A study of factors influencing determination of discharge disposition of stroke rehabilitation patients]

PURPOSE: The purpose of this study is to statistically analyze medical and socioeconomic factors which influence discharge disposition from a stroke unit. METHODS: We investigated 126 stroke patients admitted to a community hospital within 30 days from the onset of the stroke. Mean age was 65.9 +/- 13.9 (SD) years old, profile of diagnosis was 89 infarctions was 37 hemorrhages, and mean length of stay was 79.7 +/- 45.1 days. Our rehabilitation team consists of doctors, nurses, physical therapists, occupational therapists and a medical social worker. Our stroke unit accepted the stroke patients from the time of admission and attempted to begin rehabilitation as soon as possible. The patients and their families were informed about their options after discharge from the hospital. Eight factors were analyzed using a multiple logistic regression model. RESULTS: 1) Ninety-eight patients (77.8%) could return home (home group) and 28 patients (22.2%) were discharged to another hospital or a long-term care facility (LTCF group). 2) Mean age of LTCF group (70.3 +/- 12.0) was significantly higher than the home group (64.8 +/- 14.2, p < 0.05). The home group showed milder leg paresis (p < 0.01), better Barthel index (p < 0.01), a higher number of family members (p < 0.05), and a better substantial care ability (p < 0.01) than LTCF group. 3) Three factors, higher Barthel index (odds ratio: 1.36), higher number of family members (1.84), and better substantial care ability (1.94), were found to facilitate discharge to home. Two other factors, hemorrhage (0.39) and public assistance (0.04), adversely affected the likelihood of discharge to home. CONCLUSIONS: This study suggests that a stroke unit could accelerate discharge home by improving the Barthel index. In addition, socioeconomic factors should be taken into consideration.     

Ability in daily activities after early supported discharge models of stroke rehabilitation

More knowledge is needed about how different rehabilitation models in the municipality influence stroke survivors’ ability in activities of daily living (ADL). Objectives: To compare three models of outpatient rehabilitation; early supported discharge (ESD) in a day unit, ESD at home and traditional treatment in the municipality (control group), regarding change in ADL ability during the first three months after stroke. Methods: A group comparison study was designed within a randomized controlled trial. Included participants were tested with the Assessment of Motor and Process Skills (AMPS) at baseline and discharged directly home. Primary and secondary outcomes were the AMPS and the modified Rankin Scale (mRS). Results and conclusions: Included were 154 participants (57% men, median age 73 years), and 103 participants completed the study. There were no significant group differences in pre–post changed ADL ability measured by the AMPS. To find the best rehabilitation model to improve the quality of stroke survivors’ motor and process skills needs further research. Patients participating in the ESD rehabilitation models were, compared with traditional treatment, significantly associated with improved ADL ability measured by the mRS when controlling for confounding factors, indicating that patients with social needs and physical impairment after stroke may benefit from ESD rehabilitation models.     

A survey of survivors of acute stroke discharged from hospital to private nursing homes in Nottingham

Increasing numbers of disabled elderly stroke survivors are being discharged from hospital to Private Nursing Homes. However, there is little data available on which specific guidelines for the care of stroke patients in these homes can be based. A survey was undertaken therefore, to review patients on their discharge from hospital to Private Nursing Homes, and to assess the severity of their disability and handicap before and after entering the home. Nearly all patients were severely disabled on discharge from hospital, and the Barthel Activities of Daily Living scores of the survivors showed no significant change after four months. High levels of emotional distress and loneliness were identified by the Nottingham Health Profile, with little change after four months of nursing home care. The National Health Service has a continuing responsibility for the welfare of such vulnerable elderly people. The findings of this survey indicate that the emphasis of their care should be on the management of severe physical disability, exploitation of opportunities for further rehabilitation, alleviation of emotional distress and loneliness and, where appropriate, the provision of humane terminal care.     

