Clinical characteristics of patients with brainstem strokes admitted to a rehabilitation unit

OBJECTIVE: To examine the clinical characteristics of patients with brainstem strokes admitted to a rehabilitation unit. DESIGN: Retrospective cohort. SETTING: Inpatient rehabilitation unit. PARTICIPANTS: Eighty-five consecutive admissions (56 men, 29 women; mean age, 61.9+/-14.4y; range, 18-85y) with radiologically confirmed focal evidence of specific lesions within the pons, midbrain, cerebellum, and medulla. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Various clinical characteristics, including stroke-related deficits and stroke risk factors, were identified and compared between brainstem subgroups. The incidence of complications, including pneumonia, deep vein thrombosis, and seizure disorder, was also reported. RESULTS: Seventy (82%) of the strokes resulted from infarctions and 15 (18%) were caused by hemorrhages. The functional deficits of hemiparesis, ataxia, and diplopia were present in 41 (48%), 73 (86%), and 32 (38%) patients, respectively. Dysarthria was reported in 42 patients (49%) and dysphagia in 40 (47%). Pneumonia during hospitalization was a complication in 9 (11%) of the patients with brainstem stroke. The risk factors of diabetes and hypertension were present in 22 (26%) and 47 (55%) patients, respectively. Fourteen (17%) of these patients had suffered a previous stroke. CONCLUSIONS: Rehabilitation patients experience a variety of functional impairments as a consequence of brainstem stroke. These include hemiparesis, dysarthria and dysphagia, diplopia, and ataxia. A significant number of patients had pneumonia as a complication. The characteristics and impairment profiles of patients within the subgroups were similar, with the exception of the incidence of ataxia and hemiparesis.     

Outcomes of patients admitted to a chronic ventilator-dependent unit in an acute-care hospital.

The outcomes in 61 patients admitted to a chronic ventilator-dependent unit (CVDU) at Saint Marys Hospital in Rochester, Minnesota, during an 18-month period are summarized. This unit was designed for patients who could not be weaned from mechanical ventilators after repeated attempts. Most patients had been ventilator dependent for more than 21 days, but some patients were admitted to the CVDU after briefer periods if special circumstances suggested that weaning from mechanical ventilation would be difficult. The unit was organized to provide a multidisciplinary approach to the general medical and respiratory management of these patients, including a physiologic evaluation of the respiratory system to determine the actual cause of ventilator dependence and complete medical, nursing, and psychosocial assessments to help adopt a plan of care and weaning from the ventilator. Of the numerous causes for ventilator dependence in this study group, chronic obstructive pulmonary disease was the most frequent underlying diagnosis. Of the 61 patients admitted to the CVDU, 58 survived, and 53 were liberated from the mechanical ventilator. Ultimately, 35 patients were dismissed directly home from the CVDU. Five of these patients required nocturnal mechanical ventilation. An additional eight patients were dismissed home after rehabilitation. After being weaned from mechanical ventilation, 11 patients were eventually transferred to nursing homes, and 3 additional patients were transferred to a local hospital or physical medicine unit. One patient remains in the CVDU. Thus, the CVDU has successfully liberated patients from ventilator dependence. In addition, because of a decreased need for nursing care, the unit has been cost-effective.     

Occurrence and temporal evolution of upper limb spasticity in stroke patients admitted to a rehabilitation unit

