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The implementation of a 5-step reminder process and pharmacist consultation/visit improved medication adherence and reduced operative delays.
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OBJECT: The effects of sleep deprivation on performance have been well documented and have led to changes in duty hour regulation. New York State implemented stricter duty hours in 1989 after sleep deprivation among residents was thought to have contributed to a patient's death. The goal of this study was to determine if increased regulation of resident duty hours results in measurable changes in patient outcomes. METHODS: Using the Nationwide Inpatient Sample (NIS), patients undergoing neurosurgical procedures at hospitals with neurosurgery training programs were identified and screened for in-hospital complications, in-hospital procedures, discharge disposition, and in-hospital mortality. Comparisons in the above outcomes were made between New York hospitals and non-New York hospitals before and after the Accreditation Council for Graduate Medical Education (ACGME) regulations were put into effect in 2003. RESULTS: Analysis of discharge disposition demonstrated that 81.9% of patients in the New York group 2000-2002 were discharged to home compared with 84.1% in the non-New York group 2000-2002 (p = 0.6, adjusted multivariate analysis). In-hospital mortality did not significantly differ (p = 0.7). After the regulations were implemented, there was a nonsignificant decrease in patients discharged to home in the non-New York group: 84.1% of patients in the 2000-2002 group compared with 81.5% in the 2004-2006 group (p = 0.6). In-hospital mortality did not significantly change (p = 0.9). In New York there was no significant change in patient outcomes with the implementation of the regulations; 81.9% of patients in the 2000-2002 group were discharged to home compared with 78.0% in the 2004-2006 group (p = 0.3). In-hospital mortality did not significantly change (p = 0.4). After the regulations were in place, analysis of discharge disposition demonstrated that 81.5% of patients in the non-New York group 2004-2006 were discharged to home compared with 78.0% in the New York group 2004-2006 (p = 0.01). In-hospital mortality was not significantly different (p = 0.3). CONCLUSIONS: Regulation of resident duty hours has not resulted in significant changes in outcomes among neurosurgical patients.
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Hospitales de Enseñanza/legislación & jurisprudencia , Internado y Residencia/legislación & jurisprudencia , Neurocirugia/legislación & jurisprudencia , Procedimientos Neuroquirúrgicos/legislación & jurisprudencia , Admisión y Programación de Personal/legislación & jurisprudencia , Acreditación , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Educación de Postgrado en Medicina/legislación & jurisprudencia , Educación de Postgrado en Medicina/estadística & datos numéricos , Femenino , Mortalidad Hospitalaria , Hospitales de Enseñanza/estadística & datos numéricos , Humanos , Internado y Residencia/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Neurocirugia/educación , Neurocirugia/estadística & datos numéricos , Procedimientos Neuroquirúrgicos/estadística & datos numéricos , New York , Admisión y Programación de Personal/estadística & datos numéricos , Factores Socioeconómicos , Resultado del Tratamiento , Estados Unidos , Adulto JovenRESUMEN
OBJECTIVE: Postthrombolytic intracerebral hemorrhage (ICH) is an infrequent occurrence in patients with acute ischemic stroke. There is controversy surrounding the value of neurosurgical treatment of symptomatic hematomas in these patients and whether availability of neurosurgical treatment is a necessary prerequisite for administration of thrombolytic agents. We report the frequency and outcomes of patients who undergo craniotomy for postthrombolytic ICH. METHODS: Patients with acute ischemic stroke who experienced postthrombolytic ICH were identified using the Nationwide Inpatient Sample from 2002-2010 and International Classification of Diseases, 9th Revision, Clinical Modification codes. Patients were divided into patients who received craniotomy and patients who received medical management alone. Discharge destination and mortality were primary endpoints. RESULTS: An estimated 7607 patients experienced postthrombolytic ICH; 125 (1.6%) patients underwent craniotomy, and 7482 patients (98.4%) received medical treatment alone. Patients in the craniotomy group were younger (53.7 years old ± 36 vs. 72.4 years old ± 29, P = 0.09) and were frequently in the extreme severity All Patient Refined Diagnosis Related Group category compared with patients in the medical management group (92.2% vs. 55.5%, P = 0.001). The mean length of stay was also longer in the craniotomy group (21.5 days vs. 10 days, P < 0.0001). In-hospital mortality was greater in the medical management group (30.5% vs. 24.2%, P = 0.5). After adjusting for age, gender, and All Patient Refined Diagnosis Related Group severity index, the odds ratios of in-hospital mortality, discharge to extended care facility, and discharge to home or self-care were 0.8 (95% confidence interval [CI] 0.3-2.0, P = 0.5), 5.4 (95% CI 0.6-52.0, P = 0.1), and 0.2 (95% CI 0.02-1.8, P = 0.1) for the craniotomy group compared with the medical management group. CONCLUSIONS: Emergent craniotomy for postthrombolytic ICH in patients with acute stroke is a salvage treatment offered to a small proportion of patients. Although biases introduced by patient selection cannot be excluded in our analysis, the excessively high rates of death or disability associated with surgical evacuation limit the value of such a procedure in current practice.
