Early Prediction of Prognosis in Elderly Acute Stroke Patients.

Acute stroke has a high morbidity and mortality in elderly population. Baseline confounding illnesses, initial clinical examination, and basic laboratory tests may impact prognostics. In this study, we aimed to establish a model for predicting in-hospital mortality based on clinical data available within 12 hours of hospital admission in elderly (≥ 65 age) patients who experienced stroke. DESIGN: Retrospective observational cohort study. SETTING: Academic comprehensive stroke center. PATIENTS: Elderly acute stroke patients-2005-2009 (n = 462), 2010-2012 (n = 122), and 2016-2017 (n = 123). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After institutional review board approval, we retrospectively queried elderly stroke patients' data from 2005 to 2009 (training dataset) to build a model to predict mortality. We designed a multivariable logistic regression model as a function of baseline severity of illness and laboratory tests, developed a nomogram, and applied it to patients from 2010 to 2012. Due to updated guidelines in 2013, we revalidated our model (2016-2017). The final model included stroke type (intracerebral hemorrhage vs ischemic stroke: odds ratio [95% CI] of 0.92 [0.50-1.68] and subarachnoid hemorrhage vs ischemic stroke: 1.0 [0.40-2.49]), year (1.01 [0.66-1.53]), age (1.78 [1.20-2.65] per 10 yr), smoking (8.0 [2.4-26.7]), mean arterial pressure less than 60 mm Hg (3.08 [1.67-5.67]), Glasgow Coma Scale (0.73 [0.66-0.80] per 1 point increment), WBC less than 11 K (0.31 [0.16-0.60]), creatinine (1.76 [1.17-2.64] for 2 vs 1), congestive heart failure (2.49 [1.06-5.82]), and warfarin (2.29 [1.17-4.47]). In summary, age, smoking, congestive heart failure, warfarin use, Glasgow Coma Scale, mean arterial pressure less than 60 mm Hg, admission WBC, and creatinine levels were independently associated with mortality in our training cohort. The model had internal area under the curve of 0.83 (0.79-0.89) after adjustment for over-fitting, indicating excellent discrimination. When applied to the test data from 2010 to 2012, the nomogram accurately predicted mortality with area under the curve of 0.79 (0.71-0.87) and scaled Brier's score of 0.17. Revalidation of the same model in the recent dataset from 2016 to 2017 confirmed accurate prediction with area under the curve of 0.83 (0.75-0.91) and scaled Brier's score of 0.27. CONCLUSIONS: Baseline medical problems, clinical severity, and basic laboratory tests available within the first 12 hours of admission provided strong independent predictors of in-hospital mortality in elderly acute stroke patients. Our nomogram may guide interventions to improve acute care of stroke.

Ventilator-associated pneumonia in critically ill stroke patients: frequency, risk factors, and outcomes.

PURPOSE: Our main objective was to assess incidence, risk factors, and outcomes of ventilator-associated pneumonia (VAP) in stroke patients. MATERIALS AND METHODS: After obtaining approval from the Human Studies Committee, we reviewed the electronic records from our intensive care unit database of 111 stroke patients on mechanical ventilation for more than 48 hours. Thirty-six risk factors related to disease and general health status, and 8 related to care-all assigned a priori-were collected and analyzed. Selected factors with univariate statistical significance (P < .05) were then analyzed with multivariate logistic regression. RESULTS: Thirty-one patients developed pneumonia (28%). Methicillin-resistant Staphylococcus aureus (n = 12) and methicillin-sensitive S aureus (n = 7) were the most common pathogenic bacteria. Chronic lung disease, neurological status at admission as assessed by the National Institutes of Health Stroke Scale, and hemorrhagic transformation were the independent risk factors contributing to VAP. Worsening oxygenation index (arterial partial pressure of oxygen/fraction of inspired oxygen) and proton pump inhibitor use for ulcer prophylaxis were other potentially important factors. CONCLUSIONS: Pneumonia appears as a frequent problem in mechanically ventilated stroke patients. Chronic lung disease history, severity of stroke level at admission, and hemorrhagic transformation of stroke set the stage for developing VAP. The duration of both mechanical ventilation and intensive care unit stay gets significantly prolonged by VAP, but it does not affect mortality.

Mutual reporting of process and outcomes enhances quality outcomes for colon and rectal resections.

BACKGROUND: This report describes the favorable results of mutual reporting of process and outcome of care for major resections of the colon and rectum, one of six focal points for the Center for Medicare Services studies seeking to broadly reduce death and complications and enhance consistency of care. METHODS: A group of 66 surgical specialists in 9 cities in Kentucky reported cases to a quality improvement network over the past 5 years, and these data were supplemented by chart verification and patient satisfaction surveys. Consecutive colon and rectal resections (N=309) were reported by 23 general and colorectal surgeons. Eighty percent of the operations were performed by 4 surgeons. RESULTS: Forty-four percent of the patients had colorectal cancer, and 27% had diverticulitis; 84% of colon resections were performed by general surgeons whereas 77% of rectal resections were performed by colorectal specialists. Audit showed 6 leaks/fistulas and 16 patients who required unscheduled readmissions. Eleven patients had prolonged ileus. Only 2 patients died. Consensus among network surgeons included the following: 1. Mutual reporting led to a narrowing of choices and improved timing for antibiotic prophylaxis. 2. Standard order sets in one hospital led to a shortened duration of stay. 3. Surgeon participation in a quality improvement network led to a safe reduction in preoperative cardiology consultation. 4. More patients arrive with all evaluations complete due to increased utilization of preoperative anesthesiology clinics. 5. Enhanced operating room throughput has been achieved by joint anesthesia/surgery reporting and includes reduced time to induction of anesthesia and in the Post-Anesthesia Care Unit and lessened use of expensive postoperative antiemetics. 6. Reported medication errors were reduced by standard order sets, as were other reported adverse events. CONCLUSIONS: Practicing surgeons meet and/or exceed published benchmarks for colorectal resections and can further improve their outcomes by standardization and refinement of orders and procedures and improved collaboration with anesthesiologists.