Acute Care Period Research Articles

Abstract WMP59: Prognosis After Cerebral Venous Thrombosis: Long-Term Readmission Patterns in a Canadian Population-Based Cohort

Background: Information on long-term care utilization patterns following the acute care period of cerebral venous thrombosis (CVT) is limited. We examined readmission reasons and patterns after discharge from index CVT hospitalization. Methods: A population-based cohort of patients diagnosed with CVT (2000-2017) was constructed using linked administrative data. Descriptive statistics were calculated for baseline demographics and readmission causes. Readmission proportions were calculated for first readmission every year during the 10 years after diagnosis. Survival analysis was used to examine associations between patient factors and readmission events. Results: The cohort included 508 patients, 56% female and mean age 49.6 years (SD 19). Median time-to-first readmission is 1.8 years (95% CI 1.4-2.4), with 39% of patients readmitted in 1 year (95% CI 35-43) and 69% in 5 years (95% CI 64-73). Cancer-related CVT was associated with a higher rate of readmission (p<0.0001) and traumatic CVT was associated with a lower rate (p=0.005). In patients younger than age 50 (mean: 36.1 years, SD 9), headache and epilepsy were among the top five reasons for readmission. For patients older than 50 years (mean: 67.6 years, SD 11), cerebral infarction was among the top five reasons. Readmission rate stabilized over time. Conclusion: Cancer-related CVT was associated with significantly higher readmissions and traumatic CVT had significantly lower readmissions. The most common neurologic reasons for readmission differed by age group, but included headaches, seizures, and stroke. Readmission rates were highest in the first two years following discharge but stabilized over time.

Omega-3 Fatty Acids as Antiarrhythmic Drugs: Upstream Target Modulators Affecting Acute and Long-Term Pathological Alterations in Cardiac Structure and Function.

Postoperative atrial fibrillation (POAF) is a common complication in the acute care period following coronary artery bypass grafting (CABG) surgery that is associated with significant morbidity and mortality in both short-term and long-term settings. Recently, the Vaughn Williams Classification of antiarrhythmic agents, first proposed in 1975 and widely viewed as the authoritative description of their electrophysiologic actions, was updated and notably omega-3 fatty acids (Ω-3 fatty acids) have been included in class VII, described as "upstream target modulators," to mitigate pathological structural and electrophysiological remodeling changes in the aged and/or injured myocardium. A PubMed literature search was performed. Studies examining the significance of complications in patients undergoing isolated CABG surgery were selected for inclusion. Relevant data were qualitatively assessed and narratively summarized. POAF occurs in approximately 30% of patients, and inflammation from chronic coronary artery disease preoperatively, as well as acute atrial inflammation from surgery postoperatively are the leading causes. Inflammation underlies its pathophysiology; therefore Ω-3 fatty acids not only exhibit antiarrhythmic properties but are an effective anti-inflammatory treatment that may reduce the clinical risks of POAF. At present no effective prophylaxis is available to address POAF following CABG surgery. Clinical approaches that focus on the inflammatory response in this setting may optimize the response to treatment. The current literature supports the hypothesis that Ω-3 fatty acids may acutely reduce the inflammatory response via favorable alterations in the metabolism of prostaglandins and leukotrienes (eicosanoids) and specialized pro-resolving mediators.

Pressure ulcers and acute risk factors in individuals with traumatic spinal fractures with or without spinal cord injuries: A prospective analysis of the National Spinal Column/Cord Injury Registry of Iran (NSCIR-IR) data

