Search

Introduction Previous studies have shown an association between number of stroke admissions and outcomes. Small hospitals often support more remote areas and we studied national data to determine if an association exists between hospital remoteness and stroke care. Methods Data from the Irish National Audit of Stroke (INAS) on average stroke admissions, adjusted mortality for ischaemic stroke, thrombolysis rate and proportion with door to needle (DTN) ≤45 min were analysed. Hospital remoteness was quantified by distance to the next hospital, nearest neurointerventional centre and location within 10 km of the national motorway network. Results Data for 23 of 24 stroke services were evaluated. Median number of strokes admitted per year was 186 (range 84–497). Nine hospitals (39%) admitted ≥200 stroke patients per year (mean 332). Average adjusted mortality (7.0 vs. 7.3, P  = 0.67 t -test), mean thrombolysis rate (12.1% vs. 9.2%, P  = 0.09) and mean proportion of patients treated ≤45 min (40.4% vs. 31.3%, P  = 0.2) did not differ significantly between higher and lower volume hospitals. Hospitals close to the motorway network (n  = 15) had a higher mean thrombolysis rate (11.9% vs. 7.5%, P  = 0.01 t -test) and proportion DTN ≤45 min (43.7–18.4%, P  < 0.001). Number of stroke admissions did not correlate with mortality (r  = 0.06, P  = 0.78), DTN (r  = 0.12, P  = 0.95) or thrombolysis rate (r  = 0.35, P  = 0.20). Distance to next hospital correlated strongly negatively with DTN (r  = −0.47, P  = 0.02) and thrombolysis rate (−0.43, P  = 0.04). Conclusion Remoteness of hospitals is associated with worse measures of stroke outcome and management. [ABSTRACT FROM AUTHOR]

This document is a response to a letter regarding the impact of prehospital care and door-to-computed tomography scan time on stroke outcomes. The authors address the issues raised by the letter and provide information about the prehospital assessment and care of stroke patients in Ireland. They explain that Ireland has a standardized training protocol for paramedics, and all hospitals can receive pre-notification of suspected strokes from ambulances. They also mention that technical solutions like mobile stroke units have not been extensively assessed in remote areas due to cost and low frequency of use. The authors conclude that optimizing prehospital and emergency care for stroke patients is important, but there is no evidence that patients attending remote hospitals in Ireland receive poorer care in these respects. [Extracted from the article]

The North Dublin Population Stroke Study in 2012[5] showed a 9.5% non-presentation rate of stroke patients. All had active thrombolysis protocols, all had nationally developed imaging protocols and all had access to thrombectomy services with imaging review by Interventional Neuroradiologists through a central imaging system.[3] All units undergo continuous audit. All the stroke patients in the study were admitted to hospitals with organized stroke services, with accredited stroke units and with senior medical and specialized nursing staff trained in stroke care. [Extracted from the article]

Nursing home (NH) residents represent the frailest group of older people, and providing gerontologically attuned care that addresses these frailties is often a challenge within the emergency department (ED). This study sought to prospectively profile acutely unwell NH residents in order to clarify some of the challenges of providing emergency care to this group. Over an 18-week period, we prospectively reviewed all NH residents presenting to the ED of an urban university teaching hospital. Relevant data were retrieved by direct physician review (as part of a comprehensive geriatric assessment in the ED), collateral history from NH staff and primary carers, and review of electronic records. There were 155 ED visits by 116 NH residents. Their mean age was 80.3 (±9.6) years. High pre-morbid levels of dependency were reflected by a mean Barthel Index of 34.1 (±20) and almost two-thirds had a pre-existing diagnosis of dementia. One-third of visits were during ‘normal’ working hours. Patients were reviewed by their regular NH doctor pre-transfer for 36% of visits. Using accepted international criteria, over half of the visits were deemed ‘potentially preventable’. Unwell NH residents have complex medical needs. The decision to refer these patients to the ED is often made by ‘out of hours’ general practitioners and their initial care in the ED is directed by physicians with limited experience in geriatric medicine. Most referrals to the ED are potentially preventable but this would require enhancements to the package of care available in NHs. [ABSTRACT FROM AUTHOR]