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Isquemia Encefálica , Hemorragia Cerebral/mortalidad , Trombosis Intracraneal , Procedimientos Neuroquirúrgicos/mortalidad , Accidente Cerebrovascular , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/tratamiento farmacológico , Isquemia Encefálica/mortalidad , Isquemia Encefálica/cirugía , Hemorragia Cerebral/etiología , Hemorragia Cerebral/cirugía , Craneotomía/mortalidad , Bases de Datos Factuales , Femenino , Fibrinolíticos/administración & dosificación , Fibrinolíticos/efectos adversos , Mortalidad Hospitalaria , Humanos , Trombosis Intracraneal/tratamiento farmacológico , Trombosis Intracraneal/mortalidad , Trombosis Intracraneal/cirugía , Masculino , Trombolisis Mecánica/mortalidad , Persona de Mediana Edad , Alta del Paciente , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/cirugía , Adulto JovenRESUMEN
BACKGROUND AND PURPOSE: A high rate of postprocedure complications in the Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis (SAMMPRIS) trial has raised concerns whether such results are representative of intracranial stent placement in actual routine practice. METHODS: Using the Nationwide Inpatient Sample from 2008 to 2010, patients with cerebral ischemic events treated with intracranial stent as part of a clinical trial or outside the trial were identified. The composite end point (postoperative stroke, cardiac complications, and mortality) was reported. RESULTS: Of the 3447 patients who underwent intracranial stent placement, 223 patients (6.5%) were enrolled in a clinical trial. The rate of composite end point was higher in patients treated outside clinical trials compared with those treated within clinical trials (14.2% versus 4.5%; P=0.1). The proportion of patients discharged to home was higher in those treated in clinical trials (76.8% versus 49.6%; P=0.001). CONCLUSIONS: Intracranial stent placement procedures outside a clinical trial have higher rates of postoperative stroke, cardiac complication, and mortality.
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Ensayos Clínicos como Asunto , Arteriosclerosis Intracraneal/cirugía , Stents , Accidente Cerebrovascular/cirugía , Factores de Edad , Anciano , Anciano de 80 o más Años , Constricción Patológica/mortalidad , Constricción Patológica/cirugía , Femenino , Humanos , Arteriosclerosis Intracraneal/mortalidad , Masculino , Persona de Mediana Edad , Recurrencia , Accidente Cerebrovascular/mortalidad , Resultado del TratamientoRESUMEN
BACKGROUND: Intracerebral hemorrhage (ICH) is an infrequent complication of intravenous recombinant tissue plasminogen activator (rt-PA) for the treatment of acute stroke. However, such ICH is an important reason for withdrawal of care because of lack of adequate data regarding long-term patient outcomes. OBJECTIVE: To report the long-term outcomes in patients with post-thrombolytic ICH. METHODS: We analyzed patient data from a randomized, placebo-controlled trial in patients with ischemic stroke presenting within 3 h of symptom onset. Baseline clinical characteristics and outcomes defined by modified Rankin scale (mRS) were ascertained at 3, 6, and 12 months after treatment in patients who suffered from post-thrombolytic ICH. Favorable outcome was defined by mRS of 0-3 and unfavorable outcome by mRS of 4-6 at 1 year. RESULTS: A total of 48 patients suffered post-thrombolytic ICH in the trial. Fourteen patients had favorable outcomes and 34 patients had unfavorable outcomes. Clinical characteristics did not have an impact on patient outcomes at 12 months. Patients with unfavorable outcomes were more likely to have an National Institutes of Health Stroke Scale (NIHSS) score ≥ 20 at 7-10 days after treatment (64 vs. 7 %, p < 0.0009). Patients with unfavorable outcomes were more likely to have a worsening of NIHSS score of >4 points at 7-10 days from their baseline NIHSS (44 vs. 0 %, p = 0.0006). CONCLUSION: Approximately 30 % of patients with post-thrombolytic ICH have favorable outcomes at 1 year which does not support early withdrawal of care. Ascertainment of NIHSS score and worsening of NIHSS score at 7-10 days may be necessary for accurate prognostic stratification.