PurposeTo identify risk factors for developing pressure ulcers (PUs) in the acute care period of traumatic spinal fracture patients with or without spinal cord injuries (SCIs). MethodsData were collected prospectively in participating the National Spinal column/Cord Injury Registry of Iran (NSCIR-IR) from individuals with traumatic spinal fractures with or without SCIs, inclusive of the hospital stay from admission to discharge. Trained nursing staff examined the patients for the presence of PUs every 8 h during their hospital stay. The presence and grade of PUs were assessed according to the European Pressure Ulcer Advisory Panel classification. In addition to PU, following data were also extracted from the NSCIR-IR datasets during the period of 2015 – 2021: age, sex, Glasgow coma scale score at admission, having SCIs, marital status, surgery for a spinal fracture, American Spinal Injury Association impairment scale (AIS), urinary incontinence, level of education, admitted center, length of stay in the intensive care unit (ICU), hypertension, respiratory diseases, consumption of cigarettes, diabetes mellitus and length of stay in the hospital. Logistic regression models were used to estimate the unadjusted and adjusted odds ratio (OR) with 95% confidence intervals (CI). ResultsAltogether 2785 participants with traumatic spinal fractures were included. Among them, 87 (3.1%) developed PU during their hospital stay and 392 (14.1%) had SCIs. In the SCI population, 63 (16.1%) developed PU during hospital stay. Univariate logistic regression for the whole sample showed that marital status, having SCIs, urinary incontinence, level of education, treating center, number of days in the ICU, age, and Glasgow coma scale score were significant predictors for PUs. However, further analysis by multiple logistic regression only revealed the significant risk factors to be the treating center, marital status, having SCIs, and the number of days in the ICU. For the subgroup of individuals with SCIs, marital status, AIS, urinary incontinence, level of education, the treating center, the number of days in the ICU and the number of days in the hospital were significant predictors for PUs by univariate analysis. After adjustment in the multivariate model, the treating center, marital status (singles vs. marrieds, OR = 3.06, 95% CI: 1.55 – 6.03, p = 0.001), and number of days in the ICU (OR = 1.06, 95% CI: 1.04 – 1.09, p < 0.001) maintained significance. ConclusionsThese data confirm that individuals with traumatic spinal fractures and SCIs, especially single young patients who suffer from urinary incontinence, grades A-D by AIS, prolonged ICU stay, and more extended hospitalization are at increased risk for PUs; as a result strategies to minimize PU development need further refinement.

Falls in Older Adults Requiring Emergency Services: Mortality, Use of Healthcare Resources, and Prognostication to One Year.

IntroductionOlder adults who fall commonly require emergency services, but research on long-term outcomes and prognostication is sparse. We evaluated older adults transported by ambulance after a fall in the Northwestern United States (US) and longitudinally tracked subsequent healthcare use, transitions to skilled nursing, hospice, mortality, and prognostication to one year.MethodsThis was a planned secondary analysis of a cohort study of community-dwelling older adults enrolled from January 1–December 31, 2011, with follow-up through December 31, 2012. We included all adults ≥ 65 years transported by 44 emergency medical services agencies in seven Northwest counties to 51 hospitals after a fall. We matched Medicare claims, state inpatient data, state trauma registry data, and death records. Outcomes included mortality, healthcare use, and new claims for skilled nursing and hospice to one year.ResultsThere were 3,159 older adults, with 147 (4.7%) deaths within 30 days and 665 (21.1%) deaths within one year. There was an initial spike in inpatient days, followed by increases in skilled nursing and hospice. We identified four predictors of mortality: respiratory diagnosis; serious brain injury; baseline disability; and Charlson Comorbidity Index ≥ 2. Having any of these predictors was 96.6% sensitive (95% confidence interval [CI]: 95.7, 97.5%) and 21.4% specific (95% CI: 19.9, 22.9%) for 30-day mortality, and 91.6% sensitive (95% CI: 89.5, 93.8%). and 23.8% specific (95% CI: 22.1, 25.5%) for one-year mortality.ConclusionCommunity-dwelling older adults requiring ambulance transport after a fall have marked increases in healthcare use, institutionalized living, and mortality over the subsequent year. Most deaths occur following the acute care period and can be identified with high sensitivity at the time of the index visit, yet with low specificity.

Illness Perceptions, Disabilities, and Quality of Life of Patients With Hand Injury: A Prospective Study.

