Teri Green

Hemi-orolingual angioedema and ACE inhibition after alteplase treatment of stroke

One hundred seventy-six consecutive patients treated with IV tissue plasminogen activator (tPA) for acute ischemic stroke were examined prospectively, and orolingual angioedema was found in nine (5.1%; 95% CI 2.3 to 9.5). The reaction was typically mild, transient, and contralateral to the ischemic hemisphere. Risk of angioedema was associated with angiotensin-converting enzyme inhibitors (relative risk [RR] 13.6; 95% CI 3.0 to 62.7) and signs on initial CT of ischemia in the insular and frontal cortex (RR 9.1; 95% CI 1.4 to 30.0).

Impact of a Stroke Unit on Length of Hospital Stay and In-Hospital Case Fatality

Background and Purpose— Randomized trials have demonstrated reduced morbidity and mortality with stroke unit care; however, the effect on length of stay, and hence the economic benefit, is less well-defined. In 2001, a multidisciplinary stroke unit was opened at our institution. We observed whether a stroke unit reduces length of stay and in-hospital case fatality when compared to admission to a general neurology/medical ward. Methods— A retrospective study of 2 cohorts in the Foothills Medical Center in Calgary was conducted using administrative databases. We compared a cohort of stroke patients managed on general neurology/medical wards before 2001, with a similar cohort of stroke patients managed on a stroke unit after 2003. The length of stay was dichotomized after being centered to 7 days and the Charlson Index was dichotomized for analysis. Multivariable logistic regression was used to compare the length of stay and case fatality in 2 cohorts, adjusted for age, gender, and patient comorbid conditions defined by the Charlson Index. Results— Average length of stay for patients on a stroke unit (n=2461) was 15 days vs 19 days for patients managed on general neurology/medical wards (n=1567). The proportion of patients with length of stay >7 days on general neurology/medical wards was 53.8% vs 44.4% on the stroke unit (difference 9.4%; P<0.0001). The adjusted odds of a length of stay >7 days was reduced by 30% (P<0.0001) on a stroke unit compared to general neurology/medical wards. Overall in-hospital case fatality was reduced by 4.5% with stroke unit care. Conclusions— We observed a reduced length of stay and reduced in-hospital case-fatality in a stroke unit compared to general neurology/medical wards.

Predicting final disposition after stroke using the Orpington Prognostic Score

BACKGROUND Prediction of outcome after stroke is important for triage decisions, prognostic estimates for family and for appropriate resource utilization. Prognostication must be timely and simply applied. Several scales have shown good prognostic value. In Calgary, the Orpington Prognostic Score (OPS) has been used to predict outcome as an aid to rehabilitation triage. However, the OPS has not been assessed at one week for predictive capability. METHODS Among patients admitted to a sub-acute stroke unit, OPS from the first week were examined to determine if any correlation existed between final disposition after rehabilitation and first week score. The predictive validity of the OPS at one week was compared to National Institute of Health Stroke Scale (NIHSS) score at 24 hours using logistic regression and receiver operator characteristics analysis. The primary outcome was final disposition after discharge from the stroke unit if the patient went directly home, or died, or from the inpatient rehabilitation unit. RESULTS The first week OPS was highly predictive of final disposition. However, no major advantage in using the first week OPS was observed when compared to 24h NIHSS score. Both scales were equally predictive of final disposition of stroke patients, post rehabilitation. CONCLUSIONS The first week OPS can be used to predict final outcome. The NIHSS at 24h provides the same prognostic information.

Advancing nursing practice : The role of the nurse practitioner in an acute stroke program

Both patient and staff satisfaction with the SNP role has been high as it relates to quality of care delivery and accessibility of care and service. In particular, patients express satisfaction with the continuity of care experienced throughout the stroke care continuum, from acute in-hospital care to postdischarge follow-up. Improvements have been realized in systems and processes of care with the implementation of the SNP role. These include reductions in door-to-needle times in the administration of tPA (from 90 minutes to 60 minutes), rapid assessment and diagnostic interventions through coordination of are activities (e.g., door-to-CT scan times reduced from 60 minutes to 30 minutes), and faster consultation responses within the organization. Instituting the nurse practitioner role early in the development of the Calgary Stroke Program enhanced patient care while advancing the nursing discipline. The SNP has created a role that extends beyond that of physician helper to an autonomous nursing practice that has been beneficial to both patients with stroke and the regional healthcare delivery system. With the ability to practice autonomously, the nurse practitioner can aid in the expedient delivery of complex, comprehensive stroke care, as has been the case in the Calgary Stroke Program.