Download Should Mild or Moderate Stroke Patients Be Admitted to an Intensive

Should Mild or Moderate Stroke Patients Be Admitted to an
Intensive Care Unit?
Deborah E. Briggs, MD; Robert A. Felberg, MD; Marc D. Malkoff, MD;
Patti Bratina, RN; James C. Grotta, MD
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Background and Purpose—Inhospital placement of patients with mild (National Institutes of Health Stroke Scale [NIHSS]
score ⬍8) or moderate (NIHSS 8 through 16) acute strokes is variable. We assessed the outcome of such patients based
on intensive care unit (ICU) versus general ward placement.
Methods—We reviewed 138 consecutive patients admitted within 24 hours of stroke onset to 2 physically adjacent
hospitals with different admitting practices. Outcome measures included complication rates, discharge Rankin scale
score, hospital discharge placement, costs, and length of stay (LOS).
Results—Hospital A, a 626-bed university-affiliated hospital, admitted 43% of mild and moderate strokes (MMS) to an
ICU (26% of mild, 74% of moderate), whereas hospital B, a 618-bed community facility, admitted 18% of MMS to an
ICU (3% of mild, 45% of moderate; P⬍0.004). There were no significant differences in outcomes between the 2
hospitals. Analysis of only patients admitted to hospital A, and of all patients, demonstrated that mild stroke patients
admitted to the general ward had fewer complications and more favorable discharge Rankin scale scores than similar
patients admitted to an ICU. There was no statistically significant difference in LOS, but total room costs for a patient
admitted first to the ICU averaged $15 270 versus $3638 for admission directly to the ward.
Conclusions—While limited by the retrospective nature of our study, routinely admitting acute MMS patients to an ICU
provides no cost or outcomes benefits. (Stroke. 2001;32:871-876.)
Key Words: costs and cost analysis 䡲 stroke 䡲 stroke management 䡲 stroke outcome 䡲 triage
O
ptimal inhospital placement for acute stroke patients has
been variable in practice. Placement of patients with
severe stroke (National Institutes of Health Stroke Scale
[NIHSS] score ⬎17) in an intensive care unit (ICU) is fairly
routine; however, practice varies for placement of mild
(NIHSS ⬍8) and moderate (NIHSS 8 to 16) strokes. Although numerous studies have focused on the effects on cost
and outcome from the implementation of an acute stroke unit,
none to date have addressed the impact on costs and outcomes based on patients’ inhospital placement when a stroke
unit is unavailable.1,2 Considering that acute stroke units are
not widely available in community hospitals in the United
States and that nearly 75% of the 731 000 strokes occurring
annually in the United States3 are classified as mild to
moderate, the issue of inhospital placement of mild to
moderate strokes has widespread implications. Furthermore,
because of the substantial daily expenses associated with ICU
care relative to patient management on a general ward,
optimal placement of acute stroke patients is an important
cost consideration. The objective of this study is to assess the
effect on outcome and costs from placement of mild and
moderate stroke (MMS) patients in an ICU versus general
ward on admission from the emergency room (ER).
Methods
Subjects and Data Collection
We compared placement, management, and outcomes of acute stroke
patients consecutively admitted to 2 similarly sized major hospitals
that serve the same community. Hospital A is a 626-bed universityaffiliated hospital with a level-1 trauma center; hospital B is 618-bed
community hospital. Patients admitted within 24 hours of their
symptom onset were screened for inclusion criteria. We included
only patients who were admitted through the emergency department
at each hospital with a suspected diagnosis of acute stroke. All
screening and chart abstractions at both hospitals were performed by
the same 2 investigators. The specific inclusion criteria used included the following: (1) admitted for a potential ischemic stroke or
intracerebral or subarachnoid hemorrhage; (2) not transferred from
another institution where diagnosis or treatment was initiated;
(3) had focal neurological symptoms lasting at least 24 hours after
admission; (4) not transferred to another institution before stroke
evaluation could be initiated; (5) if comatose at time of ER
presentation, regained consciousness during hospital admission so
that adequate history and evaluation could be performed; and
(6) aged ⱖ18 years at time of admission.
Potential subjects were identified through 2 different methods,
depending on patient tracking available at each hospital. At hospital
A, patients to screen were found by reviewing all patients discharged
with International Classification of Diseases, 9th Revision (ICD-9),
codes 430 to 438.9. Available charts for all identified patients who
Received August 9, 2000; final revision received December 6, 2000; accepted December 11, 2000.