Few studies have tracked hand injury patients past the acute care period. Postdischarge tracking of hand injury patients may identify time points most patients require assistance, which can help direct interventions to reduce post-hand injury sequelae. To examine hand injury patients' experiences during early recovery to illness perceptions, disabilities, and quality of life and to identify predictors of quality of life at 1 month and 3 months after hospital discharge. This prospective observational study of hand injury patients was performed at a teaching hospital in Taiwan. Data were collected at patient discharge, 1 month, and 3 months after discharge, from January 2017 to October 2018. The variables measured included illness perceptions, disabilities, and quality of life. A total of 117 patients participated in the study. The patients reported more positive illness perceptions at 3 months versus 1 month after discharge. The impact of disabilities on patient work was significantly greater at 1 month than at 3 months after discharge. Quality of life was better at 3 months than at 1 month after discharge. Predictors of quality of life after hospital discharge were demographic variables, clinical variables, and illness perceptions. Patients with lower education reported poorer psychological quality of life after discharge. Primary care providers should perform a comprehensive assessment of patients prior to their discharge. Patients should undergo regular follow-ups to reduce comorbidities and improve their outcomes.

The Cost of a Fall Among Older Adults Requiring Emergency Services.

The cost of a fall among older adults requiring emergency services is unclear, especially beyond the acute care period. We evaluated medical expenditures (costs) to 1 year among community-dwelling older adults who fell and required ambulance transport, including acute versus post-acute periods, the primary drivers of cost, and comparison to baseline expenditures. Retrospective cohort analysis. Forty-four emergency medical services agencies transporting to 51 emergency department in seven northwest counties from January 1, 2011, to December 31, 2011, with follow-up through December 31, 2012. We included 2,494 community-dwelling adults, 65 years and older, transported by ambulance after a fall with continuous fee-for-service Medicare coverage. The primary outcome was total Medicare expenditures to 1 year (2019 U.S. dollars), with separation by acute versus post-acute periods and by cost category. We included 48 variables in a standardized risk-adjustment model to generate adjusted cost estimates. The median age was 83 years, with 74% female, and 41.9% requiring admission during the index visit. The median total cost of a fall to 1 year was $26,143 (interquartile range (IQR) = $9,634-$68,086), including acute care median $1,957 (IQR = $1,298-$12,924) and post-acute median $20,560 (IQR = $5,673-$58,074). Baseline costs for the previous year were median $8,642 (IQR = $479-$10,948). Costs increased across all categories except outpatient, with the largest increase for inpatient costs (baseline median $0 vs postfall median $9,477). In multivariable analysis, the following were associated with higher costs: high baseline costs, older age, comorbidities, extremity fractures (lower extremity, pelvis, and humerus), noninjury diagnoses, and surgical interventions. Compared with baseline, costs increased for 74.6% of patients, with a median increase of $12,682 (IQR = -$185 to $51,189). Older adults who fall and require emergency services have increased healthcare expenditures compared with baseline, particularly during the post-acute period. Comorbidities, noninjury medical conditions, fracture type, and surgical interventions were independently associated with increased costs.

Understanding factors that contribute to variations in bronchiolitis management in acute care settings: a qualitative study in Australia and New Zealand using the Theoretical Domains Framework

BackgroundBronchiolitis is the most common reason for infants under one year of age to be hospitalised. Despite management being well defined with high quality evidence of no efficacy for salbutamol, adrenaline, glucocorticoids, antibiotics or chest x-rays, substantial variation in practice occurs. Understanding factors that influence practice variation is vital in order to tailor knowledge translation interventions to improve practice. This study explores factors influencing the uptake of five evidence-based guideline recommendations using the Theoretical Domains Framework.MethodsSemi-structured interviews were undertaken with clinicians in emergency departments and paediatric inpatient areas across Australia and New Zealand exploring current practice, and factors that influence this, based on the Theoretical Domains Framework. Interview transcripts were coded using thematic content analysis.ResultsBetween July and October 2016, 20 clinicians (12 doctors, 8 nurses) were interviewed. Most clinicians believed chest x-rays were not indicated and caused radiation exposure (beliefs about consequences). However, in practice their decisions were influenced by concerns about misdiagnosis, severity of illness, lack of experience (knowledge) and confidence in managing infants with bronchiolitis (skills), and parental pressure influencing practice (social influences). Some senior clinicians believed trialling salbutamol might be of benefit for some infants (beliefs about consequences) but others strongly discounted this, believing salbutamol to be ineffective, with high quality evidence supporting this (knowledge). Most were concerned about antibiotic resistance and did not believe in antibiotic use in infants with bronchiolitis (beliefs about consequences) but experienced pressure from parents to prescribe (social influences). Glucocorticoid use was generally believed to be of no benefit (knowledge) with concerns surrounding frequency of use in primary care, and parental pressure (social influences). Nurse’s reinforced evidence-based management of bronchiolitis with junior clinicians (social/professional role and identity). Regular turnover of medical staff, a lack of ‘paediatric confident’ nurses and doctors, reduced senior medical coverage after hours, and time pressure in emergency departments were factors influencing practice (environmental context and resources).ConclusionsFactors influencing the management of infants with bronchiolitis in the acute care period were identified using the Theoretical Domains Framework. These factors will inform the development of tailored knowledge translation interventions.

