RESUMO
The current standard of practice for patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator (tPA) requires critical monitoring for 24-hours post-treatment due to the risk of symptomatic intracranial hemorrhage (sICH). This is a costly and resource intensive practice. In this study, we evaluated the safety and efficacy of this standard 24-hour ICU monitoring period compared with a shorter 12-hour ICU monitoring period for minor stroke patients (NIHSS 0-5) treated with tPA only. Stroke mimics and those who underwent thrombectomy were excluded. The primary outcome was length of hospital stay. Secondary outcome measures included sICH, deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days, and favorable functional outcome defined as modified Rankin scale (mRS) of 0-2 at 90 days. Of the 122 patients identified, 77 were in the 24-hour protocol and 45 were in 12-hour protocol. There was significant difference in length of hospital stay for the 24-hour ICU protocol (2.8 days) compared with the 12-hour ICU protocol (1.8 days) (P < 0.001). Although not statistically significant, the 12-hour group had favorable rates of sICH, 30-day readmission rates, favorable discharge disposition and favorable functional outcome. Rates of DVT, PE and aspiration pneumonia were identical between the groups. Compared with 24-hour ICU monitoring, 12-hour ICU monitoring after thrombolysis for minor acute ischemic stroke was not associated with any increase in adverse outcomes. A randomized trial is needed to verify these findings.
RESUMO
OBJECTIVE: This study was designed to evaluate predictors of hospital length of stay (LOS) and readmissions among nonsurgical ischemic stroke patient, and the impact of inpatient medication management. METHODS: This retrospective cohort study includes adult patients (≥18 years) hospitalized with a diagnosis of nonsurgical ischemic stroke from November 2007 to March 2013. In November 2011, an inpatient medication management model was implemented in the stroke unit. At the end of the study period, patients were matched before and after implementation of the inpatient medication management model (non-PHC [pharmacist-hospitalist collaborative] and PHC, respectively) to evaluate change in outcomes. The primary outcome of the study is an evaluation of predictive factors affecting LOS and readmissions. Additionally, changes in LOS and all-cause readmission at 30, 60, and 90 days when compared between PHC and non-PHC were evaluated. FINDINGS: A total of 151 PHC patients were matched to 248 non-PHC patients. There was no difference in LOS between the PHC and non-PHC patients (mean adjusted difference -.14; P = .66). Similar finding was observed for readmissions (P > .05). Insurance type was a significant predictor of LOS, with Medicare patients having an extended LOS compared to patients with private insurance (mean difference -1.00; P = .005). Patients taking statins and patients aged less than 80 years had a lower 30-day readmission rate compared to nonstatin users and patients aged 80 years or older, respectively (P < .05). CONCLUSIONS: Insurance type and severity of illness are important predictors of LOS, whereas readmissions are mostly influenced by age and statin use.
