Discharge Destination Home Research Articles

Clarification of Factors Determining Discharge Destination Among Elderly Patients After Stroke With Low Levels of Independence in Activities of Daily Living: A Retrospective Study

To determine factors influencing discharge destination of elderly patients after stroke with low levels of independence in activities of daily living (ADL). Cross-sectional study. A community-based public hospital in a rural area in Japan. A total of 67 patients with low daily function among 205 elderly patients with stroke screened for eligibility (N=67). Not applicable. Motor component of functional independence measure (M-FIM) at discharge and discharge destination-home or long-term care facility (LCF). Among the 205 eligible patients, 147 were discharged home and 58 were discharged to LCFs. Patients with an M-FIM score of ≤30 at discharge were defined as patients deemed difficult to discharge home because of low independence levels in ADL. Of the 147 patients discharged home, 24 (16.3%) had M-FIM scores of ≤30. Of the 58 patients discharged to LCFs, 43 (74.1%) had M-FIM scores of ≤30. Patients with an M-FIM score of ≤30 at discharge significantly tended to be discharged home if they obtained oral intake vs tube feeding as a nutritional method (P=.047) and higher cognitive component of FIM scores at discharge (P=.002). All six patients who lived alone among patients with an M-FIM score of ≤30 were discharged to LCFs. Two patients on tube feeding were discharged home. Nutritional method, cognitive function at discharge, and the prestroke living situation with or without household caregivers are important factors of discharge among elderly patients after stroke with low independence levels in ADL. However, only a small number of severely disabled patients were successfully discharged home.

Abstract P98: Cerebral Venous Sinus Thrombosis in Patients With Covid-19

Background: Because COVID-19 is thought to be pro-thrombotic and could theoretically increase the severity of cerebral venous sinus thrombosis (CVST), we sought to examine the outcomes of CVST patients with comorbid COVID-19 infection. Methods: We performed a retrospective analysis using the Vizient ® Clinical Data Base (CDB), a healthcare analytics platform employed by participating US hospitals. We identified CVST with the ICD-10 codes I63.6, I67.6, G08.x, O22.5, and O87.3. We created three cohorts of patients: CVST with confirmed or suspected COVID-19 in April, May or June 2020, CVST with influenza-like illness (ILI) in 2019, and CVST without ILI in 2019. The outcomes are 1) in-hospital death and 2) favorable discharge (discharge destination home or acute rehabilitation). We fit logistic regression models to our outcomes and adjusted for patient age, sex, race/ethnicity, Elixhauser comorbidity score, acute respiratory failure requiring intubation, and hospital length of stay. Results: We identified 73 patients with CVST and COVID-19, 159 with CVST and ILI, and 4,146 with CVST and no COVID-19 or ILI. The patient death rates were 20.6%, 8.8%, and 5.1%, respectively, and favorable discharge rates were 58.9%, 52.8%, and 77.3%, respectively. Compared to CVST patients with ILI, those with COVID-19 were not significantly more likely to die in-hospital (adjusted OR 1.43, 95% CI 0.44-4.66, p=0.557) or to have favorable discharge (adjusted OR 1.75, 95% CI 0.58-5.25, p=0.321). Compared to CVST patients without ILI or COVID-19, those with COVID-19 were also not significantly more likely to die in-hospital (adjusted OR 0.87, 95% CI 0.35-2.12, p=0.751) or to have favorable discharge (adjusted OR 1.52, 95% CI 0.62-3.69, p=0.358). Conclusion: Although CVST patients with COVID-19 had a higher in-hospital death rate and lower favorable discharge rates, after adjusting for potential confounders there was no association between worse outcomes in CVST patients with COVID-19. This suggests that while CVST may complicate COVID-19, it does not portend a worse prognosis than CVST in patients with either ILI or no ILI or COVID-19.

The Effectiveness of Hospital in Motion, a Multidimensional Implementation Project to Improve Patients' Movement Behavior During Hospitalization.