Survival Analysis of the Clinical Episodes of Stroke Using Data from Western Delta Region of Nigeria

This study is designed to investigate the epidemiology of stroke burden in Western Delta Region of Nigeria. To achieve this, statistical tools were used to analyze and interpret the prevalence of this diseases in the study area- with focus on the medical records (case files) of hundred and twenty-one (221) patients who suffered from stroke and were seen at selected government hospitals in the region, from 2003- 2016. The clinical episodes (CEs) of stroke for the patients who were admitted during acute care period (without discharge against medical advice) and were then assessed for various investigations and treatment interventions and long term care were obtained and statistically studied. The Kaplan-Meier survival estimator shows the survival rate to be 75% in 2003 and 25% in 2016. The year 2009 recorded the highest CEs (28) with survival function (0.23) and 2014 the lowest (4) with survival function (0.11). These have implications for all stakeholders in health matters in the study area. The study recommends an organized effort from both the government and the private sector to tackle the rising stroke burden in Western Delta Region of Nigeria.

Association of Specific Lower Extremity Injuries With Delayed Amputation.

Despite medical interventions to preserve viability and functionality of injured limb(s) among combat-injured service members, delayed amputations may occur. The goal of this study was to determine whether specific lower extremity (LE) injuries were associated with delayed amputations. The Expeditionary Medical Encounter Database was queried for combat-related LE injuries between 2003 and 2015. The Abbreviated Injury Scale (AIS) was used to categorize LE injuries by severity. Injury episodes with a maximum LE AIS of 1 or amputation on the day of injury were excluded. The final sample included 2,996 service members with at least one LE injury with an AIS ≥2. The frequencies of specific LE fractures and nerve and vessel injuries were determined. Logistic regression with paired independent variables was performed to examine the impact of multiple LE injuries on the odds of delayed amputation. Delayed LE amputation was identified in 308 (10.3%) service members in the sample. The delayed and no amputation groups did not differ in age and service branch. The majority of injury episodes were blast-related and with an Injury Severity Score ≥9. The most frequent fractures were tibia (34.4%) and fibula (29.3%), but the highest rates of delayed amputation were in those with navicular (36.2%), talus (30.0%), or calcaneus (28.1%) fractures. Odds of amputation were highest among service members with the calcaneus fracture and LE nerve injury (odds ratio [OR]: 41.74; 95% confidence interval [CI], 14.70, 118.55; p < 0.001), calcaneal fracture and LE vessel injury (OR: 17.99; 95% CI: 10.53, 30.74; p < 0.001), and calcaneus and tibia fractures (OR: 15.12; 95% CI: 9.54, 23.96; p < 0.001) combinations. Odds of delayed amputation increased substantially with specific injury combinations. These findings may guide clinical decision-making in the acute care period.

