Performance measures for in-hospital care of acute ischemic stroke in public hospitals in Chile

Abstract

BackgroundThe aim of this study were to describe acute care of ischemic stroke patients and adherence to performance measures, as well as the outcomes of these events, in a sample of patients treated in public hospitals in Chile.MethodsWe retrospectively reviewed the medical charts of patients with ischemic stroke from a sample of seven public hospitals in the Metropolitan Region of Santiago. We analyzed adherence to the following evidence-based measures: clinical evaluation at admission, use of intravenous thrombolysis, dysphagia screening and prescription of antithrombotic therapy at discharge. As outcome measures we analyzed post-stroke pneumonia and 30-day case-fatality. We used a logistic regression model by each outcome with generalized estimating equations, which accounted for clustering of patients within hospitals and included sex, age (years), clinical status at admission (reduced level of consciousness, speech disturbance, aphasia and hemiplegia), comorbidities, dysphagia screening and neurological evaluation at admission as measures of acute stroke care.ResultsWe reviewed the charts of 677 patients, of which 52.3% were men. The mean age was 69.8 years in women and 66.3 years in men. Diagnosis of stroke was confirmed by a computed tomography scan within 4.5 hours of symptom onset in only 9.6% of the patients. Intravenous thrombolysis was administered in 1.7%. Dysphagia screening was performed in 12.1% (95% CI 9.7-15.0) and antithrombotic therapy was prescribed in 68.9% (95% CI 64.6-72.9). Pneumonia was diagnosed in 23.6% (95% CI 20.4-27.2). Thirty-day fatality was 8.7% (95% CI 6.7-11.3). The variables independently associated with 30-day case fatality were age (OR 1.08, 95% 1.06-1.10), pneumonia (OR 7.7, 95% 95% CI 4.0-14.7), aphasia (OR 2.4, 95% CI 1.1-5.6), reduced level of consciousness (OR 2.4, 95% CI 1.3-4.4), and speech disturbance (OR 1.4, 95% CI 1.0-1.9). No association was found between 30-day case fatality and dysphagia screening or neurological evaluation at admission. The factors associated with post-stroke pneumonia were female sex (OR 1.6, 95% CI 1.0-2.3), age (OR 1.04 95% CI 1.03-1.05), diagnosis of diabetes (OR 1.8, 95% CI 1.4-2.4), aphasia (OR 2.0, 95% CI 1.5-2.7), hemiplegia (OR 1.6, 95% CI 1.1-2.4), and reduced level of consciousness on admission (OR 3.4, 95% CI 2.1-5.5). No association was found between pneumonia and dysphagia screening or neurological evaluation at admission.ConclusionsAdherence to evidence-based performance measures was low. Administration of intravenous thrombolysis was particularly low and diagnostic confirmation of ischemic stroke was delayed. The occurrence of post-stroke pneumonia was frequent and should be reduced. To improve acute stroke care in Chile, organizational change in the health service is urgently needed.

Impact of Dysphagia Assessment and Management on Risk of Stroke-Associated Pneumonia: A Systematic Review

“…2). There was one retrospective review [33]. Europe [26-28, 31, 32, 34] hosted 50% of studies, United States 25% [29,35,36] and the remainder were in Chile [33], Japan [37] and Canada [30].…”

Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis

“…In contrast, several studies reported wide confidence intervals and no statistically significant association between the reported KPIs and stroke case fatality; stroke unit admission (24), swallow/nutritional assessment (25,28,35), antiplatelets for ischemic stroke (23,28), anticoagulants for ischemic stroke, lipid management (28), DVT prophylaxis (28) and blood pressure lowering therapy (23). Surprisingly, in one study (17) the CT/MRI brain imaging was associated with increased risk of early case fatality (RR:…”

“…Significant associations within single studies were observed for thrombolysis (19), early medical assessment (24), OT assessment (17), and antidepressant therapy (20), but there 28 was no evidence for the association between stroke case fatality and hyperthermia management (28), and neurological assessment (35).…”

Desfechos clínicos de pacientes com acidente vascular cerebral isquêmico após terapia trombolítica

“…Hoffmeister et al (6) found 23.6% patients with pneumonia. Bruening and Al-Khaled (29) obtained 22.7%, while Gumbinger et al (27) registered 8% of patients with hospital-acquired pneumonia.…”

“…The shorter the time window between onset of stroke symptoms and drug infusion, greater the chances of a good prognosis. (6) The main clinical outcomes associated with this treatment are: significantly improved National Institute of Health Stroke Scale NIHSS score, hospital discharge, low occurrence of symptomatic hemorrhagic transformation, and low treatment-related deaths. (7,8) In Brazil, intravenous thrombolysis for ischemic stroke is conducted in several hospitals.…”