Background: Greater numbers of older patients are accessing hospital services. Specialist geriatric input at presentation may improve outcomes for at-risk patients. The Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI) frailty measure, developed for use in the community, has also been used in the emergency department (ED). Aim: To measure frailty, review its prevalence in older patients presenting to ED and compare characteristics and outcomes of frail patients with their non-frail counterparts. Design: Patient characteristics were recorded using symphony® electronic data systems. SHARE-FI assessed frailty. Cognition, delirium and 6 and 12 months outcomes were reviewed. Methods: A prospective cohort study was completed of those aged≥70 presenting to ED over 24h, 7 days a week. Results: Almost half of 198 participants (46.7%, 93/198) were classified as frail, but this was not associated with a significant difference in mortality rates (OR 0.89, 95% CI 0.58-1.38, P=0.614) or being alive at home at 12 months (OR 1.07, 95% CI 0.72-1.57, P=0.745). Older patients were more likely to die (OR 2.34, 95% CI 1.30-4.21, P=0.004) and less likely to be alive at home at 12 months (OR 0.49, 95% CI 0.23-0.83, P=0.009). Patients with dementia (OR 0.24, P=0.005) and on ≥5 medications (OR 0.37, 95% CI 0.16-.87, P=0.022) had a lower likelihood of being alive at home at 12 months. Conclusions: Almost half of the sample cohort was frail. Older age was a better predictor of adverse outcomes than frailty as categorized by the SHARE-FI. SHARE-FI has limited predictability when used as a frailty screening instrument in the ED. [ABSTRACT FROM AUTHOR]

Background: Studies have demonstrated that a significant minority of older persons presenting to acute hospital services are cognitively impaired; however, the impact of dementia on long-term outcomes is less clear. Aim: To evaluate the prevalence of dementia, both formally diagnosed and hitherto unrecognised in a cohort of acutely unwell older adults, as well as its impact on both immediate outcomes (length of stay and in-hospital mortality) and 12-month outcomes including readmission, institutionalisation and death. Design: Prospective observational study. Methods: 190 patients aged 70 years and over, presenting to acute hospital services underwent a detailed health assessment including cognitive assessment (standardised Mini Mental State Examination, AD8 and Confusion Assessment Method for the Intensive Care Unit). Patients or informants were contacted directly 12 months later to compile 1-year outcome data. Dementia was defined as a score of 2 or more on the AD8 screening test. Results: Dementia was present in over one-third of patients (73/190). Of these patients, 36% (26/73) had a prior documented diagnosis of dementia with the remaining undiagnosed before presentation. The composite outcome of death or readmission to hospital within the following 12 months was more likely to occur in patients with dementia (73% (53/73) vs. 58% (68/117), P=0.043). This finding persisted after controlling for age, gender, frailty status and medical comorbidities, including stroke and heart disease. Conclusion: A diagnosis of dementia confers an increased risk of either death or further admission within the following 12 months, highlighting the need for better cognitive screening in the acute setting, as well as targeted intervention such as comprehensive geriatric assessment. [ABSTRACT FROM AUTHOR]

Background: The analysis of routinely collected hospital data informs the design of specialist services for at-risk older people.Aim: Describe the outcomes of a cohort of older emergency department (ED) attendees and identify predictors of these outcomes.Design: retrospective cohort study.Methods: All patients aged 65 years or older attending an urban university hospital ED in January 2012 were included (N = 550). Outcomes were retrospectively followed for 12 months. Statistical analyses were based on multivariate binary logistic regression models and classification trees.Results: Of N = 550, 40.5% spent ≤6 h in the ED, but the proportion was 22.4% among those older than 81 years and not presenting with musculoskeletal problems/fractures. N = 349 (63.5%) were admitted from the ED. A significant multivariate predictor of in-hospital mortality was Charlson comorbidity index [CCI; odds ratio = 1.19, 95% confidence interval: 1.07, 1.34, P = 0.002]. Among patients who were discharged from ED without admission or after their first in-patient admission (N = 499), 232 (46.5%) re-attended ED within 1 year, with CCI being the best predictor of re-attendance (CCI ≤ 4: 25.8%, CCI > 5: 60.4%). Among N = 499, 34 (6.8%) had died after 1 year of initial ED presentation. The subgroup (N = 114) with the highest mortality (17.5%) was composed by those aged >77 years and brought in by ambulance on initial presentation.Conclusions: Advanced age and comorbidity are important drivers of outcomes among older ED attendees. There is a need to embed specialist geriatric services within frontline services to make them more gerontologically attuned. Our results predate the opening of an acute medical unit with specialist geriatric input. [ABSTRACT FROM AUTHOR]