From the Department of Neurology, UT–Houston Medical School, Houston, Tex, and Ochsner Clinic, New Orleans, La (R.A.F.).
Presented in part at the 124th American Neurological Association meeting, Seattle, Wash, October 12, 1999.
Correspondence to James Grotta, MD, UT-STAT Stroke Treatment Team, Department of Neurology, UT–Houston Medical School, 6431 Fannin, MSB
7.044, Houston, TX 70330. E-mail [email protected]
© 2001 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org
871
872
Stroke
April 2001
had a corresponding ICD-9 code for acute stroke were reviewed for
inclusion criteria. Of the 378 charts requested at hospital A, 373 were
available for review. Three hundred four of the patients reviewed did
not meet the above-specified criteria. The time frame used at hospital
A included discharge dates of 6/27/97 through 10/10/97, which
corresponded to qualifying patients consecutively admitted from
6/25/97 through 10/4/97. At hospital B, patients were identified
through the ER log for all admitted patients, where an admission
diagnosis of stroke or rule-out of stroke was used. Two hundred one
charts were requested from hospital B, and 191 were available for
review. One hundred twenty-two patients did not meet the abovespecified criteria. The screening process at hospital B was based on
consecutive presentations to the ER during the time frame of 6/29/97
through 12/6/97. The most common reasons that the majority of
patients at both hospitals did not qualify were either that symptoms
had resolved within 24 hours or the patient was transferred from an
outlying hospital where treatment was initiated. Also, several patients with severe strokes did not qualify because they arrived
comatose and never regained consciousness before dying or having
treatment withdrawn within 24 hours of admission.
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Outcome Measures
Prespecified outcome measures collected and analyzed included the
following:
Length of stay. The LOS included the number of hospital days,
starting at admission from ER to discharge home or other discharge
arrangement, ie, inpatient rehabilitation. For each patient, the total
days spent in an ICU versus a general ward was captured.
Discharge Rankin Scale score. The modified Rankin scale (MRS)
was used.4 This scale has 6 grades, ranging from 0 (no symptoms) to
5 (severe disability); 6 corresponds to death. We considered a
discharge to hospice equivalent to an MRS of 6. These scores were
extrapolated from the daily progress notes, transfer notes, and/or
discharge summary for each patient.
Discharge Rankin code. Rankin scores from 0 to 2 were recoded
as one value and those from 3 to 6 as a second value, as supported
by the ECASS Trial.4,5
Discharge placement from hospital. Types of discharge placement
included home, inpatient rehabilitation, skilled nursing facilities,
hospice, specialty hospitals, and transitional care facilities. For the
purpose of evaluating discharge placement as an outcome measure,4
patients who were discharged home or to inpatient rehabilitation
were considered together versus all other discharge placements. We
defined good outcomes as going home or inpatient rehabilitation
versus subacute rehabilitation, institutionalization in a skilled nursing facility, or death. Inpatient rehabilitation is defined as rehabilitation of less than 90 days with the goal of discharge to home.
Complication rates. This rate comprised the total number of
complications directly related to each patient’s hospitalization for
acute stroke. Complications included the following: aspiration pneumonia, pulmonary embolus, deep-vein thrombosis, hemorrhagic
conversion of ischemic stroke, urinary tract infections/hematuria,
gastrointestinal bleeds, line infections, falls, acute renal failure,
herniation, hyponatremia, enteral feeding tube complications, sepsis,
respiratory failure requiring intubation, pancreatitis, hypokalemia,
antibiotic reaction, hematoma formation from catheterization sites,
recurrent strokes, seizures, decubitus ulceration, and hydrocephalus
requiring a ventricular peritoneal shunt. All of the complications
included were documented in the progress notes, occurred during the
hospitalization, and could be verified by laboratory or radiology
results as well as by treatment. For instance, aspiration pneumonias
were documented pneumonias that were diagnosed and confirmed
through history and chest x-ray by the primary team and subsequently treated with antibiotics.
Other Data Classifications
Two prespecified major groupings of stroke patients were used for
the various analyses performed in this study. These groupings
included the following:
Admission placement. The classification ICU included neurology,
surgical, medicine, and coronary care units. Ward classification
TABLE 1.