The Impact of Pre-existing Health Conditions on Cost of Recovery after Workplace Injury: Insight from population-based data linkage in the State of Victoria, Australia

ABSTRACTObjectiveComorbidity is known to affect length of hospital stay and mortality after trauma but less is known about its impact on recovery beyond the acute care period. A main challenge to study the impact of pre-existing conditions is that information on these conditions is not collected systematically and comprehensively. The aim of this study was to investigate the role of pre-existing health conditions in recovery from workplace injury using linked data. ApproachIn Victoria, Australia, approximately 85% of the labour force is covered by the state workers compensation scheme regulated by WorkSafe Victoria. The scheme provides financial compensation for healthcare and income support to eligible injured workers. . One year of WorkSafe claims for injuries that occurred between 1/07/2008 and 31/06/2009 (N = 49,171) were linked to eight years of pre-injury hospital admission admissions and emergency department presentations, received from the state Department of Health and Human Services. Main outcomes of the study included the total and categorical cost of recovery (e.g. hospital, medical, allied health) measured over short (2-6 months), medium (1-2 years) and long-term (5 years) periods. All models controlled for characteristics of the worker, workplace and injury.ResultsThe preliminary results show that the cost of recovery from workplace injury is significantly associated with history of pre-injury admissions: Workers with pre-injury admissions have higher cost of recovery including longer periods of time off work as well as further cost of health service use during recovery. As this is an ongoing project, further detailed results will be presented at the conference such as the impact of admission under each category of pre-existing conditions according to ICD codes on a wide range of outcomes after workplace injury.Conclusion Our findings are expected to help government injury compensation regulators to better understand the drivers of compensation costs and other key system outcomes such as return to work. The findings will support better allocation of financial resources, better internal management of claims and efficient allocation of physical and human resources and therefore greater client satisfaction leading to ensuring faster recovery, return to work and more effective as well as efficient service provision.

Diagnostic performance of S100B protein serum measurement in detecting intracranial injury in children with mild head trauma

ObjectiveTo assess the accuracy of S100B serum level to detect intracranial injury in children with mild traumatic brain injury.MethodsA multicenter prospective cohort study was carried out in the paediatric emergency...

Ischemic Stroke: A Consequence of a Diseased Immune System?

Stroke is a leading cause of long-term disability and the second leading cause of death globally. Approximately 795,000 strokes are reported each year in the US, 87 percent of which are ischemic. [1] The direct medical cost associated with stroke in 2009 was approximately $22.8 billion, with an additional $13.8 billion in indirect costs associated with lost productivity, unemployment, rehabilitation, and follow-up care [1]. The incidence of stroke is expected to increase dramatically over the next decade primarily because of an increase in the elderly population and increased incidence of stroke among the middle-aged population. We must develop and implement improved acute and long-term care options to mitigate the increasing burden of stroke. This special edition was designed to address innovative areas of stroke research that are expected to have a tremendous impact on current and future clinical care of stroke patients. Historically, ischemic stroke has been studied and treated as a disease of the cerebrovascular system. However, there is a well-characterized and understudied immunological response to ischemic stroke that provides an opportunity for targeting novel therapeutic and rehabilitation strategies. In the opening articles, Doll et al. and Famakin describe the innate and adaptive immune response to stroke and suggests the time window for targeting the immune response to stroke may be longer than previously expected. Studies are needed to follow stroke patients over the course of their injury and recovery to identify time specific patterns of cytokine responses and potential avenues for anti-inflammatory treatment beyond the acute care period. In the third article by Schulze et al, we are reminded of the significant contribution the catecholamine and steroid responses have on guiding the immune response to stroke recovery. Petrone et al. also describes the effects of estrogen on the immune response and how this modulation of the immune response may account for sex differences in ischemic stroke incidence and severity. Continued study in this area will not only be important for stroke, but also other types of brain injuries (traumatic, blast, neurodegenerative) that inevitably alter the hormonal balance and subsequently have immunological consequences. It is interesting to consider whether a common mechanism of immune dysfunction underlies many complex diseases, such as stroke, heart disease, myocardial infarction, and atherosclerosis. While it is possible that the immune system is similarly altered, gene-environment interactions may control the timing or severity of the dysfunction, and epigenetic modifications may provide a common molecular mechanism to link the immune response among different disease states. In their review, Saban et al. propose a new theoretical model to guide ischemic stroke research to further understand the extent to which epigenetic signatures bridge the psycho-social environment. Our knowledge of the epigenetic control of the immunological consequences of ischemic stroke is limited and requires a new approach to clinical and pre-clinical studies. The question remains whether we can truly model the human condition of ischemic stroke. Given the advances in genomic technology, systems modeling, and biomedical engineering we must re-invent stroke research and begin to utilize human patients as the best model to study the condition. Thus, new collaborations between scientists, clinicians, engineers and patients will be the key to future success. We hope this special edition broadens your horizons to the possibility of ischemic stroke being an immunological disease. Before we can begin to make significant improvements in clinical care of stroke, we must strengthen our research collaborations and be creative in our approach. Our patients depend on it.