急性缺血性卒中患者进行超早期康复对功能结局的改善

目的研究在急性缺血性卒中患者中进行超早期康复治疗能否更好地改善其日常生活的独立性。方法将96名发病24h内入院的前循环急性缺血性卒中患者随机分为2组,超早期康复组在发病24h内开始接受包括下床站立活动的康复治疗;标准康复组在发病72h至7d开始康复治疗。康复治疗均由专业治疗师进行,每日1次,每次不少于30min,共14d。主要观察指标包括恢复至独立行走50m所需的天数,次要指标包括发病后30d和90d时的NIHSS评分和Bathel指数。结果超早期康复组共纳入41名患者,标准康复组55名患者。和标准康复组相比,超早期康复组恢复至独立行走50m的时间要明显缩短[(8.71±14.162)dvs(16.64±20.338)d,t=-2.138,P=0.035)]。90d时超早期康复组患者获得良好独立日常生活能力的比例(以Bathel指数达到95～100的比例表示,75.6%vs56.4%,χ2=3.891,P=0.049)更大。其余观察指标两组间无统计学差异。结论超早期康复治疗可以使缺血性卒中患者更早地恢复独立行走能力,并能改善功能结局。     

Predicting place of discharge from hospital for patients with a stroke or hip fracture on admission

OBJECTIVES: To determine the predictive power of patient and service characteristics on place of discharge following hospital admission for an acute stroke and for hip fracture. METHODS: Prospective cohort of 440 acute stroke and 572 hip fracture patients aged 65 years or over admitted from home to six district general hospitals and associated community hospitals, three in the North and three in the South of England. RESULTS: Age, marital status, living arrangements, mental health status at admission, pre-admission self-rated disability, pre-admission use of home-care services, post-admission staff assessments of functional dependency as measured by Barthel Index and of confusion as measured by the modified Crichton Royal Behavioural Rating Scale and nursing staffs' expectation of place of discharge are all significantly related to place of discharge for stroke and hip fracture participants. Logistic regression correctly predicted discharge destination for 87% of stroke patients from data available at time of admission and 83% of hip fracture patients. Of the 30% of stroke patients discharged to an institution, the model correctly predicted 73%. However, of the 19% of hip fracture patients discharged to an institution, only 28% were correctly predicted. CONCLUSIONS: Data about older patients admitted to hospital with an acute condition should be routinely collected by hospital staff to inform clinical management and to permit risk-adjusted audit.     

三级康复护理对脑卒中患者生活质量影响的研究

目的：探讨三级康复护理对脑卒中偏瘫患者生活质量的影响。方法：32例患者随机分为康复组16例和对照组16例。在医院接受一级康复护理后,对照组接受常规康复治疗护理,康复组恢复期在医院接受二级康复护理,维持期在护理人员指导下在家接受三级康复护理。采用生活质量测评表（QOL）评价患者生活质量。结果：康复前,两组患者QOL总得分及各项得分均无统计学差异（P均>0.05）。6个月后,组内比较发现得分均降低,差异有统计学意义（P均<0.05）;但组间比较发现康复组得分均比对照组低,差异有统计学意义（P均<0.05）。结论：三级康复护理可明显改善脑卒中偏瘫患者的生活质量,值得在临床中进一步推广应用。     

脑卒中偏瘫患者的早期康复护理的临床观察

目的探讨早期康复护理干预对脑卒中偏瘫患者的神经缺损症状功能恢复的影响,为临床康复治疗提供依据。方法采用随机对照试验,选择发病两周内的脑卒中患者64例,随机分为早期康复护理治疗组（31例）及对照组（33例）,治疗前后定期对患者进行神经功能缺损评定,日常生活活动能力（ADL）评定,神经功能缺损评定采用中国卒中量表（CSS）,ADL评定采用Barthel指数量表,以治疗第28天CSS和ADL改变作为主要疗效判断标准。结果28d后治疗组、对照组CSS相比差异有统计学意义（P〈0．05）;两组ADL相比差异有统计学意义（P〈0．05）,治疗组无明显不良反应。结论给予早期康复护理可以明显改善脑卒中偏瘫患者日常生活能力,减少并发症的发生。     

Three different outcomes in older community-dwelling patients receiving intermediate care in nursing home after acute hospitalization

Objectives

To evaluate the recovery and outcome of older communitydwelling patients admitted to intermediate care (IC) in nursing homes after acute hospitalization, and to compare patients who were able and unable to return directly to their own homes.

Design

Prospective, observational, cohort study conducted between June 2011 and 2014.

Setting

A 19- bed IC unit in a nursing home with increased multidisciplinary staffing.

Participants

A total of 961 community-dwelling patients, ≥70 years of age, considered to have a rehabilitation potential and no major cognitive impairment or delirium, transferred from internal medicine, cardiac, pulmonary and orthopaedic hospital departments.

