General Medical Ward Care Research Articles

Effects of Interdisciplinary Team Care Interventions on General Medical Wards: A Systematic Review.

Improving the quality of health care for general medical patients is a priority, but the organization of general medical ward care receives less scrutiny than the management of specific diseases. Optimizing teams' performance improves patient outcomes in other settings, and interdisciplinary practice is a major target for improvement efforts. However, the effect of interdisciplinary team interventions on general medical ward care has not been systematically reviewed. To describe the range of objective patient outcomes used in studies of general medical ward interdisciplinary team care, and to evaluate the performance of interdisciplinary interventions against them. We searched EMBASE, MEDLINE, and PsycINFO from January 1, 1998, through December 31, 2013, for interdisciplinary team care interventions in adult general medical wards using an objective patient outcome measure. Reference lists of included articles were also searched. The last search was conducted on January 29, 2014, and the narrative and statistical analysis was conducted through December 1, 2014. Study quality was assessed using the Cochrane Effective Practice and Organization of Care group's tool. Thirty of 6934 articles met the selection criteria. The studies included 66,548 patients, with a mean age of 63 years. Nineteen of 30 (63%) studies reported length of stay, readmission, or mortality rate as their primary outcome, or did not specify the primacy of their outcomes. The most commonly reported objective patient outcomes were length of stay (23 of 30 [77%]), complications of care (10 of 30 [33%]), in-hospital mortality rate (8 of 30 [27%]), and 30-day readmission rate (8 of 30 [27%]). Of 23 interventions, 16 (70%) had no effect on length of stay, 12 of 15 (80%) did not reduce readmissions, and 14 of 15 (93%) did not affect mortality. Five of 10 (50%) interventions reduced complications of care. In an exploratory quantitative analysis, the interventions did not consistently reduce the relative risk of early readmission or early mortality, or the weighted mean difference in length of stay. All studies had a medium or high risk of bias. Current evidence suggests that interdisciplinary team care interventions on general medical wards have little effect on traditional measures of health care quality. Complications of care or preventable adverse events may merit inclusion as quality indicators for general medical wards. Future study should clarify how best to implement interdisciplinary team care interventions and establish quality metrics that are credible to both health care professionals and patients in this setting.

Early mobilization after stroke: early adoption but limited evidence.

In the last decade, increasing attention has been paid to understanding the components of care that might contribute to the stroke unit effect. Early mobilization, in its many guises, is one component of care proposed to contribute to the survival and recovery benefits of stroke unit care.1 This topical review provides an overview of the current evidence, research, and practice recommendations for early mobilization after stroke. As a term, early mobilization is problematic. There is no common understanding of the meaning of early (eg, hours, days, weeks, months) or mobilization (movement of, eg, cells, joints, limbs, people). A recurring theme in this review, inadequate definition currently limits our ability to synthesize information on the topic. For example, in some clinical trials of mobility interventions started soon after stroke, mobilization is used to describe a program of task-specific standing and walking retraining (rehabilitation) delivered by therapists or nurses and continued throughout the acute hospital stay.2,3 In other cases, mobilization refers simply to moving a patients’ limbs in bed or sitting them out of bed. The timing of commencement of activity is also highly variable and often hard to determine. As both what we do (intervention type, intensity, frequency, amount), and when we do it, may confer benefit or harm, we highlight variations in definition where relevant. We have focused our review on out-of-bed interventions commencing in the first 24 to 72 hours after stroke, as this is the period of greatest clinical uncertainty. Early mobilization was first discussed at a Swedish consensus conference on stroke care in the mid-1980s (Bo Norving and Bent Indredavik, personal communication, 2014) with several local guidelines in Norway and Sweden recommending the practice. Early mobilization became more prominent in the literature in the early 1990s when Indredavik and colleagues reported their clinical …

Abstract T P271: Establishment of Stroke Ward Results in Immediate Reduction of Major Complications