ObjectiveHospital in Motion is a multidimensional implementation project aiming to improve movement behavior during hospitalization. The purpose of this study was to investigate the effectiveness of Hospital in Motion on movement behavior.MethodsThis prospective study used a pre-implementation and post-implementation design. Hospital in Motion was conducted at 4 wards of an academic hospital in the Netherlands. In each ward, multidisciplinary teams followed a 10-month step-by-step approach, including the development and implementation of a ward-specific action plan with multiple interventions to improve movement behavior. Inpatient movement behavior was assessed before the start of the project and 1 year later using a behavioral mapping method in which patients were observed between 9:00 am and 4:00 pm. The primary outcome was the percentage of time spent lying down. In addition, sitting and moving, immobility-related complications, length of stay, discharge destination home, discharge destination rehabilitation setting, mortality, and 30-day readmissions were investigated. Differences between pre-implementation and post-implementation conditions were analyzed using the chi-square test for dichotomized variables, the Mann Whitney test for non-normal distributed data, or independent samples t test for normally distributed data.ResultsPatient observations demonstrated that the primary outcome, the time spent lying down, changed from 60.1% to 52.2%. For secondary outcomes, the time spent sitting increased from 31.6% to 38.3%, and discharges to a rehabilitation setting reduced from 6 (4.4%) to 1 (0.7%). No statistical differences were found in the other secondary outcome measures.ConclusionThe implementation of the multidimensional project Hospital in Motion was associated with patients who were hospitalized spending less time lying in bed and with a reduced number of discharges to a rehabilitation setting.ImpactInpatient movement behavior can be influenced by multidimensional interventions. Programs implementing interventions that specifically focus on improving time spent moving, in addition to decreasing time spent lying, are recommended.

Abstract WP308: BEMI (Brain Emergency Management Initiative) for Optimizing Hub-EMS-Spoke Transfer Networks

Objective: To evaluate an expedited “Brain Emergency Management Initiative (BEMI)” transfer process within a telestroke network with the goal of decreasing transfer delays and time to stroke embolectomy intervention. Methods: We conducted an exploratory, retrospective assessment of consecutive acute telestroke patients transferred for potential intervention to compare outcomes in pre-BEMI vs. BEMI periods. Baseline characteristics included age, sex, ethnicity, stroke risk factors, and NIHSS. Times included Spoke In, Spoke Out, Hub In, and groin puncture. Outcomes included discharge destination home, and Symptomatic Intracranial Hemorrhage (SxICH). Results: Overall, 68 transfers were assessed. There were no differences for age, sex, diabetes, hypertension, or atrial fibrillation. There was a higher NIHSS in BEMI (11 pre-BEMI vs. 20 BEMI;p=0.01). There was a shorter spoke door in to door out (143 vs 118 minutes; p=0.01) and spoke door out to hub door in (23min pre-BEMI vs. 21min BEMI;p=0.001). For embolectomy patients, there was a shorter hub door in to reperfusion (83min Pre-BEMI vs. 74min BEMI;p=.04), and rt-PA decision to groin puncture (155min Pre-BEMI vs.130min BEMI;p=.01). There were no sxICH or discharge home differences. Though NIHSS was correlated with home discharge destination (r=-0.26;p=0.04), Hispanic ethnicity (r=0.33;p=0.01), hub door in to reperfusion (r=0.11;p=0.04) and spoke out to reperfusion (r=0.28;p=0.04), no relationship was strong. Conclusions: In our Hub-EMS-Spoke telestroke network, BEMI led to improved evaluation times. Rapid transfer protocols are critical for improving outcomes. BEMI can serve as a model for future rapid stroke transfer pathways. Further work assessing generalizability and outcomes is underway.

Transcatheter Aortic Valve Replacement: The New Standard in Patients With PreviousCoronaryBypassGrafting?

The aim of this study was to assess how the introduction of transcatheter aortic valve replacement (TAVR) has changed clinical practice and outcome in patients who have previously undergone coronary artery bypass grafting (CABG). A significant proportion of patients admitted for aortic valve replacement have previously undergone CABG and are therefore at increased operative risk in case of redo surgery. In-hospital outcome data were analyzed from patients with or without previous CABG undergoing isolated surgical aortic valve replacement or TAVR in Germany from 2007 to2013. In total, 32,581 TAVR and 55,992 surgical aortic valve replacement procedures were performed in patients with (n= 6,221) or without (n= 82,352) previous CABG. TAVR increased markedly in patients with previous CABG, from 18 procedures in 2007 to 1,191 in 2013, while surgical aortic valve replacement decreased in these patients from 471 to 179 procedures. In 2013, TAVR was the preferred therapy in almost 90% of patients with previous CABG. In-hospital mortality was increased in patients with previous CABG compared with those without (7.6% vs. 6.3% for TAVR and 7.2% vs. 2.6% for surgical aortic valve replacement). Bleeding and stroke rates were also increased with redo surgical aortic valve replacement procedures (with vs. without previous CABG: stroke, 3.2% vs. 1.8%; relevant bleeding, 29.6% vs. 13.4%; acute kidney injury, 4.2% vs. 2.9%), whereas this was not the case with TAVR (stroke, 2.1% vs. 2.6%; relevant bleeding, 7.3% vs. 8.3%; acute kidney injury, 6.3% vs. 5.4% respectively). A similar influence was seen in resource utilization (discharge destination home: TAVR after CABG, 51%; surgical aortic valve replacement after CABG, 31%). Since its introduction in 2007, TAVR has been increasingly used in Germany in patients with previous CABG, and in-hospital outcome data support the trend away from redo surgery.