High Burden of Palliative Needs among Older Intensive Care Unit Survivors Transferred to Post–Acute Care Facilities. A Single-Center Study

Adults with chronic critical illness (tracheostomy after ≥ 10 d of mechanical ventilation) have a high burden of palliative needs, but little is known about the actual use and potential need of palliative care services for the larger population of older intensive care unit (ICU) survivors discharged to post-acute care facilities. To determine whether older ICU survivors discharged to post-acute care facilities have potentially unmet palliative care needs. We examined electronic records from a 1-year cohort of 228 consecutive adults ≥ 65 years of age who had their first medical-ICU admission in 2009 at a single tertiary-care medical center and survived to discharge to a post-acute care facility (excluding hospice). Use of palliative care services was defined as having received a palliative care consultation. Potential palliative care needs were defined as patient characteristics suggestive of physical or psychological symptom distress or anticipated poor prognosis. We examined the prevalence of potential palliative needs and 6-month mortality. The median age was 78 years (interquartile range, 71-84 yr), and 54% received mechanical ventilation for a median of 7 days (interquartile range, 3-16 d). Six subjects (2.6%) received a palliative care consultation during the hospitalization. However, 88% had at least one potential palliative care need; 22% had chronic wounds, 37% were discharged on supplemental oxygen, 17% received chaplaincy services, 23% preferred to not be resuscitated, and 8% were designated "comfort care." The 6-month mortality was 40%. Older ICU survivors from a single center who required postacute facility care had a high burden of palliative care needs and a high 6-month mortality. The in-hospital postcritical acute care period should be targeted for palliative care assessment and intervention.

Cost Burden of Post Stroke Condition in Nigeria: A Pilot Study

Aim:Estimation of cost burden of a disease condition is a very important part of health care policy making worldwide. Till now, such documents are lacking especially on non-communicable diseases in the health policy making process in Nigeria. This article therefore attempts to report the results of a prospective cross-sectional study on the cost burden of a cerebrovascular accident condition (stroke) in Nigeria. It estimates the direct health care cost for a minimum period of 12weeks and maximum of 36weeks for post stroke hemiplegia.Study Design/Setting:It was a collaborative cross-sectional study amongst centers situated in urban and sub-urban environments in Southern Nigeria. It involved a hospital of an Oil and Gas Company in Port Harcourt, Nigeria, two Government tertiary hospitals in Port Harcourt and Benin-City, all in South-South Nigeria, the industrial hub of the country. A Private Specialist hospital in Lagos, South-West Nigeria, the corporate hub of the country was also included.Method:Patients diagnosed and admitted for management for cerebrovascular accident (stroke) in the above named health facilities formed the subjects of this study. Medical records (case files) of two hundred and forty (240) stroke patients managed within the last six years (2005- 2011) were randomly selected from the medical record departments of the study centers. Files of the patients who were admitted during acute care period (without discharge against medical advice) and were followed on out-patient basis without default within the study period were purposively utilized. The files were then assessed for the various investigations and treatment interventions of acute and long term care and the costs thereof. Ethical approval to access patients’ case files was sought and granted by the Research Ethics Committee of the different study centers.Results:The results revealed that it requires an average of N95,100: 00 ($600) and N767,900: 00 ($4860)in a government and a private hospital, respectively to access care within the first 36weeks of post stroke affectation in Nigeria.Conclusion:The outcome of this study suggests that managing stroke constitutes a huge direct cost burden unaffordable by an average Nigerian stroke sufferer. The implication is that lack of means for rehabilitative care may result in disability adjusted life years which further compounds burdens in terms of indirect cost on the sufferers’ and care givers’ productivity. It is therefore recommended that awareness of this disorder is created by policy makers and implementers where it does not exist and increased where it does with health promotion and preventive measures.