Kong KH, Lee J, Chua KS. Occurrence and temporal evolution of upper limb spasticity in stroke patients admitted to a rehabilitation unit.ObjectivesTo document the temporal development and evolution of upper limb spasticity, and to establish clinical correlates and predictors of upper limb spasticity in a cohort of stroke patients.DesignProspective cohort study.SettingA rehabilitation unit.ParticipantsPatients (N=163) with a first-ever ischemic stroke.InterventionsNot applicable.Main Outcome MeasuresAshworth Scale for measuring upper limb spasticity, Motor Assessment Scale for upper limb activity, Motricity Index for upper limb strength, and Modified Barthel Index for self-care. Upper limb spasticity was defined as an Ashworth Scale score of 1 or greater.ResultsUpper limb spasticity occurred in 54 patients (33%) at 3 months after stroke. Development of spasticity at later stages of the stroke was infrequent, occurring in only 28 patients (17%). In patients with mild spasticity (Ashworth Scale score 1) at 3 months after stroke, worsening of spasticity occurred in only 1 patient. On the other hand, almost half of the patients with moderate spasticity (Ashworth Scale score 2) at 3 months progressed to severe spasticity (Ashworth Scale score 3). Poor upper limb activity was the most important correlate of “moderate to severe spasticity” (Ashworth Scale score ≥2) (P<.001), and poor upper limb strength on admission to rehabilitation, the most important predictor of “moderate to severe spasticity” (P<.001).ConclusionsUpper limb spasticity was relatively infrequent in this study, occurring in 33% of patients at 3 months after stroke. Selective monitoring to detect severe spasticity is recommended for patients with an Ashworth Scale score of 2 or greater at 3 months after stroke, and in patients with severe upper limb weakness on admission to rehabilitation.     

Study of patients admitted to a telemetry unit

The current situation of the telemetry unit of Vigil de Qui?ones Hospital was studied. Telemetry indications, results, and problems observed since the unit was inaugurated were studied to determine the usefulness of telemetric heart rate monitoring and centralized surveillance in an intensive care unit (ICU) in detecting severe arrhythmias, controlling antiarrhythmic treatment, and evaluating why and to what extent telemetry is clinically useful. In our center, telemetry is used to monitor patients with well-established needs. In most cases, arrhythmias are monitored, most frequently premature ventricular complexes, sinus bradycardia and supraventricular tachycardia. Telemetry was useful in arrhythmia treatment and the follow-up of patients with temporary or permanent pacemakers. In a significant percentage of patients (8.62%), telemetry was the key to their ICU admission and, possibly, their survival. There were generally few problems with signal transmission.     

Demographics and clinical outcomes of patients admitted to a respiratory intensive care unit located in a rehabilitation center

INTRODUCTION: A recent survey of respiratory intensive care units (RICU) in Italy showed that RICUs in Italy are mainly (85%) located in acute care hospitals. Forty-seven percent of the patients are admitted from emergency departments, and only 18% are admitted from intensive care units (ICU), so the percentage of patients admitted for difficulty in weaning is low (8%). Patient demographics and admission patterns in RICUs located outside acute care hospitals have not been previously described. METHODS: We analyzed admission patterns, demographics, treatment, and outcomes of patients during the first year of operation of a 7-bed RICU located in a rehabilitation center that does not have an emergency department. RESULTS: In the 1-year study period, 96 RICU patients were admitted for acute or chronic respiratory failure. The patients' mean Simplified Acute Physiology Score II was 28.9 +/- 3.6. Sixty-five percent of the patients were transferred from the ICU, 17% from medical wards of other hospitals, 7% and 5%, respectively, from the medical and surgical wards of our hospital, and 6% came directly from home for a periodic check. Difficulty in weaning from mechanical ventilation was the main reason for admission (42%), followed by simple monitoring (37%) and need for acute ventilatory invasive or noninvasive support (21%). Thirty-one patients had COPD, 23 had acute hypoxemic respiratory failure, 30 had post-surgical complications, and 12 had neuromuscular disease. Twenty-seven of 40 patients admitted for difficulty in weaning were liberated from ventilation. Intrahospital mortality was 13%. Fifty percent of patients were discharged directly to home; those patients' mean Dependence Nursing Scale score (which measures the degree of patient independence) improved during hospital stay (decreased from 23 to 12 [p < 0.05]), whereas the remaining patients were transferred to long-term facilities or an acute care hospital. CONCLUSIONS: The admission pattern at our RICU in a rehabilitation center is quite different from that of an RICU in an acute care hospital. Most of our patients are admitted from ICU because of difficulty with weaning. This may be the consequence of the institutional philosophy of rehabilitation centers, which strive to achieve greater patient independence.     