Background and Purpose: Randomized controlled trials have consistently shown that stroke units decrease both mortality and morbidity compared with conventional care in general medical wards. There are however limited data on the specific types of in-hospital medical complications and their effect on outcomes. The objective of this study was to determine whether establishing a specialized geographically defined Stroke Ward results in reducing the major complications in patients suffering from acute stroke within the same hospital system. Methods: This is a prospective study from January 2014 till July 2014. Data was collected from a web-based stroke registry in two phases. In phase 1 (from January 1, 2014 till March 08, 2014), we collected data of stroke patients admitted at in the medical wards. In phase 2, a protocol-based multidisciplinary care Stroke Ward became operational where most of the patients were admitted. Outcomes measures were number and type of complications, mortality, discharge disposition, and length of stay, and were adjusted for age, sex, and medical co-morbidities. Results: There were 130 admissions in phase 1 and 345 in phase 2. Commonest complications included, aspiration pneumonia 29% vs 12% (p<0.001) and pressure ulcers in 35% vs 11% (p<0.001). Average length of stay decreased from 12 days to 4 days (p<0.001). In phase 1, 70 % of patients were discharged home, while 23% were transferred to rehabilitation while in phase 2, 75% of patients were discharged home, while 18% patients were sent to rehabilitation. Ninety percent of complications happened in medical wards, mainly in patients who over stayed in emergency department (more than 8 hours) waiting for bed in Stroke Ward or medical floor. Conclusion: A protocol based multidisciplinary care Stroke Ward care significantly reduces common early complications of acute stroke. It also helps in significantly reducing the length of stay, saving total bed days at a tertiary care hospital, hence improving the overall care of these patients.

Selective admission into stroke unit and patient outcomes: a tale of four cities.

Care of stroke patients costs considerably more in specialized stroke units (SU) compared to care in general medical wards (GMW) but the technology may be cost effective if it leads to significantly improved outcomes. While randomized control trials show better outcomes for stroke patients admitted to SU, observational studies report mixed findings. In this paper we use individual level data from first-ever stroke patients in four European cities and find evidence of selection by the initial severity of stroke into SU in some cities. In these cases, the impact of admission to SU on outcomes is overestimated by multivariate logit models even after controlling for case-mix. However, when the imbalance in patient characteristics and severity of stroke by admission to SU and GMW is adjusted using propensity score methods, the differences in outcomes are no longer statistically significant in most cases. Our analysis explains why earlier studies using observational data have found mixed results on the benefits of admission to SU.

Impact of Stroke Care Unit on Patient Outcomes in a Community Hospital

Geographically distinct multidisciplinary stroke care units (SCUs) have been shown by systematic reviews to have superior patient outcomes compared with conventional care in general medical wards. However, the effectiveness of SCUs in smaller North American community hospitals is less well defined. The objective of this study was to determine the impact of establishing a specialized SCU at a community hospital on patient outcomes. This is a retrospective cohort study of 805 patients with stroke admitted to 2 community hospitals in Edmonton, Canada, from 2003 to 2009 using an administrative database. Stroke was identified by International Classification of Disease, 10th Edition, codes. One of the community hospitals established a SCU on January 1, 2007. This date was used to subdivide the patient population into 2 cohorts: phase 1 from 2003 to 2006 and phase 2 from 2007 to 2009. Outcomes measured were mortality, discharge disposition, length of stay, and complications and were adjusted for age, sex, and medical comorbidities. Patient mortality decreased significantly from 17.1% to 8.3% (adjusted odds ratio [OR], 0.54; 95% confidence interval [CI], 0.31-0.95) after SCU implementation, whereas it remained ≈19% at the control hospital. SCU also increased the odds that patients would be discharged home independently (adjusted OR, 2.17; 95% CI, 1.49-3.15; P<0.001] without increasing length of stay. Establishing a SCU in a community hospital not only increases the survival of stroke patients, but also the proportion of patients discharged home to live independently. The benefits of SCU reported in larger tertiary centers extend to smaller community hospitals with more limited resources.

Do All Age Groups Benefit From Organized Inpatient Stroke Care?

Organized inpatient stroke care consists of a multidisciplinary approach aimed at improving stroke outcomes. It is unclear whether elderly individuals benefit from these interventions to the same extent as younger patients. We sought to determine whether the reduction in mortality or institutionalization seen with organized stroke care was similar across all age groups. This was a case-cohort study of patients with acute ischemic stroke seen between July 2003 and March 2005 and captured in the Registry of the Canadian Stroke Network. After stratifying by age category, we assessed for evidence of effect modification by age on the reduction in stroke fatality associated with stroke unit/organized care. Among 3631 patients with ischemic stroke, stroke case-fatality at 30 days was lower for patients admitted to a stroke unit compared with those admitted to general medical wards (10.2% versus 14.8%; P<0.0001 with an absolute risk reduction=4.6%, number needed to treat=22). All age groups achieved a similar benefit of stroke unit care versus general medical ward care (absolute risk reduction for 30-day stroke fatality was 4.5% for <60 years; 3.4% for 60 to 69 years; 5.3% for 70 to 79 years; and 5.5% for those >80 years). Increasing levels of organized care were associated with lower stroke fatality or institutionalization. The beneficial effect of stroke units/organized care on survival was seen even after adjustment for multiple prognostic factors and after excluding patients on palliative approach. There was no evidence of effect modification by age in any analyses. Stroke units and organized inpatient care reduce death or institutionalization with the same magnitude of effect across all age groups.

