Study design: Retrospective cohort study.
Setting: National Health Service public hospitals, England.
Synopsis: This study evaluated six quality-safety indicators among 93,621 stroke admits from April 1, 2009, to March 31, 2010. Investigators found performance on five of six indicators was significantly worse on weekends. Specifically, the percent of same-day brain scans was 43.1% on weekends, compared with 47.6% on weekdays, and seven-day in-hospital mortality for Sunday admissions was 11%, compared with an overall mean mortality of 8.9%.
It is possible that some of the observed effect could be due to unmeasured differences in patients admitted on weekends compared to weekdays.
Bottom line: This study suggests that, similar to other clinical conditions, significant disparities might exist between weekend and weekday care of stroke patients.
Citation: Palmer WL, Bottle A, Davie C, Vincent CA, Aylin P. Dying for the weekend: a retrospective cohort study on the association between day of hospital presentation and the quality and safety of stroke care. Arch Neurol. 2012;9:1-7.
Hospital Admissions from Emergency Departments Increasing
Clinical question: What proportion of current hospital admissions use the ED as an admission portal?
Background: Historically, outpatient providers’ offices admitted clinically stable patients with acute problems. From 1997 to 2007, ED visit rates increased by more than a third. Currently, a quarter of all acute-care outpatient visits occur in the ED.
Study design: Retrospective, observational cohort study.
Setting: The Nationwide Inpatient Sample (NIS) database, with approximately 8 million annual hospital stays, weighted to produce national averages.
Synopsis: NIS data from 1993 to 2006 showed the number of hospital admissions increased by 15%, while the proportion of admissions from the ED increased by 50%. The total proportion of inpatients entering from the ED increased to 43.8% from 33.5% (P<0.001). Twelve of the 13 most frequent inpatient clinical conditions also had a proportional increase in admissions from the ED (P<0.0001).
Possible explanations for the increases include difficulty arranging timely outpatient sick visits and overuse of the ED for issues that could be more appropriately addressed by primary-care offices. Furthermore, public education campaigns for heart attack or stroke emphasize early emergency care. Patients and providers expect rapid specialized care and early treatment that is readily available in ED.
More efficient use of inpatient resources is a focus of the Affordable Care Act. To inform health policy, research is needed to determine the drivers of admission trends, as well as the value and cost of emergency care.
Bottom line: The proportion of hospital admissions from the ED is increasing, but the implications for healthcare delivery are inadequately understood.
Citation: Schuur JD, Venkatesh AK. The growing role of emergency departments in hospital admissions. N Engl J Med. 2012;367(5):391-393.
Avoiding Intensive Glucose Control in Acute Stroke
Clinical question: Is intensive insulin treatment beneficial in patients with acute stroke?
Background: Although post-stroke hyperglycemia is associated with worse outcomes in acute stroke patients, it is unknown if intensive insulin treatment improves prognosis or infarct size.
Study design: Unblinded randomized controlled trial.
Setting: Single academic medical center in France.
Synopsis: Study authors randomized acute stroke patients (NIHSS from 5 to 25) to intensive insulin treatment or subcutaneous insulin therapy within 24 hours of admission. Initial median blood sugars were ~120 mg/dL in both groups. Mean blood sugars of <126 mg/dL were achieved at 24 hours in 95% of the intensive group and 67% of the subcutaneous group. The MRI infarct size at follow-up scanning was significantly larger in the intensive insulin group, but there were no differences in functional outcomes, serious adverse events, or mortality between the groups.