Admission
Placement
ICU
Inhouse Placement Comparisons Between Hospitals
Stroke Severity
Hospital A
Hospital B
P*
Mild only
9 (26)
1 (3)
0.004
Moderate only
14 (74)
9 (45)
0.072
Mild/mod
23 (43)
10 (18)
0.004
Severe
15 (100)
10 (83)
0.108
Values are expressed as number (percentages) unless otherwise indicated.
*Significance levels are based on 2-tailed Student t test.
incorporated all other placements, such as general floor beds (medicine or neurology), intermediate care units, or observation units. Not
every patient was seen by a neurologist during admission nor
admitted to a stroke service.
Stroke severity. Stroke classifications were based on the admission
NIHSS extrapolated from the admission history and examination
performed by a neurologist or ER physician. The NIHSS is a
42-point scale that has been validated for use in stroke studies to
analyze stroke severity and measure neurological deficits.6 The
validity of estimating the NIHSS score retrospectively from the
medical record has also been verified.7 All extrapolations were done
by the same 2 investigators. Severe strokes corresponded to an
NIHSS score ⬎17, mild strokes to an NIHSS ⬍8, and moderate
strokes to an NIHSS score of 8 to 16. These groupings are consistent
with those used in other stroke studies.8,9
Other prespecified data collected included patient demographics
and medical comorbidities, as well as, the number and type of
diagnostic studies performed. The comorbid factors collected include: diabetes mellitus, hypertension, congestive heart failure,
coronary artery disease, previous stroke, atrial fibrillation, hypercholesterolemia, and tobacco use within the past 10 years. Comorbid
factors were identified either through history or physical examination, radiological studies, or other studies documented in the patient’s chart. For instance, prior strokes could be identified through
CT or MRI, or atrial fibrillation identified through EKG, if not
elicited from the history. The type of studies captured in the database
included MRI/MR angiography of the head, CT scan of the head,
cardiac echo, cerebral angiogram, and carotid Doppler sonography.
Statistical Analysis
All outcome measures were compared between the major groupings
(admission placement and stroke severity) used for the study.
Statistical analysis was performed with SPSS software (version
8.0.0; SPSS, Inc). All comparisons for continuous variables between
the major groupings used an independent 2-tailed Student t test.
Categorical or nonparametric data such as discharge Rankin score
were analyzed with ␹2 tests. Statistical significance was set at
P⬍0.05.
The sample size used was based on an initial analysis of 25
patients at each hospital. The main hypothesis used to establish
power was that there is no statistical difference in LOS for acute
stroke patients admitted to the 2 hospitals. We based our sample size
on this end point because it was “hard” and not subject to bias, and
it is the major determinant of hospital costs, which is of interest to
hospital administrators and healthcare planners who might be particularly likely to use our data to stimulate further similar analyses.
With total hospital days as the main outcome variable, a sample size
of 136 (68 patients per hospital) was required to meet 80% power
and a 2-sided significance level of 5%.
Results
Hospital A admitted approximately 43% of the MMS patients
to the ICU, whereas hospital B admitted 18% of the MMS
patients to an ICU (P⫽0.004) (Table 1). Patients admitted to
each hospital shared similar baseline characteristics (Table 2).