Cost-Effectiveness of Stroke Unit Care Followed by Early Supported Discharge

Stroke places a significant burden on the economy in England and Wales with the overall societal costs estimated at pound7 billion per annum. There is evidence that both stroke units (SUs) and early supported discharge (ESD) are effective in treating patients with stroke. This study assesses the cost-effectiveness of the combination of these 2 strategies and compares it with the care provided in SU without ESD and in a general medical ward without ESD. The objective of this study was to model the long-term (10 years) cost-effectiveness of SU care followed by ESD. The study design was cost-effectiveness modeling. The study took place in SUs in the coverage area of the South London Stroke Register, UK. The modeled population was incident ischemic stroke cases (N=844) observed between 2001 and 2006. SU care followed by ESD was compared with SU care without ESD and general medical ward care without ESD. Main outcome measures were health service and societal costs and cost per quality-adjusted life-year gained. Using the cost-effectiveness threshold of pound30000, as commonly used in the UK, SU care followed by ESD is the cost-effective strategy compared with the other 2 options. The incremental cost-effectiveness ratio of SU care followed by ESD is pound10661 compared with the general medical ward without ESD care and pound17721 compared with the SU without ESD. SU care followed by ESD is both an effective and a cost-effective strategy with the main gains in years of life saved.

A Very Early Rehabilitation Trial (AVERT)

Inthedevelopedworld,oneinfourmenandoneinfivewomencan expect to suffer a stroke if they live to 85 years (1). Strokeresults in both premature death and disability however, incontrast tocoronaryheartdiseaseand cancer,its major burdenis chronicdisability rather than death (2). We know that strokepatients who have received organised multidisciplinary care inaStrokeCareUnit(SCU)environmenthavereducedmortalityand dependency (3). However, it is uncertain which compo-nents of the SCU management strategies are responsible forimproved outcomes. The strongest evidence for the benefit ofstarting mobilisation as early as possible after stroke comesfrom a post hoc analysis of the Norwegian randomized trial ofSCU vs. general medical ward care and using discharge at sixweeks as a surrogate outcome measure (4). Patients managedin the SCU (and receiving very early mobilisation, hereafterknown as VEM) were 64% less likely to be dead or disabled.Of the factors that distinguished stroke unit from generalmedical care, VEM was found to be the strongest predictor ofimprovedoutcometogetherwithbetter bloodpressurecontrol(5).Thisanalysis indicatedthatVEMmayaccountforas muchas 78% of the SCU benefit. Starting mobilisation (i.e. sittingout of bed, standing and walking) very early after stroke andcontinuing it at frequent intervals until discharge, may reducethe levelofdisabilityexperienced by strokepatients and reducethe number of patients requiring nursing home care (5).Although preliminary, the evidence from these studies hasprompted the inclusion of early mobilisation in acute strokecare best practice guidelines both in Australia (6) and inter-nationally (7). As there is only a low level of evidence tosupporttheseguidelinesthereisanobviousneedtoconductaninterventional trial of early mobilisation to determine whetherearly mobilisation of stroke patients is safe, improves out-comes and is cost effective. In order to do this we havecommenced A Very Early Rehabilitation Trial (AVERT). Ouris to determine the efficacy and cost effectiveness of this earlyintervention.AVERT differs from many previous rehabilitation trials on anumber of levels. First, it has been designed to mirror otheracute interventional trials of stroke such as thrombolysis andneuroprotection. This design objective was imperative giventhe frequently poor methodological quality of rehabilitationtrials. Second, AVERT is a large, multicentre randomisedcontrolled trial, adequately powered to detect a benefit ofsimilar magnitude to other proven interventions, with broadinclusion criteria to be assured that the result is generalisable.Finally, a detailed economic evaluation is included to allow acost effectiveness assessment to be made to assist in healthplanning and to allow comparison with other proven inter-ventions. If positivethese features should helpdrivechanges inclinical practice.The trial design is a randomised controlled trial of VEM(intervention) vs. standard care (control), with blinded assess-ment of outcome and intention-to-treat analysis.The hypothesis is that VEM of stroke patients (in addi-tion to standard care), compared with standard care alonewill:reduce death and disability at 3-month post stroke,reduce the number and severity of complications experi-enced by stroke patients,result in better quality of life at 12 months, andbe cost-effective.The study includes patients over 18 years with confirmedstroke admitted to hospital within 24h of onset of strokesymptoms. Patients must be rouseable. Patients who aremoderately to severely disabled before stroke (modified Ran-kin Scale (8) 42) will be excluded. In addition, we will excludethoseshowingrapidearlydeteriorationofsymptoms,orwithaconcurrent diagnosis of rapidly deteriorating disease (e.g.terminal cancer). Patients with unstable coronary or othermedical conditions that would impose hazard to the patientwill also be excluded. Physiological variables (e.g. heart rate,blood pressure, O