Measurements

Demographic data, clinical information, comprehensive geriatric assessment (CGA), discharge destination and length of stay. Residence status and mortality 1 month, 2 months, 3 months, and 6 months after discharge from the hospital.

Results

The trajectory of recovery was divided into 3 groups: 1) Rapid recovery, able to return home after median 14 days in IC (n=785, 82%); 2) Slow recovery, requiring additional transfer to other nursing home after IC, but still able to return home within 2 months (n=106, 11%). 3) Poor recovery, requiring transfer to other nursing home after IC and still in a nursing home or dead at 2 months (n=66, 7%). Significant different clinical characteristics were demonstrated between the patients in the 3 groups. After 6 months, the recovery of patients with rapid or slow recovery was similar, 87% were living at home, compared to only 20% of the patients with poor recovery. In multiple logistic regression analysis, slow or poor recovery was significantly associated with low scores on the Barthel index and orthopaedic admission diagnosis.

Conclusions

Although the majority of patients selected for treatment in the IC unit were able to recover and return home, a group of patients needed extra time, up to 2 months, to recover and another group had a poor chance of recovering and returning home. Different caring pathways for different patient groups may be considered in the PAC setting.

     

Dietary intake,nutritional status and rehabilitation outcomes of stroke patients in hospital

Background: Nutrition affects rehabilitation through its influence on physical and mental functioning, although little attention has been paid to effects on rehabilitation outcomes. The present study aimed to describe nutritional status and food consumption in stroke patients within 2 weeks of hospital admission and before discharge, as well as to investigate the effects of nutritional and dietary factors on rehabilitation outcomes. Methods: One hundred patients from a consecutive cohort admitted to a metropolitan hospital with acute stroke were recruited and assessed by a single researcher, with 38 reassessed at discharge. Nutritional status was assessed using Mini‐Nutritional Assessment and anthropometric indices and dietary intake was assessed by 1‐day weighed dietary records. Rehabilitation outcomes were changes in Barthel index scores and the rehabilitation efficiency index. Results: Few (n = 9; 10%) consumed ≥100% of the estimated average requirement (EAR) for energy within 2 weeks of admission and 13 (33%) had energy intakes <50% of EAR before discharge. A small but increasing proportion (7% at admission, 13% at discharge) were identified as being malnourished across the inpatient stay. Younger age, lower Barthel index and a higher energy intake in the early stages of admission predicted the extent and rate of restoration of functional abilities by discharge (F = 7.503, P = 0.001; F = 14.558, P < 0.001). Conclusions: Given a general finding of nutritional deterioration identified for these patients, as well as the identification of energy intake as a modifiable influence on the extent and rate of recovery, there is clearly scope for the multidisciplinary development of nutritional support for stroke patients to improve rehabilitation outcomes.     

护理干预对脑卒中病人生存质量的影响

目的探讨护理干预对脑卒中病人生存质量的影响。方法选取2012年1月—2013年10月入住我科的脑卒中病人128例为研究对象,随机分为对照组64例和干预组64例。对照组给予常规护理,干预组在常规护理基础上进行康复训练和康复指导。比较2组入院时和出院时Barthel评分。结果入院时2组病人Barthel评分差异无统计学意义（P〉0.05）,出院时Barthel评分试验组明显优于对照组（P〈0.01）。结论护理干预能提高脑卒中病人生存质量。     

康复联动型卒中单元在地市级医院急性脑梗死治疗中的应用

目的 评价康复联动型卒中单元在地市级医院急性脑梗死治疗中的疗效.方法 急性脑梗死患者随机进入康复联动型卒中小组病房(77例)和普通病房(73例),比较治疗前后两组患者神经功能(NIHSS评分)、日常生活能力(ADL Barthel指数)及住院时间.结果 两组患者治疗前平均NIHSS评分分别为9.26与9.12(P＞0.05),治疗后分别为2.62与7.64(P＜0.01),治疗前平均ADLBarthel指数分别为52.04与53.16(P＞0.05),治疗后分别为87.26与64.20(P＜0.01),两组平均住院日分别为22.25 d及26.67 d(P＜0.05).结论 康复联动型卒中单元模式应用于脑梗死急性期治疗,可改善患者的神经功能及日常生活能力,缩短住院时间,在地市级医院优于普通卒中病房.     