There was no difference in mean LOS for the 69 patients
Briggs et al
TABLE 2. Stroke Patient Demographic Comparisons
Between Hospitals
Demographics, by
Stroke Severity
Hospital A
(n⫽69)
Hospital B
(n⫽69)
Admission of Mild and Moderate Strokes
873
TABLE 3. Outcome Comparisons Between Hospitals, by
Stroke Severity
P*
Mild strokes (n⫽72)
Stroke Severity
Hospital A
(n⫽69)
Hospital B
(n⫽69)
P*
4.63
5.05
0.816
Mild (n⫽72)
Average patient age, y
62.83
67.46
0.145
Average length of stay, d
Male sex, %
51
57
0.656
Average discharge Rankin†
1.91
2.16
0.821
0.210
Discharge Rankin 0–2
69%
65%
0.739
Discharge to home or
inpatient rehabilitation
91%
86%
0.505
Average complication rate
0.20
0.19
0.943
8.00
10.95
0.315
Average no. of comorbidities
2.03
2.41
Diabetes, %
23
38
0.706
Hypertension, %
74
73
0.988
CAD, %
17
32
0.646
Moderate (n⫽39)
CVA history, %
23
43
0.671
Dyslipidemia, %
11
22
0.648
Average length of stay, d
Tobacco use history, %
40
16
0.514
Average discharge Rankin†
3.32
3.50
0.399
26%
15%
0.382
Atrial fibrillation, %
CHF, %
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6
14
0.597
Discharge Rankin 0–2
11
5
0.534
Discharge to home or
inpatient rehabilitation
63%
65%
0.905
Average complication rate
0.47
0.45
0.932
5.81
7.12
0.417
Moderate strokes (n⫽39)
Average patient age, y
64.37
70.10
0.115
Male sex, %
47
50
0.847
Average no. of comorbidities
2.32
2.30
0.968
Mild and moderate (n⫽111)
Average length of stay, d
Average discharge Rankin†
2.41
2.63
0.891
Discharge Rankin 0–2
54%
47%
0.505
Discharge to home or
inpatient rehabilitation
81%
79%
0.738
Average complication rate
0.30
0.28
0.911
11.47
12.42
0.820
Diabetes, %
42
30
0.736
Hypertension, %
68
80
0.875
CAD, %
21
40
0.594
CVA history, %
42
20
0.518
Dyslipidemia, %
5
15
0.546
Average length of stay, d
Tobacco use history, %
21
15
0.801
Average discharge Rankin†
5.00
4.83
0.869
Atrial fibrillation, %
21
30
0.736
Discharge Rankin 0–2
0%
0%
CHF, %
11
0
0.331
Discharge to home or
inpatient rehabilitation
33%
50%
䡠䡠䡠
0.381
Average complication rate
1.47
0.75
0.185
Severe strokes (n⫽27)
Average patient age, y
60.67
72.0
0.062
Male sex, %
67
33
0.091
Average no. of comorbidities
1.87
2.42
0.406
Diabetes, %
20
25
0.854
Hypertension, %
60
58
0.983
CAD, %
20
33
0.686
CVA history, %
20
42
0.543
Dyslipidemia, %
13
17
0.877
Tobacco history, %
20
8
0.597
Atrial fibrillation, %
20
42
0.646
CHF, %
13
0
0.334
Values are expressed as number or percentages unless otherwise indicated.
CAD indicates coronary artery disease; CVA, cerebral vascular accident; and
CHF, congestive heart failure.
*Significance levels are based on 2-tailed Student t test.
admitted to hospital A (7.04⫾8.83), versus the 69 patients
admitted to hospital B (8.04⫾9.38). Although there were
significant differences in placement of MMS patients between the 2 hospitals, there were no significant differences in
outcomes of these patients (Table 3). Severe stroke patients
were not included in further analyses comparing the 2
hospitals because the 2 hospitals did not differ significantly in
Severe (n⫽27)
Values are expressed as number or percentages unless otherwise indicated.
*Significance levels are based on 2-tailed Student t test or ␹2 test.
†Modified Rankin Scale ranging from 0 to 6.
their placement (P⫽0.108, Table 1) or outcomes (Table 3) of
severe patients.
Because there were significant interhospital differences in
admission placement of MMS, we carried out further analysis
of these patients. As there were no differences in outcomes
between hospitals for MMS patients, we first compared
outcomes of all MMS patients pooled from the 2 hospitals
based on placement to the ICU versus the general ward (Table
4). This analysis showed no outcomes difference for mild or
for moderate strokes admitted to the ICU versus the ward, but
when MMS strokes were combined, discharge MRS and
complication rates were more favorable in patients admitted
to the general ward.