Recent Trends in the Care of Patients With Non–ST-Segment Elevation Acute Coronary Syndromes

The extent to which national health quality improvement initiatives have altered reported treatment gaps among patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) is unknown. We sought to determine recent trends in adherence to guideline-based therapies for NSTE ACS. We evaluated the treatment of patients with high-risk (positive cardiac markers and/or ischemic ST-segment changes) NSTE ACS enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA (American College of Cardiology/American Heart Association) Guidelines (CRUSADE) Quality Improvement Initiative from 2002 through 2004 (a total of 113 595 patients over 11 calendar quarters). We analyzed adherence to guideline-recommended therapies, including medications used in the acute care period (<24 hours after presentation), invasive procedures, in-hospital outcomes, and discharge therapies and interventions. The use of each class I guideline recommendation, as well as overall adherence to the guidelines, improved significantly (P<.001) during the study period. In the acute care setting, the use of antiplatelet agents increased by 5% and beta-blockers by 12%; at hospital discharge, the use of antiplatelet agents increased by 3% and beta-blockers by 8%. Heparin use in the acute care period increased by 6%, largely owing to a 9% increase in the use of low-molecular-weight heparin. Use of glycoprotein IIb/IIIa inhibitors in the acute care period also increased by more than 13%. At discharge, clopidogrel use increased by 22%, lipid-lowering agents by 11%, and angiotensin-converting enzyme inhibitors by 5%. While adherence improved, many patients still failed to receive 100% indicated treatments at the end of the study period. During the 4 years since the initial release of the ACC/AHA guidelines for NSTE ACS, adherence to class I recommendations has significantly improved among hospitals participating in CRUSADE. Still, further improvements are needed for optimal implementation of the these guidelines.

Health care and social welfare costs in home‐based and hospital‐based rehabilitation after stroke

During the 1990s most western European and Organization of Economic Cooperation and Development (OECD) countries experienced financial difficulties and were forced to cut back on or restrain health care expenditures. Home rehabilitation has received attention in recent years because of its potential for cost containment. Often forgotten, however, is the redistribution of costs from one caregiver to another. The aim of this study was to analyse whether a redistribution of costs occurs between health care providers (the County councils) and social welfare providers (the municipalities) in a comparison of home-based rehabilitation and hospital-based rehabilitation after stroke. The study population included 123 patients, 53 in the home-based rehabilitation group and 68 in the hospital-based rehabilitation group. The patients were followed up at 6 and 12 months after onset of stroke. Resource use over a 12-month period included acute hospital care, in-hospital rehabilitation, home rehabilitation and use of home-help service as well as nursing home living. The hospital-based rehabilitation group had significantly fewer hospitalization days after a decision was made about rehabilitation at the acute care ward and consequently the cost for the acute care period was significantly lower. The cost for the rehabilitation period was significantly lower in the home-based rehabilitation group. However, the cost for home help service was significantly higher in the home-based rehabilitation group. The total costs for the care episode did not differ between the two groups. The main finding of this study is that there seems to occur a redistribution of costs between health care providers and social welfare providers in home rehabilitation after stroke in a group of patients with mixed degree of impairment.

Predictors of outcome in severely head-injured children.