National stroke audit: a tool for change?

OBJECTIVES: To describe the standards of care for stroke patients in England, Wales and Northern Ireland and to determine the power of national audit, coupled with an active dissemination strategy to effect change. DESIGN: A national audit of organisational structure and retrospective case note audit, repeated within 18 months. Separate postal questionnaires were used to identify the types of change made between the first and second round and to compare the representativeness of the samples. SETTING: 157 trusts (64% of eligible trusts in England, Wales, and Northern Ireland) participated in both rounds. PARTICIPANTS: 5589 consecutive patients admitted with stroke between 1 January 1998 and 31 March 1998 (up to 40 per trust) and 5375 patients admitted between 1 August 1999 and 31 October 1999 (up to 40 per trust). Audit tool-Royal College of Physicians Intercollegiate Working Party stroke audit. RESULTS: The proportion of patients managed on stroke units rose between the two audits from 19% to 26% with the proportion managed on general wards falling from 60% to 55% and those managed on general rehabilitation wards falling from 14% to 11%. Standards of assessment, rehabilitation, and discharge planning improved equally on stroke units and general wards, but in many aspects remained poor (41% formal cognitive assessment, 46% weighed once during admission, 67% physiotherapy assessment within 72 hours, 24% plan documented for mood disturbance, 36% carers' needs assessed separately). CONCLUSIONS: Nationally conducted audit linked to a comprehensive dissemination programme was effective in stimulating improvements in the quality of care for patients with stroke. More patients are being managed on stroke units and multidisciplinary care is becoming more widespread. There remain, however, many areas where standards of care are low, indicating a need for investment of skills and resources to achieve acceptable levels.     

Costs of health care and social services during the first year after ischemic stroke

OBJECTIVES: Knowledge of resource use and costs can be useful when evaluating existing services or planning new services. This study investigates the use of health care and social services during the first year after a stroke. Total costs are calculated, costs are compared across subgroups of patients, and resource items of major importance for the total costs are identified. METHODS: The study is based on a database comprising data on all stroke patients admitted to a university hospital in Copenhagen, Denmark, over a 1-year period, 1994-95. Patients were followed for 1 year after the stroke, and data on resource use during and after hospitalization were collected prospectively at interviews. This paper focuses on a subset of 385 patients who were admitted because of cerebral infarct or unspecified stroke. RESULTS: The mean cost, based on all patients, of health care and social services during the first year was 142,900 DKK (US $25,500). The hospital care until the first discharge, including acute care and rehabilitation, cost 101,600 Danish krones (DKK) (US $18,100), i.e., 71% of the total cost. Major resource items after discharge were nursing homes, readmissions, outpatient rehabilitation, and home help. The cost during the first year varied with a number of factors, with the most important being survival and degree of disability. Patients who survived the acute phase and who had severe disability (Barthel Activities of Daily Living [ADL] Index: 0-9) 7-10 days after admission had a total cost during the first year that was five times as high as patients with no disability (Barthel ADL Index: 20). CONCLUSION: Costs of health care and social services during the first year after a stroke vary considerably. Disability as measured with the Barthel ADL Index is a stronger predictor of costs than Scandinavian Stroke Scale scores and other clinical and demographic variables.     

The role of geriatric intermediate care facilities in long-term care for the elderly in Japan

Geriatric intermediate care facilities (GICFs) were first established in 1987 to help the hospitalized elderly return home within 3 months. Users of the GICFs are the elders who do not require hospitalization, but are mentally or physically impaired. Rather than providing unnecessary medical services, GICFs emphasize nursing care and rehabilitation so that users can carry out their daily tasks independently. Due to the limited supply of institutional and in-home services for the elderly in long-term care systems in Japan, only half of the discharged users were able to return home and a quarter stayed at GICFs for over 1 year, contrary to the initial purpose. This suggests that in addition to serving as an intermediate facility between institutions and private homes, GICFs should enlarge their role of home care supporting facilities in ways that would enable them to provide frail elderly patients at home with respite care and daycare services.     

