Lack of laboratory assessment of severe hyponatraemia is associated with detrimental clinical outcomes in hospitalised patients.

OBJECTIVE: Increased mortality with severe hyponatraemia is well known. What is less clear is the mortality risk according to the pattern of the developing hyponatraemia and whether this may be affected by the intervention of the clinician. METHODS: From our laboratory database, we retrospectively collected data of a 12-month period of adult patients with severe hyponatraemia (< or = 120 mmol/l). One hundred and thirteen patients were identified. Normonatraemic controls (n = 113) were identified by plasma sodium of 135 mmol/l over the same period, and whose nadir during hospitalisation was > or = 130 mmol/l. Results are mean +/- SD unless stated otherwise. Duration of hospitalisation and clinical outcomes was confirmed from hospital records. RESULTS: The mean nadir plasma sodium of the hyponatraemic group was 116.0 +/- 4.4 mmol/l and 134.0 +/- 2.8 mmol/l in controls. Although the hyponatraemic patients were younger than controls (65.8 +/- 18.4 vs. 72.3 +/- 14.9 years; p = 0.004), they had higher mortality (24 vs. 7, p = 0.002) and longer hospitalisation than controls: median (IQR), 12 (7-22) vs. 7 (3-16.5) days (p < 0.001). A total of 55 patients developed severe hyponatraemia following admission. This subgroup comprised a higher proportion of surgical patients (23.6% vs. 1.7%, p < 0.001) than those with severe hyponatraemia on admission. Furthermore, both mortality (n = 17 vs. n = 7; p = 0.02) and duration of hospitalisation, median 19 days (IQR 10-35) vs. 9.5 (5-15) days (p < 0.001), were greater. Failure to measure plasma and urinary osmolalities was associated with increased mortality. CONCLUSIONS: Severe hyponatraemia is associated with prolonged admission and increased mortality compared with normonatraemic patients. Progressive hyponatraemia following admission incurs a higher risk of death. This may represent illness-severity, inappropriate management or inadequate investigation.

Access to stroke care in England, Wales and Northern Ireland: the effect of age, gender and weekend admission.

STUDY OBJECTIVES: To determine whether access to high-quality stroke care is affected by the age or gender of the patient or by weekend admission. DESIGN: Data were collected as part of the National Sentinel Audit of stroke in 2004, both on the organisation of in-patient stroke care and the process of care to hospitals managing stroke patients. SETTING: Two hundred and forty-six hospitals from England, Wales and Northern Ireland took part in the 2004 National Stroke Audit, a response rate of 100%. These sites audited te care of 8,718 patients. AUDIT TOOL: Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool. RESULTS: Overall standards of care for cases of stroke in England, Wales and Northern Ireland are low. Older patients are less likely to be treated in a stroke unit than younger patients (risk ratio comparing 85 + years with those <65 years 0.82 (95% CI 0.75-0.90). Seventy-one per cent of patients under 65 years were scanned within 24 h compared to 51% aged over 85 years. Older patients were also less likely than younger ones to receive secondary prevention and some aspects of rehabilitation, especially around higher functioning. Standards were consistently better for patients of all ages managed in stroke units compared to general wards. At weekends, patients were less likely to be admitted directly to a stroke unit (risk ratio 0.77 95% CI 0.69-0.86) and brain imaging was performed less often for older (85 + years) patients (weekday 56%, weekend 40%). There was little evidence of differences in standards of care between males and females. CONCLUSION: There is clear evidence of an age effect on the delivery of stroke care in England, Wales, and Northern Ireland, with older patients being less likely to receive care in line with current clinical guidelines. Quality of acute care is also less good for patients admitted at weekends. No systematic evidence for sexism was identified.