Nutritional status of cancer patients and its relationship to function in an inpatient rehabilitation setting

Background Malnutrition is associated with prolonged hospitalization, lower survival rate, and various medical complications. However, little is known about malnutrition and its relationship with the functional status. We undertook this retrospective study to examine whether or not malnutrition affects rehabilitation outcome in patients who had undergone cancer rehabilitation.Methods We conducted a review of the charts of 30 consecutive cancer patients who had been admitted to the inpatient rehabilitation unit in a tertiary cancer center, from the beginning of March 2001 to the end of April 2001.Results The patients mean rehabilitation stay was 9 days and their mean age was 58 years (range 22–86 years). On rehabilitation admission, 15 of the patients (50%) had a below normal prealbumin (<18 mg/dl) level (95% confidence interval 31–69%), and on discharge 10 of the patients (33%) had a below normal prealbumin level (95% CI 17–54%). The serum prealbumin concentration level correlated with motor functional independence measure scores on admission. After inpatient rehabilitation, statistically significant gains in functional independence measure scores (P<0.0001) were obtained in patients with below normal admission prealbumin, as well as in those whose prealbumin levels were within the normal range; no statistically significant difference was found in functional gain between these two groups.Conclusion Our study showed that a large number of cancer rehabilitation patients had malnutrition. Nevertheless, functional gain was achieved in all patients after rehabilitation, whether or not malnutrition was present. We conclude that malnourished patients should still be considered candidates for rehabilitation.     

Outcomes for haematological cancer patients admitted to an intensive care unit in a university hospital

Background

Haematological cancer (HC) patients are increasingly requiring intensive care (ICUs). The aim of this study was to investigate the outcome of HC patients in our ICU and evaluate 5 days-full support as a breakpoint for patients’ re-assessment for support.

Hyponatremia in patients admitted to a coronary care unit

Calculation of osmolal gap in plasma and urine samples from patients after acute myocardial infarction was carried out to see whether changes in these variables support the concept of a "sick-cell" mechanism being responsible for the hyponatremia associated with acute myocardial infarction. Some supportive evidence was found on the first day after admission but, overall, the evidence was not convincing.     

Drug misuse among patients admitted to a general hospital

Aims In this paper we report the prevalence of prescribed drugs of misuse and illicit drugs used by patients admitted to a general hospital and the level of detection of drug problems by general medical staff.

Design This is a prospective questionnaire survey, interview and case note review.

Setting This study is a snapshot of one week's admission to a general hospital.

Findings Of the 408 people approached, 285 (70%) participated in the study. One hundred and sixty‐six people (62%) reported misuse of drugs at some time in their lives. Of these, 46 (17%) reported use of illegal drugs at some time in their lives, 22 (8%) in the past year, and 7 (2.6%) in the previous month. The most frequently reported drug type used ever, in the past year, and in the previous month, was over‐the‐counter medication and sedatives. All nine dependent patients identified by the interview were polydrug users and were significantly younger. Two of these patients were assessed for substance misuse by the medical staff.

Conclusion This study suggests that younger patients should be asked about their drug use, especially their use of more readily available drugs. At present, few questions are being asked by health professionals, leaving drug misuse to continue to drain both healthcare and society's resources.     

Nursing home patients admitted to a medical intensive care unit

To investigate admissions from nursing homes to a medical intensive care unit (ICU), the authors detailed the major interventions, costs, and outcomes for such patients (n = 67) over a 3-year period and then compared them with those for ICU patients receiving home care or visiting nurse services (240 patients) before admission and all others older than 65 years of age (949 patients). These three groups comprised 37% of total ICU admissions. In contrast to younger patients admitted primarily with acute ischemic heart disease, nursing home patients were more likely to be admitted with cardiopulmonary arrest, infection, and gastrointestinal bleeding. Major interventions of intubation and mechanical ventilation were most frequent for nursing home patients, but total hospital charges differed little among the groups. In-hospital mortality for the nursing home group (28%) was significantly higher than for the home care group (7%) and others older than 65 years of age (7%). Cumulative mortality for the nursing home group reached 66% by 8 months, versus 32% and 26% in the other groups, respectively.     