Is stroke unit care portable? A systematic review of the clinical trials

It is not known if mobile stroke teams can achieve the good results seen in trials of geographically discrete stroke wards (stroke units). To establish the effectiveness of mobile stroke teams. Systematic review of controlled clinical trials that compared peripatetic systems of organised stroke care (stroke team care) with alternative hospital services. Systematic review and meta-analysis (using Cochrane Collaboration methodology and involving the primary trialists). Clinical outcomes included death, dependency, the need for institutional care and measures of the process of care such as the delivery of key investigations and treatments. Six clinical trials (1,085 patients) were identified; five (781 patients) compared some form of stroke team care with conventional care in general medical wards and one (304 patients) compared team care with a comprehensive stroke unit. Compared with care in general wards, stroke team care improved some aspects of the process of care, but clinical outcomes were similar. Compared with a comprehensive stroke unit, stroke team patients were significantly less likely to survive (P <0.001), return home (P < 0.001) or regain independence (P < 0.0001). Most aspects of the process of care were also poorer than in the stroke unit. Care from a mobile stroke team had no major impact on death, dependency or the need for institutional care.

Suicide; A Statement of Suffering

This article is designed to focus on the provision of nursing care in general medical wards following the admission of persons who have attempted suicide or who have a previous history of attempting suicide. The authors explore, analyse and synthesize how nurses, as key players in the health care team, may begin by recognizing the uniqueness of the individual, and by cotravelling therapeutically with the person on part of his or her journey towards recovery and healing. Efforts are made to demonstrate how nurses can influence the health gain of this group of people and their families. Professional attitudes and related ethical aspects, such as autonomy, respect for autonomy and paternalism, are also examined within the context of the nursing care of people who have attempted suicide. The need to enhance sensitive and caring communication skills for nurses who work with this group of people is tentatively considered. Some reasoning about why there may be difficulties in specific areas of communication such as empathy are contested and explored.

Suicide: a statement of suffering.

This article is designed to focus on the provision of nursing care in general medical wards following the admission of persons who have attempted suicide or who have a previous history of attempting suicide. The authors explore, analyse and synthesize how nurses, as key players in the health care team, may begin by recognizing the uniqueness of the individual, and by cotravelling therapeutically with the person on part of his or her journey towards recovery and healing. Efforts are made to demonstrate how nurses can influence the health gain of this group of people and their families. Professional attitudes and related ethical aspects, such as autonomy, respect for autonomy and paternalism, are also examined within the context of the nursing care of people who have attempted suicide. The need to enhance sensitive and caring communication skills for nurses who work with this group of people is tentatively considered. Some reasoning about why there may be difficulties in specific areas of communication such as empathy are contested and explored.

An Assessment of Intermediate Coronary Care

The effect of intermediate coronary care, with and without ECG monitoring, was compared with general medical ward care on the basis of mortality, resuscitation, and detection and treatment of arrhythmias from days 3 to 14 after admission in 2,095 cases of acute coronary heart disease. Mortality was significantly reduced (P less than .02), and number of successful resuscitations for ventricular fibrillation was increased (P less than .05) but only in the unit with monitoring. Number of arrhythmias detected was significantly increased, particularly incidence of ventricular ectopics and heart block (P less than .02). Number of arrhythmias corrected to sinus rhythm was increased, but not significantly. Death from pulmonary embolism fell (P less than .01). Review of causes of death and autopsies showed an increased proportion of deaths due to intractable heart failure and cardiogenic shock. Not only specially trained nurses, but also ECG monitoring, were necessary to obtain the benefits of this treatment.