Care pathways and healthcare use of stroke survivors six months after admission to an acute-care hospital in France in 2012

IntroductionCare pathways and healthcare management are not well described for patients hospitalized for stroke. MethodsAmong the 51 million beneficiaries of the French national health insurance general scheme (77% of the French population), patients hospitalized for a first stroke in 2012 and still alive six months after discharge were included using data from the national health insurance information system (Sniiram). Patient characteristics were described by discharge destination–home or rehabilitation center (for < 3 months)–and were followed during their first three months back home. ResultsA total of 61,055 patients had a first admission to a public or private hospital for stroke (mean age; 72 years, 52% female), 13% died during their stay and 37% were admitted to a stroke management unit. Overall, 40,981 patients were still alive at six months: 33% of them were admitted to a rehabilitation center (mean age: 73 years) and 54% were discharged directly to their home (mean age 67 years). For each group, 45 and 62% had been previously admitted to a stroke unit. Patients discharged to rehabilitation centers had more often comorbidities, 39% were highly physically dependent and 44% were managed in specialized neurology centers. For patients with a cerebral infarction who were directly discharged to their home 76% received at least one antihypertensive drug, 96% an antithrombotic drug and 76% a lipid-lowering drug during the following month. For those with a cerebral hemorrhage, these frequencies were respectively 46, 33 and 28%. For those admitted to a rehabilitation center, more than half had at least one visit with a physiotherapist or a nurse, 15% a speech therapist, 10% a neurologist or a cardiologist and 15% a psychiatrist during the following three months back home (average numbers of visits for those with at least one visit: 23 for physiotherapists and 100 for nurses). Patients who returned directly back home had fewer physiotherapist (30%) or nurse (47%) visits but more medical consultations. The 3-month re-hospitalization rate for patients who were discharged directly to their home was 23% for those who had been admitted to a stroke unit and 25% for the others. In rehabilitation centers, this rate was 10% for patients who stayed < 3 months. ConclusionsThese results illustrate the value of administrative databases to study stroke management, care pathways and ambulatory care. These data should be used to improve care pathways, organization, discharge planning and treatments.

Prise en charge des infections invasives à méningocoques en DDASS de Seine-Maritime

Care pathways and healthcare management are not well described for patients hospitalized for stroke.Among the 51 million beneficiaries of the French national health insurance general scheme (77% of the French population), patients hospitalized for a first stroke in 2012 and still alive six months after discharge were included using data from the national health insurance information system (Sniiram). Patient characteristics were described by discharge destination–home or rehabilitation center (for < 3 months)–and were followed during their first three months back home.A total of 61,055 patients had a first admission to a public or private hospital for stroke (mean age; 72 years, 52% female), 13% died during their stay and 37% were admitted to a stroke management unit. Overall, 40,981 patients were still alive at six months: 33% of them were admitted to a rehabilitation center (mean age: 73 years) and 54% were discharged directly to their home (mean age 67 years). For each group, 45 and 62% had been previously admitted to a stroke unit. Patients discharged to rehabilitation centers had more often comorbidities, 39% were highly physically dependent and 44% were managed in specialized neurology centers. For patients with a cerebral infarction who were directly discharged to their home 76% received at least one antihypertensive drug, 96% an antithrombotic drug and 76% a lipid-lowering drug during the following month. For those with a cerebral hemorrhage, these frequencies were respectively 46, 33 and 28%. For those admitted to a rehabilitation center, more than half had at least one visit with a physiotherapist or a nurse, 15% a speech therapist, 10% a neurologist or a cardiologist and 15% a psychiatrist during the following three months back home (average numbers of visits for those with at least one visit: 23 for physiotherapists and 100 for nurses). Patients who returned directly back home had fewer physiotherapist (30%) or nurse (47%) visits but more medical consultations. The 3-month re-hospitalization rate for patients who were discharged directly to their home was 23% for those who had been admitted to a stroke unit and 25% for the others. In rehabilitation centers, this rate was 10% for patients who stayed < 3 months.These results illustrate the value of administrative databases to study stroke management, care pathways and ambulatory care. These data should be used to improve care pathways, organization, discharge planning and treatments.