Early and intensive rehabilitation predicts good functional outcomes in patients admitted to the stroke intensive care unit

Purpose.?Earlier and more intense rehabilitation benefit stroke patients. Yet, studies have caution intensive therapy during acute brain injury. This study examined the rehabilitation commencement time and intensity as predictors of functional outcomes in acute stroke patients admitted to the stroke intensive care unit (ICU).

Method.?Sociodemographic, medical, rehabilitative and functional data were collected on 154 acute stroke patients. Regression analyses were used to identify predictors for the basic activities of daily living (Barthel Index, BI) and the walking ability at discharge.

Result.?Rehabilitation commencement time and intensity significantly predicted the BI score at discharge after adjusting for initial severity (National Institute of Health Stroke Scale, NIHSS) and age (p?<?0.05). For the walking function at discharge, only the rehabilitation intensity was a significant predictor after adjusting for initial severity and age (p?<?0.05). Furthermore, with increasing rehabilitation intensity, patients with severe stroke benefited more than those with moderate stroke.

Conclusion.?Rehabilitation commencement time and intensity, after adjusting for admission functional status and severity of stroke, remained to be important predictors of stroke functional outcomes. This study supported the recommendation to commence rehabilitation early and intensively and provided evidence that this claim can be extended to acute stroke patients admitted to an ICU.     

Pathway for patients admitted with gastroenteritis to a military hospital

As part of the Clinical Effectiveness Programme, a care pathway was developed for use within the isolation facility in a military hospital in Iraq. The development of the care pathway was necessary to provide direction and to standardize the care provided. A care pathway using a structured and planned approach was developed, critically appraised and amended to ensure evidence-based and patient-focused care. This article provides an amended methodology for the development of further pathways suitable for use within military nursing based on the standard pathway produced by De Lue (2002). The production of the pathway and supporting guideline will ensure standardized care for patients admitted with gastroenteritis.     

Determinants of outcome for patients admitted to a long-term ventilator unit

BACKGROUND: This prospective cohort study was done to identify determinants of successful weaning from mechanical ventilation among patients admitted to the 10-bed long-term ventilator unit (LTVU) of a teaching hospital. METHODS: Prospective patient surveillance and data collection were done on 472 patients admitted to the LTVU over a 4-year period (January 1996 to December 1999). RESULTS: Multiple logistic regression analysis showed that the absence of home mechanical ventilation at the time of hospital admission, absence of intensive care unit (ICU) readmission, and admission to the LTVU from a nonmedical service were independently associated with successful weaning. No statistical difference between hospital survivors and nonsurvivors was associated with length of stay in the LTVU and length of stay in the hospital. CONCLUSIONS: Patients admitted to an LTVU require prolonged hospitalizations and intensive resource utilization. These data suggest that improved methods for identifying patients who are unlikely to benefit from prolonged mechanical ventilation may assist physicians in their discussions with patients and family members as they consider various treatment options.     

Delirium in patients admitted to a step-down unit: Analysis of incidence and risk factors

Background

Delirium is a rather common complication among patients admitted in intensive care units (ICUs), and rather than a single entity, it can be considered a spectrum of diseases where, besides overt cases, there are also many subsyndromal forms. Although there are many data about ICU delirium, there are few data concerning this complication in patients transferred from the ICU to a step-down unit (SDU) once clinically stable.

Objectives

With the present study, we wanted to assess the incidence of and risk factors for delirium and subsyndromal forms and their impact on clinical outcome in a group of patients transferred from an ICU to an SDU.

Methods

All patients transferred from an ICU to our SDU over a 2-year period were screened for delirium and subsyndromal delirious forms using the Intensive Care Delirium Screening Checklist, a simple tool already validated in the ICU. The following data were also recorded: demographic data, severity score (SAPS II), reason for admission to the SDU, length of stay, death rate, use of sedatives, impact of delirium on weaning from mechanical ventilation (MV).

