Inpatient Care Coordination Could Impact Clinical Outcomes, Duration of Hospital Stays

Washington, DC—Clinical and in-hospital process variables are associated with hospital length of stay (LOS) in acute ischemic stroke patients, according to data presented at the 2015 annual meeting of the American Academy of Neurology. Specifically, results from the study demonstrate that coordination of inpatient care processes, combined with the assessment and treatment of comorbidities, could impact hospital LOS as well as long-term clinical outcomes.

“For mild ischemic stroke patients, time to therapy evaluations and likelihood of return to the emergency department were associated with length of stay, whereas the majority of clinical factors—including mRS [modified Rankin Scale], NIHSS [National Institutes of Health Stroke Scale] score, and infarct location—were not,” reported Sun Kim, MD, Assistant Professor of Medicine, Stanford University Medical Center, CA. “However, a greater percentage of those with more prolonged hospital LOS received intravenous (IV) tPA [tissue plasminogen activator], which likely impacted LOS.”

The initial hospitalization of patients diagnosed with ischemic stroke significantly affects long-term outcomes and represents the majority of healthcare costs within the first year, Dr Kim explained. Poststroke care includes post-IV tPA monitoring, initiation of pharmacotherapies for stroke risk factor modification, correction of hemodynamic abnormalities, and obtainment of necessary neuroimaging and other studies to help clarify the cause of ischemic stroke.

Services such as physical, occupational, and speech–language therapies are necessary to identify and treat physical barriers that are modifiable to avoid complications such as falls and aspiration, Dr Kim said.

“Optimization of the delivery of comprehensive poststroke care has a positive clinical and financial impact, including potentially reducing poststroke complications,” observed Dr Kim. “We hypothesize that hospital LOS is correlated with clinical characteristics, in-hospital care processes, and long-term clinical outcomes.”

Study Details

For this study, researchers performed a single-center retrospective chart analysis using electronic health record data on a cohort of 95 patients admitted between September 2012 and September 2013 with a diagnosis of acute ischemic stroke and hospital LOS <3 days. Patients were grouped into 3 categories: patients with an LOS ≤1 day (group 1); patients with an LOS of >1 but ≤2 days (group 2); and patients with an LOS of >2 but ≤3 days (group 3).

“Clinical and demographic characteristics such as age, gender, premorbid mRS score, and vascular risk factors were recorded,” noted Dr Kim. “In-hospital variables such as time to obtain neurological consultation, time to initial CT [computed tomography] scan, time to initial MRI [magnetic resonance imaging], and time to various therapy services were also recorded and compared across groups. Return emergency department visits within 1 year of initial encounter were recorded for each group and differentiated by vascular versus other cause of return encounter.”

When comparing patients in group 1 versus groups 2 and 3, patients in group 1 had a significantly higher rate of history of stroke (35% vs 18%; P = .04). There was no significant difference in the presence of other vascular risk factors, premorbid mRS, or initial NIHSS score. Patients in group 1 also received significantly less IV tPA when compared with patients in groups 2 and 3. There were no significant differences seen between groups in time to patients receiving an initial neurologic consultation or neuroimaging studies.

Key Opportunity for Improvement

The study’s most notable finding was that inpatient therapy evaluations took place later in patients with LOS >1 day (P <.01), suggesting opportunities for improvement for this process. Early discharge was also associated with improved clinical outcomes. Patients discharged within 1 day were less likely to return to the emergency department within 1 year of an event than patients discharged after a longer LOS. Although there was no significant difference in return emergency department visits for cardiac disease within 1 year, there was less recurrent stroke or transient ischemic attack (TIA) in group 1 (0% vs 12%; P <.01).

“These results,” concluded Dr Kim, “suggest that coordination of inpatient care processes, in addition to assessing and treating comorbidities, could impact hospital LOS and, perhaps, long-term outcome such as recurrence of stroke or TIA.”