There are also suitable treatments during the chronic phase following a stroke

In contrast to the chronic phase, for the acute and rehabilitation phases following a stroke it is sufficiently clear what care is adequate care. Most stroke patients no longer have contact with healthcare professionals in the chronic phase. In this phase, new psychosocial problems may develop. Long (3, 5, 12 and 29 years) post stroke, 4 patients (aged 38-67 years) presented at an outpatient rehabilitation clinic with new complaints: social problems, emotional changes and cognitive impairments. Their relatives (spouses and children) perceived a substantial burden. A short-term outpatient, multidisciplinary rehabilitation programme was offered to them. The International Classification of Functioning, Disability and Health model was used to evaluate the health problems in relation to the environmental and personal factors. Psycho-education, learning cognitive strategies, supporting the family, and starting new leisure activities were important parts of the rehabilitation programme to increase participation and quality of life. The chronic phase following a stroke is not a stable phase and in this phase, rehabilitation interventions can be helpful too and should therefore be offered.     

Early home-supported discharge of stroke patients: a health technology assessment

OBJECTIVES: A comprehensive and systematic assessment (HTA) of early home-supported discharge by a multidisciplinary team that plans, coordinates, and delivers care at home (EHSD) was undertaken and the results were compared with that of conventional rehabilitation at stroke units. METHODS: A systematic literature search for randomized trials (RCTs) on "early supported discharge" was closed in April 2005. RCTs on EHSD without information on (i) death or institution at follow-up, (ii) change in Barthél Index, (iii) length of hospital stay, (iv) intensity of home rehabilitation, or (v) baseline data are excluded. Seven RCTs on EHSD with 1,108 patients followed 3-12 months after discharge are selected for statistical meta-analysis of outcomes. The costs are calculated as a function of the average number of home training sessions. Economic evaluation is organized as a test of dominance (both better outcomes and lower costs). RESULTS: The odds ratio (OR) for "Death or institution" is reduced significantly by EHSD: OR = .75 (confidence interval [CI], .46-.95), and number needed to treat (NNT) = 14. Referrals to institution have OR = .45 (CI, .31-.96) and NNT = 20. The reduction of the rate of death is not significant. Length of stay is significantly reduced by 10 days (CI, 2.6-18 days). All outcomes have a nonsignificant positive covariance. The median number of home sessions is eleven, and the average cost per EHSD is 1,340 USD. The "action mechanism" and financial barriers to EHSD are discussed. CONCLUSIONS: EHSD is evidenced as a dominant health intervention. However, financial barriers between municipalities and health authorities have to be overcome. For qualitative reasons, a learning path of implementation is recommended where one stroke unit in a region initiates EHSD for dissemination of new experience to the other stroke units.     

延续性护理对脑卒中出院患者康复的效果观察

目的 探讨延续性护理干预对脑卒中患者出院康复的临床效果。方法 选取本院选收治的176例首发脑卒中偏瘫患者为研究对象,据随机数表法,分为对照组和观察组,各组88例,对照组实施常规护理策略,观察组予以常规护理策略＋延续性护理;2组接受出院后为期6个月干预后,比较2组复发因素控制、神经功能缺损、生活自理能力、抑郁水平及遵医依从性。结果 观察组血压、空腹血糖、低密度脂蛋白和纤维蛋白原达标率显著高于对照组(P<0.05);在神经功能和生活自理方面,观察组恢复情况均显著优于对照组(P<0.05);抑郁水平却显著低于对照组(P<0.05);观察组遵医依从性也均显著优于对照组(P<0.05)。结论 延续性护理显著改善脑卒中出院患者神经功能,提高生活自理能力和遵医依从行为,降低抑郁水平,有效促进患者康复,值得推广应用。     

Educational levels and the functional dependence of ischemic stroke survivors

We evaluated the functional dependence of stroke survivors from the Study of Stroke Mortality and Morbidity, using the Rankin Scale. Out of 355 ischemic stroke survivors (with a mean age of 67.9 years), 40% had some functional dependence at 28 days and 34.4% had some functional dependence at 6 months. Most predictors of physical dependence were identified at 28 days. These predictors were: low levels of education [illiterate vs. > 8 years of education, multivariate odds ratio (OR) = 3.7; 95% confidence interval (95%CI): 1.60-8.54] and anatomical stroke location (total anterior circulation infarct, OR = 16.9; 95%CI: 2.93-97.49). Low levels of education and ischemic brain injury influenced functional dependence in these stroke survivors. Our findings reinforce the necessity of developing strategies for the rehabilitation of stroke patients, more especially in formulating specific strategies for care and treatment of stroke survivors with low socioeconomic status.