Results

Among the 234 patients, the incidence of delirium and subsyndromal forms was 7.6% and 20%, respectively. Subsyndromal forms diagnosed at admission represented a risk factor for the subsequent development of delirium (odds ratio [OR], P < .0001). A previous episode of brain failure during ICU stay and older age were risks factors for the development of subsyndromal forms, whereas not needing MV was a protective factor. Delirium significantly prolonged the stay in the SDU but did not influence survival and the process of weaning from MV. Overall, the percentage of patients with an abnormal Intensive Care Delirium Screening Checklist score at discharge (5%) was reduced compared with that recorded at admission (18%).

Conclusions

Delirium may still occur after discharge from an ICU in patients who are transferred to an SDU. The strategy of care adopted in the SDU seems to positively affect the recovery from a delirious state. Patients with subsyndromal forms should be promptly recognized and treated because of the risk of developing delirium. Weaning from MV is not hindered by delirium.     

Risk factors associated with hospital admission in COVID-19 patients initially admitted to an observation unit

BackgroundNo set guidelines to guide disposition decisions from the emergency department (ED) in patients with COVID-19 exist. Our goal was to determine characteristics that identify patients at high risk for adverse outcomes who may need admission to the hospital instead of an observation unit.MethodsWe retrospectively enrolled 116 adult patients with COVID-19 admitted to an ED observation unit. We included patients with bilateral infiltrates on chest imaging, COVID-19 testing performed, and/or COVID-19 suspected as the primary diagnosis. The primary outcome was hospital admission. We assessed risk factors associated with this outcome using univariate and multivariable logistic regression.ResultsOf 116 patients, 33 or 28% (95% confidence interval [CI] 20–37%) required admission from the observation unit. On multivariable logistic regression analysis, we found that hypoxia defined as room-air oxygen saturation < 95% (OR 3.11, CI 1.23–7.88) and bilateral infiltrates on chest radiography (OR 5.57, CI 1.66–18.96) were independently associated with hospital admission, after adjusting for age. Two three-factor composite predictor models, age > 48 years, bilateral infiltrates, hypoxia, and Hispanic race, bilateral infiltrates, hypoxia yield an OR for admission of 4.99 (CI 1.50–16.65) with an AUC of 0.59 (CI 0.51–0.67) and 6.78 (CI 2.11–21.85) with an AUC of 0.62 (CI 0.54–0.71), respectively.ConclusionsOver 1/4 of suspected COVID-19 patients admitted to an ED observation unit ultimately required admission to the hospital. Risk factors associated with admission include hypoxia, bilateral infiltrates on chest radiography, or the combination of these two factors plus either age > 48 years or Hispanic race.     

Redefining the coronary care unit: an observational study of patients admitted to hospital in England and Wales in 2003

BACKGROUND: Coronary care units were developed in the 1960s as specially equipped and staffed areas where patients with acute myocardial infarction could be monitored and offered rapid resuscitation from life-threatening arrhythmias. Awareness of the morbidity and mortality of the wider spectrum of acute coronary ischaemia was unrecognized at that time. AIM: To examine the relative frequencies with which thrombolytic treatment and resuscitation from cardiac arrest are provided for patients with myocardial infarction in cardiac care units (CCUs), emergency departments (EDs) and other medical wards. DESIGN: Observational study. METHODS: We analysed records from the National Audit of Myocardial Infarction Project (MINAP) for 61 688 patients admitted to 230 acute hospitals in England and Wales during 2003, and who received a final diagnosis of myocardial infarction, for locations of initiation of thrombolytic therapy and of first cardiac arrest within hospital. RESULTS: Overall, 84% of 27 881 patients with ST-segment-elevation infarction, but only 42% of 30 382 patients with non-ST-elevation infarction, were admitted to a CCU. Of those receiving thrombolytic treatment for ST-elevation infarction, 68.3% of 21 595 did so in the ED. Within the first 4 h after arrival, the majority of episodes of cardiac arrest occurred in the ED: 709 (57%) vs. 488 (39%) in CCU, and 49 (4%) in medical wards. DISCUSSION: The traditional role of the CCU in providing early resuscitation and thrombolytic treatment for patients with ST elevation infarction has largely been devolved to the ED. The role of the CCU should be re-evaluated, and the service re-designed to provide specialist care for all presentations of acute coronary syndrome.