Acute stroke management in the local general hospital.
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BACKGROUND AND PURPOSE: The majority of stroke patients are treated in local general hospitals. Despite this fact, little is known about stroke care in these institutions. We sought to investigate the status quo of acute stroke management in nonspecialized facilities with limited equipment and resources. METHODS: Four general hospitals located in smaller cities of a rural area in Germany participated in this study. The 4 hospitals were similar in structure and technical equipment; none had a CT scanner in-house. We reviewed the medical records of every stroke patient hospitalized in 1 of the 4 hospitals within a period of 8 weeks within 1 year. RESULTS: We collected data of a total of 95 patients at all 4 hospitals. The frequency of diagnostic tests was low: at least 1 CT scan was obtained in only 36.8% of all cases, whereas diagnostic methods available in-house were used more frequently, such as Doppler ultrasound (49.0%), echocardiography (42.3%), and 24-hour ECG registration (48.4%). Each hospital had a different therapeutic approach. Main therapeutic options were the use of pentoxyfilline (0% to 90.5%), osmodiuretics (0% to 90%), piracetam (0% to 93.3%), and hydroxyethylstarch (4.8% to 30%). Medication for long-term secondary prevention was given to 69.8% of all patients. CONCLUSIONS: This study provides one of the few data samples reflecting stroke care in smaller general hospitals. The findings demonstrate a partially suboptimal level of care in these institutions. To achieve future improvements, extended human and technical resources as well as research for stroke care should not be restricted to academic stroke centers. (+info)
Should mild or moderate stroke patients be admitted to an intensive care unit?
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BACKGROUND AND PURPOSE: Inhospital placement of patients with mild (National Institutes of Health Stroke Scale [NIHSS] score <8) or moderate (NIHSS 8 through 16) acute strokes is variable. We assessed the outcome of such patients based on intensive care unit (ICU) versus general ward placement. METHODS: We reviewed 138 consecutive patients admitted within 24 hours of stroke onset to 2 physically adjacent hospitals with different admitting practices. Outcome measures included complication rates, discharge Rankin scale score, hospital discharge placement, costs, and length of stay (LOS). RESULTS: Hospital A, a 626-bed university-affiliated hospital, admitted 43% of mild and moderate strokes (MMS) to an ICU (26% of mild, 74% of moderate), whereas hospital B, a 618-bed community facility, admitted 18% of MMS to an ICU (3% of mild, 45% of moderate; P<0.004). There were no significant differences in outcomes between the 2 hospitals. Analysis of only patients admitted to hospital A, and of all patients, demonstrated that mild stroke patients admitted to the general ward had fewer complications and more favorable discharge Rankin scale scores than similar patients admitted to an ICU. There was no statistically significant difference in LOS, but total room costs for a patient admitted first to the ICU averaged $15 270 versus $3638 for admission directly to the ward. CONCLUSIONS: While limited by the retrospective nature of our study, routinely admitting acute MMS patients to an ICU provides no cost or outcomes benefits. (+info)
Survival of patients transferred to tertiary intensive care from rural community hospitals.
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BACKGROUND: Accessibility to tertiary intensive care resources differs among hospitals within a rural region. Determining whether accessibility is associated with outcome is important for understanding the role of regionalization when providing critical care to a rural population. METHODS: In a prospective design, we identified and recorded the mortality ratio, percentage of unanticipated deaths, length of stay in the intensive care unit (ICU), and survival time of 147 patients transferred directly from other hospitals and 178 transferred from the wards within a rural tertiary-care hospital. RESULTS: The two groups did not differ significantly in the characteristics measured. Differences in access to tertiary critical care in this rural region did not affect survival or length of stay after admission to this tertiary ICU. The odds ratio (1.14; 95% confidence interval 0.72-1.83) for mortality associated with transfer from a rural community hospital was not statistically significant. CONCLUSIONS: Patients at community hospitals in this area who develop need for tertiary critical care are just as likely to survive as patients who develop ICU needs on the wards of this rural tertiary-care hospital, despite different accessibility to tertiary intensive-care services. (+info)
Development and implementation of resuscitation guidelines: a personal experience.
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OBJECTIVES: to develop and implement guidelines on the appropriate use of cardiopulmonary resuscitation, which would ensure patient involvement in decision-making about cardiopulmonary resuscitation whenever possible but without offering illusory choices where resuscitation was unlikely to succeed. DESIGN: quantitative guidelines were developed after a review of the literature on survival after cardiopulmonary resuscitation. Patients were classified according to their estimated likelihood of survival to discharge after resuscitation: < 1%, group A; 1-10%, group B; and > 10%, group C. Qualitative guidelines were developed after consideration of the legal and ethical principles of cardiopulmonary resuscitation. It was decided to inform competent patients in group A that cardiopulmonary resuscitation would be inappropriate, and to seek the preferences of competent patients in group B. The operation of the guidelines was examined in patients aged 65 years or more admitted under a single consultant in an acute community hospital. RESULTS: 147 patients were studied: 39 in group A, 26 in group B and 82 in group C. Of 36 patients in groups A and B judged competent, cardiopulmonary resuscitation discussions were only undertaken in 17, usually because acute distress or anxiety precluded effective communication. Of the 23 patients or family members from whom cardiopulmonary resuscitation preferences were sought, four opted for full cardiopulmonary resuscitation and six for limited cardiopulmonary resuscitation (usually witnessed-arrest only and no ventilation). CONCLUSION: it is difficult to involve acutely ill elderly patients in cardiopulmonary resuscitation decision-making. Limited cardiopulmonary resuscitation is a useful option for patients, relatives and doctors. (+info)
Breast cancer survival by teaching status of the initial treating hospital.
