that some early deaths could have been delayed beyond 30 days if patients or families had agreed to more aggressive measures. From these data, we estimate the magnitude of a "withdrawal of care" bias to be approximately 40% of the observed short-term mortality.Conclusions: Acute stroke mortality may be more reflective of patient/family preferences than the provision of evidence-based care. Neurology Mortality has increasingly been used as a measure of the quality of care provided to stroke patients.1 However, it has been shown to be inconsistent across multiple evaluating systems and is overly reliant on proprietary risk-adjustment methods. Despite this, the Center for Medicare and Medicaid Services (CMS) is developing a 30-day risk-adjusted stroke mortality measure for public reporting purposes.Whether inpatient stroke mortality is reflective of evidence-based practice is uncertain. Hospital-based deaths may arise from unsafe practices, deviations from standards of care, or progression of the underlying disease. Deaths also occur when patients or families elect to withhold or withdraw life-sustaining interventions, thereby allowing a natural death rather than prolonging life in a state deemed unacceptable to the patient. These choices may be guided by written advanced directives or discussions with surrogates, suggesting an informed, patient-centered decision. Research has shown that the majority of deaths on an inpatient neurology service resulted from withdrawal of life-sustaining support at the patient/family request.2 In addition, involvement of palliative care services is common after stroke, 3 especially among higher educated patients. 4 We conducted a review of ischemic stroke mortalities at our institution to better describe the manner in which deaths occur after stroke, and estimate the potential impact that decisions to withhold/ withdraw treatments have on short-term ischemic stroke mortality. Specifically: What are the characteristics of stroke patients who die? How do stroke patients die-are deaths due to deviations from evidence-based practices? How much could early stroke mortality be affected by decisions to withhold/ withdraw life-sustaining measures?

show abstract

Causes of Mortality on a University Hospital Neurology Service

Abstract: Most mortality in this acute care neurology setting occurs in the course of stroke, epilepsy, or complicated tumor management and is managed through withdrawal of care with family participation.

Cited by 8 publications

References 26 publications

Neuroinfection survey at a neurological ward in a Brazilian tertiary teaching hospital

Neuroinfection survey at a neurological ward in a Brazilian tertiary teaching hospital

Variation in Do-Not-Resuscitate Orders for Patients With Ischemic Stroke

Early stroke mortality, patient preferences, and the withdrawal of care bias

Contact Info

Product

Resources

About