Determine variables in the acute care period associated with survival and pediatric intensive care unit (PICU) length of stay (LOS) for children with severe traumatic brain injury. Retrospective cohort. Level 1 pediatric trauma center. Children (0-17 yrs) admitted 1991 to 1995 with nonpenetrating traumatic brain injury and admission Glasgow Coma Scale score of <or=8. None. The first 72 hrs of hospitalization were analyzed in detail for 136 patients. The primary end point was survival; secondary end points were PICU LOS, cost, and day at which Glasgow Coma Scale score was >or=14. Predictors of outcome were abstracted, including Pediatric Trauma Score, Glasgow Coma Scale score, Pediatric Risk of Mortality, physiologic variables, computed tomography evidence of brain injury, and neuroresuscitative medications. The fatality rate was 24%. Age and gender were similar between groups (p >or= .1). Survival was independently predicted by 6-hr Glasgow Coma Scale score (odds ratio [OR] 4.6; 95% confidence interval [CI] 2.06-11.9; p < .001) and maximum systolic blood pressure (OR 1.05; 95% CI 1.01-1.09; p < .02). Odds of survival increased 19-fold when maximum systolic blood pressure was >or=135 mm Hg (OR 18.8; 95% CI 2.0-178.0; p < .01). By discharge, 67% of patients had an age-appropriate Glasgow Coma Scale score. Median hospital costs were 8,798 dollars for survivors: only mannitol use independently predicted high cost (odds ratio 4.9; 95% CI 1.2-19.1; p < .01). For survivors, median PICU LOS was 2 days, although 25% had LOS >6 days. Six-hour Glasgow Coma Scale score (OR 0.62; 95% CI 0.48-0.80; p < .001) and mannitol (OR 7.9; 95% CI 2.3-27.3; p < .001) were each independently associated with a prolonged LOS among survivors. Patients with higher 6-hr Glasgow Coma Scale scores were more likely to survive. Adjusting for severity of injury, survival was associated with maximum systolic blood pressure >or=135 mm Hg, suggesting that supranormal blood pressures are associated with improved outcome. Mannitol administration was associated with prolonged LOS, yet conferred no survival advantage. We suggest reevaluation of blood pressure targets and mannitol use in children with severe traumatic brain injury.

Postcomatose unawareness/vegetative state following severe brain injury: a content methodology.

Postcomatose unawareness/vegetative state (PCU/VS) is an altered state of consciousness that may follow coma. It is characterized by wakefulness without awareness of self or the environment. While most frequently associated with trauma, it is also associated with anoxia, vascular injury or encephalitis. In this article, the clinical phenomenon of PCU/VS is explored using the content methodology process (CMP) in order to explicate content for nursing practice. There are five steps in the process: literature review, identification of the characteristic features and patient behaviors associated with PCU/VS, description of the specific abilities that are affected, formulation of nursing assessment and intervention approaches, and evaluation of these approaches in clinical practice and research. In this article, there is an extensive review and analysis of the literature related to PCU/VS. Substantive nursing knowledge was developed using the CMP. It was determined that the Freeman Questionnaire and the Sensory Stimulation Assessment Measure are appropriate tools to assess the interpretative abilities of patients with PCU/VS during the acute care period. Sensory regulation techniques that are appropriate for use during patient care to promote the recovery of cognitive abilities were identified. Both the recommended tools and the intervention approaches require further validation in empirical research.

Towards a disability-oriented epidemiology of traumatic brain injury.

The aim of this study was to investigate the value of using a disability-oriented approach to the epidemiology of traumatic brain injury (TBI) in order to improve health administration by preventing long-term sequelae. The epidemiology of disease was established by registration system of inpatients which covers more than 99% of all hospital admissions in The Netherlands. Some international differences and national trends are discussed. The disability-related epidemiology was investigated by means of structured interviews, 3-7 years after the injury, in a clustered sample of 51 patients with major TBI according to the ICD-9-CM. The survey included evaluation scales such as the Sickness Impact Profile, the Barthel Index, and a Disability Rating Questionnaire. Concerning the disease-related epidemiological data, the overwhelming majority of all TBI patients went home, which suggests good recovery. Nevertheless, the disability-oriented research revealed long-term situational, cognitive and behavioral disabilities in at least 67% of the major-TBI population, whereas only 10% received any rehabilitation services at all after the acute-care period. It is concluded that preventive measures and a comprehensive service for brain injury survivors should be based both on disease and disability-oriented data.