Patients with acute stroke are less likely to be admitted directly to a stroke unit when hospital beds are scarce: A Swedish multicenter register study

Darehed, David; Norrving, Bo; Stegmayr, Birgitta; Zingmark, Karin; Blom, Mathias

doi:10.1177/2396987317698328

Cited by 10 publications

(11 citation statements)

References 26 publications

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“…Similar to DTN time, admission directly to a SU from the ED is expected to be predominantly related to organizational factors (such as hospital bed availability and regional guidelines) and therefore accessible to interventions . We found that direct SU admission showed a pronounced sequential pattern across both days of the week and time of day, where we especially want to emphasize that admission rates drop during nighttime.…”

Section: Discussionmentioning

confidence: 80%

“…Community hospitals showed the best absolute rates of direct SU admission, which probably can be attributed to organizational factors since Swedish community hospitals in general have more SU beds per capita than more specialized hospitals . We hypothesize that keeping more staff on duty during weekends (to improve discharge capabilities), increasing overall bed capacity, and implementing guidelines that prioritize stroke patients for admission to a stroke unit all could increase SU admission rates . Comparing temporal resiliency, university hospitals were significantly more resilient to variation for evening admissions compared to specialized non‐university hospitals.…”

Section: Discussionmentioning

confidence: 94%

“…We found that direct SU admission showed a pronounced sequential pattern across both days of the week and time of day, where we especially want to emphasize that admission rates drop during nighttime. We believe these patterns are driven by hospital bed shortages . As most patients are discharged from hospitals during weekdays with fewer discharges on weekends, hospital bed shortages build up during weekends to peak on Sundays .…”

Section: Discussionmentioning

confidence: 99%

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Diurnal variations in the quality of stroke care in Sweden

et al. 2019

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Time of admission affects the quality of care across a wide range of clinical presentations including acute stroke. [1][2][3][4][5][6][7][8][9][10][11] In particular, a recently published meta-analysis revealed increased short-term mortality and disability at discharge in stroke patients who had presented off-hours. 12 However, less is known about the underlying causes of these effects. 13,14 A recent study on general emergency admissions found that the magnitude of the weekend effect was significantly reduced when adjusting for patient comorbidity and common blood tests, suggesting that differences in patient characteristics contribute. 15Objectives: A recent study of acute stroke patients in England and Wales revealed several patterns of temporal variation in quality of care. We hypothesized that similar patterns would be present in Sweden and aimed to describe these patterns.Additionally, we aimed to investigate whether hospital type conferred resilience against temporal variation. Materials and Methods:We conducted this nationwide registry-based study using data from the Swedish Stroke Register (Riksstroke) including all adult patients registered with acute stroke between 2011 and 2015. Outcomes included process measures and survival. We modeled time of presentation as on/off-hours, shifts, day of week, 4-hour, and 12-hour time blocks. We studied hospital resilience by comparing outcomes across hospital types. Results:A total of 113 862 stroke events in 72 hospitals were included. The process indicators and survival all showed significant temporal variation. Door-to-needle (DTN) time within 30 minutes was less likely during nighttime than daytime (OR 0.50; 95% CI 0.41-0.60). Patients admitted during off-hours had lower odds of direct stroke unit (SU) admission (OR 0.72; 95% CI 0.70-0.75). 30-day survival was lower in nighttime vs daytime presentations (OR 0.90, 95% CI 0.84-0.96). The effects of temporal variation differed significantly between hospital types for DTN time within 30 minutes and direct SU admission where university hospitals were more resilient than specialized non-university hospitals. Conclusions:Our study shows that variation in quality of care and survival is present throughout the whole week. We also found that university hospitals were more resilient to temporal variation than specialized non-university hospitals. K E Y W O R D S off-hours, quality of care, stroke, temporal variation, weekend effect, weekly variation S U PP O RTI N G I N FO R M ATI O N Additional supporting information may be found online in the Supporting Information section at the end of the article. How to cite this article: Darehed D, Blom M, Glader E-L, et al. Diurnal variations in the quality of stroke care in Sweden. Acta

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Section: Discussionmentioning

confidence: 80%

Section: Discussionmentioning

confidence: 94%

Section: Discussionmentioning

confidence: 99%

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Diurnal variations in the quality of stroke care in Sweden

et al. 2019

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“…Unfortunately, our study shows a decreased rate of stroke unit admissions over time, where university hospitals alone accounted for this decrease. We believe the reason for this is a shortage of hospital beds, as shown in our previous work (23), since university hospitals have fewer stroke unit beds per capita than specialized non-university hospitals and community hospitals (24). The solution to this problem is likely multifactorial.…”