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BACKGROUND: A number of studies have documented variation in treatment patterns by treatment setting or by region. In order to better understand how treatment setting might affect survival, we compared the survival outcomes of women with node-negative breast cancer who were initially treated at teaching hospitals with those of women initially treated at community hospitals. METHODS: We constructed a retrospective cohort consisting of a random sample of 938 cases, initially diagnosed in 1991, drawn from the Ontario Cancer Registry. Exposure was defined by the type of hospital in which the initial breast cancer surgery was performed. Outcomes were ascertained through follow-up of vital statistics. RESULTS: The crude 5-year survival rate was 88.7% for women who had their initial surgery in a community hospital and 92.5% for women who had their initial surgery in a teaching hospital. Women in higher income neighbourhoods experienced better survival at 5 years regardless of which type of hospital they were treated in. Multivariate proportional hazards regression modelling demonstrated a 53% relative reduction in risk of death among women with tumours less than or equal to 20 mm in diameter who were treated at a teaching hospital (relative risk [RR] = 0.47, 95% confidence interval [CI] 0.23-0.96), whereas among those with larger tumours there was no demonstrated difference in survival (RR = 1.32, 95% CI 0.73-2.32). Other variables that were significant in the model were age at diagnosis, estrogen receptor status and the use of radiation therapy. INTERPRETATION: Women with node-negative breast cancer and tumours less than or equal to 20 mm in diameter who were initially seen at a teaching hospital had significantly better survival than women with similar tumours who were initially seen at a community hospital. Survival among women with larger tumours was not statistically significantly different for the 2 types of hospital. (+info)
Monitoring clinical research: report of one hospital's experience.
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Monitoring of research by research ethics boards has been recommended by various organizations that fund clinical studies and by other groups. However, little evidence has been reported on the processes, costs and outcomes of these activities, information that would be helpful to guide the boards in their current work and future policies. We report here 3 years of monitoring experience by the research ethics board of a 313-bed university-affiliated community hospital. Activities newly implemented at the beginning of the study period included the use of recruitment logs, audits of completed consent forms and interviews with research subjects. Over the study period, we monitored 33 protocols, through 188 consent form audits and interviews with 17 research subjects. In addition, 26 of 34 research investigators and collaborators responded to a survey about the monitoring. In general, the investigators were supportive of monitoring activities, but most were not willing to contribute financially. The types of monitoring we conducted are feasible and may be suitable (or could be adapted) for use in other institutions. (+info)
Comparison of lymphoid neoplasm classification. A blinded study between a community and an academic setting.
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The revised European-American classification of lymphoid neoplasms has been reported as reproducible among expert pathologists and feasible in a community setting. We evaluated the reproducibility of lymphoid neoplasm diagnoses between a community and an academic center. We subtyped 188 lymphoid neoplasms using revised European-American classification criteria. Clinical findings, histologic or cytologic preparations, paraffin-section immunostains, and flow cytometry data were reviewed as appropriate. Diagnoses were compared only after completion of the study. Lymphoma subtype was concordant for 167 (88.8%) of 188 cases. Discordant cases included 15 B-cell, 2 T-cell, and 4 Hodgkin lymphomas. For B-cell neoplasms, discordance was most often due to classifying diffuse large cell lymphoma as another aggressive subtype of lymphoma (n = 6), marginal zone lymphoma as another subtype (n = 4), or follicle center lymphoma grade II as grade III (n = 3). For Hodgkin disease, discordance was most often due to classifying nodular sclerosis as mixed cellularity type (n = 3). Comparison of community and academic center diagnoses demonstrated high concordance for most revised European-American classification subtypes. Some sources of discordance have been addressed in the new World Health Organization classification of neoplastic diseases of the hematopoietic and lymphoid tissues. (+info)
Where health and welfare meet: social deprivation among patients in the emergency department.
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CONTEXT: As a safety net provider for many disadvantaged Americans, the emergency department (ED) may be an efficient site not only for providing acute medical care, but also for addressing serious social needs. OBJECTIVE: To characterize the social needs of ED patients, and to evaluate whether the most disadvantaged patients have connections with the health and welfare system outside the ED. DESIGN: Cross-sectional survey conducted over 24 hours in the fall of 1997. SETTING: Three EDs: an urban public teaching hospital, a suburban university hospital, and a semirural community hospital. PARTICIPANTS: Consecutive patients presenting for care, including those transported by ambulance. The survey response rate was 91% (N = 300; urban = 115, suburban = 102, rural = 83). MAIN OUTCOME MEASURE: Index of socioeconomic deprivation described by the US Census Bureau (based on food, housing, and utilities). RESULTS: Of all ED patients, 31% reported one or more serious social deprivations. For example, 13% of urban patients reported not having enough food to eat, and 9% of rural patients reported disconnection of their gas or electricity (US population averages both less than 3%). While 40% of all patients had no consistent health care outside the ED (< or = 1 visit/year), those with higher levels of social deprivation had the least contact with the health care system outside the ED (P < .01). Although those with higher levels of deprivation were more likely to receive public assistance, still almost one-quarter of patients with high-level social deprivation were not receiving public aid. CONCLUSION: Many ED patients suffer from fundamental social deprivations that threaten basic health. The most disadvantaged of these patients frequently lack contact with other medical care sites or public assistance networks. Community efforts to address serious social deprivation should include partnerships with the local ED. (+info)