Section: Discussionmentioning

confidence: 74%

Time Trends and Monthly Variation in Swedish Acute Stroke Care

et al. 2019

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Background and Purpose: Studies of monthly variation in acute stroke care have led to conflicting results. Our objective was to study monthly variation and longitudinal trends in quality of care and patient survival following acute stroke.Methods: Our nationwide study included all adult patients (≥18 years) with acute stroke (ischemic or hemorrhagic), admitted to Swedish hospitals from 2011 to 2016, and that were registered in The Swedish Stroke Register (Riksstroke). We studied how month of admission and longitudinal trends affected acute stroke care and survival. We also studied resilience to this variation among hospitals with different levels of specialization.Results: We included 132,744 stroke admissions. The 90-day survival was highest in May and lowest in January (84.1 vs. 81.5%). Thrombolysis rates and door-to-needle time within 30 min increased from 2011 to 2016 (respectively, 7.3 vs. 12.8% and 7.7 vs. 28.7%). Admission to a stroke unit as first destination of hospital care was lowest in January and highest in June (78.3 vs. 80.5%). Stroke unit admission rates decreased in university hospitals from 2011 to 2016 (83.4 vs. 73.9%), while no such trend were observed in less specialized hospitals. All the differences above remained significant (p < 0.05) after adjustment for possible confounding factors.Conclusion: We found that month of admission and longitudinal trends both affect quality of care and survival of stroke patients in Sweden, and that the effects differ between hospital types. The observed variation suggests an opportunity to improve stroke care in Sweden. Future studies ought to focus on identifying the specific factors driving this variation, for subsequent targeting by quality improvement efforts.

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“…As transfers to stroke centers continue to increase, there is a greater potential for hospital crowding, which has been shown to delay stroke unit admission. 28 Moreover, Rincon et al found that delayed admission to the neuro-ICU for critically ill stroke patients was associated with poor outcomes at discharge. 29 Our findings suggest the need for hospitals, critical care transport services, and other healthcare providers to consider both place and time when planning and coordinating acute stroke triage.…”

Section: Discussionmentioning

confidence: 99%

Availability of Hospital Resources and Specialty Services for Stroke Care in North Carolina

Patel

Honvoh

Fernández

et al. 2019

Southern Medical Journal

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Objectives: Effective regionalization of acute stroke care requires assessment and coordination of limited hospital resources. We described the availability of stroke-specific hospital resources (neurology specialty physicians and neuro-intensive care unit [neuro-ICU] bed capacity) for North Carolina overall and by region and population density. We also assessed daily trends in hospital bed availability. Methods: This statewide descriptive study was conducted with data from the State Medical Asset Resource Tracking Tool (SMARTT), a Web-based system used by North Carolina to track available medical resources within the state. The SMARTT system was queried for stroke-specific physician and bed resources at each North Carolina hospital during a 1-year period (June 2015-May 2016), including daily availability of neuro-ICU beds. We compared hospital resources by geographic region and population density (metropolitan, urban, and rural). Results: Data from 108 acute care hospitals located in 75 of 100 counties in North Carolina were included in the analysis. Fifty-seven percent of hospitals had no neurology specialty physicians. Western and eastern North Carolina had the lowest prevalence of these physicians. Most hospitals (88%) had general ICUs, whereas only 17 hospitals (16%) had neuro-ICUs. Neuro-ICUs were concentrated in metropolitan areas and in central North Carolina. On average, there were 276 general ICU and 27 neuro-ICU beds available statewide each day. Daily neuro-ICU bed availability was lowest in eastern and southeastern regions and during the week compared with weekends. Conclusions: In North Carolina, stroke-specific hospital subspecialists and resources are not distributed evenly across the state. Daily bed availability, particularly in neuro-ICUs, is lacking in rural areas and noncentral regions and appears to decrease on weekdays. Regionalization of stroke care needs to consider the geographic distribution and daily variability of hospital resources.

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Patients with acute stroke are less likely to be admitted directly to a stroke unit when hospital beds are scarce: A Swedish multicenter register study

Cited by 10 publications

References 26 publications

Diurnal variations in the quality of stroke care in Sweden

Diurnal variations in the quality of stroke care in Sweden

Time Trends and Monthly Variation in Swedish Acute Stroke Care

Availability of Hospital Resources and Specialty Services for Stroke Care in North Carolina

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