Hospital A admitted a similar number of MMS patients to
the ICU versus the general ward (43% to the ICU versus 57%
to a general ward). The demographic characteristics (patient
age, percent male sex, and average number of comorbidities)
were similar between these patient populations though there
was a trend for younger patients with fewer comorbidities in
the ICU patients (data not shown). Further analysis of
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TABLE 4. Outcome Comparisons Combining MMS Patients at
Both Hospitals, by Inhouse Placement
Stroke Severity
ICU Admission
(n⫽23)
Ward Admission
(n⫽31)
P*
Mild (n⫽72)
Average length of stay, d
TABLE 5. Outcome Comparisons Between Inhouse Placement
at Hospital A
Stroke Severity
ICU Admission
(n⫽23)
Ward Admission
(n⫽31)
P*
5.78
4.23
0.591
Mild (n⫽35)
5.70
4.71
0.707
Average length of stay
Average discharge Rankin†
2.50
1.97
0.198
Average discharge Rankin†
2.78
1.62
0.044
Discharge Rankin 0–2
40%
71%
0.054
Discharge Rankin 0–2
33%
81%
0.008
Discharge to home or
inpatient rehabilitation
80%
90%
0.335
Discharge to home or
inpatient rehabilitation
78%
96%
0.090
Average complication rate
0.50
0.15
0.105
Average complication rate
0.56
0.08
0.032
7.14
10.40
0.443
Moderate (n⫽39)
Average length of stay, d
Moderate (n⫽19)
8.57
10.88
0.440
Average length of stay
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Average discharge Rankin†
3.22
3.69
0.236
Average discharge Rankin†
3.07
4.00
0.294
Discharge Rankin 0–2
26%
12%
0.126
Discharge Rankin 0–2
36%
0%
0.120
Discharge to home or
inpatient rehabilitation
74%
50%
0.301
Discharge to home or
inpatient rehabilitation
71%
40%
0.211
Average complication rate
0.52
0.38
0.604
Average complication rate
0.43
0.60
0.683
6.61
5.23
0.514
Mild and moderate (n⫽111)
Average length of stay, d
Mild and moderate (n⫽54)
7.70
5.97
0.328
Average length of stay
Average discharge Rankin†
3.00
2.32
0.006
Average discharge Rankin†
2.96
2.00
0.051
Discharge Rankin 0–2
30%
59%
0.032
Discharge Rankin 0–2
35%
68%
0.016
Discharge to home or
inpatient rehabilitation
76%
82%
0.447
Discharge to home or
inpatient rehabilitation
74%
87%
0.217
Average complication rate
0.52
0.19
0.033
Average complication rate
0.48
0.16
0.082
Values are expressed as number or percentages unless otherwise indicated.
*Significance levels are based on 2-tailed Student t test or ␹2 test.
†Modified Rankin Scale ranging from 0 to 6.
Values are expressed as number or percentages unless otherwise indicated.
*Significance levels are based on 2-tailed student t test or ␹2 test.
†Modified Rankin Scale ranging from 0 to 6.
outcomes and costs of MMS patients were performed within
hospital A. Severe stroke patients were not included in this
analysis because during the time of this study hospital A
admitted all of its severe strokes to an ICU. A separate article
will compare severe stroke patients admitted to an ICU versus
stroke unit after the latter was opened.
Analysis of mild stroke patients placed in an ICU versus
general ward showed that patients with mild strokes had
better outcomes when placed on the ward. Moderate stroke
patients showed no statistical differences in outcome regardless of inhospital placement though there was a trend in favor
of ICU admission (Table 5). In attempting to identify a cutoff
baseline NIHSS score above or below which moderate
patients might be better off in an ICU, we found a similar
general positive correlation between baseline NIHSS score
and discharge Rankin score in moderate patients regardless of
whether they were admitted to the ICU or the ward
(R2⫽0.273 for ICU and R2⫽0.09 for ward; see Figure 1). No
evident range of baseline NIHSS scores identified patients
who benefited more from ICU care.
Pertaining to the cost considerations for acute stroke, LOS
was the major variable used for short-term stroke costs. Table
6 outlines the cost differential between placement in an ICU
versus the general ward for MMS at hospital A.
based on inhospital placement where a stroke unit is not
available. An extensive literature search was performed that
covered US-based research completed in the last 10 years.
Realizing that our analysis, conducted in Houston acute-care
hospitals, cannot be generalized outside the unique healthcare
system in the United States, we excluded any studies conducted outside of the United States, where practice patterns
and costs may be different. We also found that studies limited
only to US Medicare data did not provide useful data on the
question of admission placement of stroke patients.
Although many studies were available for review for acute
stroke outcome measurements, the outcome measures widely
used are variable.4,10 The main outcomes measures we selected are variables that are readily accepted as qualitative
outcome measures, ie, length of hospital stay, functional
ability (discharge Rankin score and placement), and complication rates. There were also several studies available that
established predictors of hospital costs for acute stroke.10,11
Whereas many variables pertaining to direct stroke costs, ie,
number of diagnostic tests performed, patient’s premorbid
conditions, and basic demographic characteristics (such as
patient’s age, sex, or ethnicity) are controversial, most studies
agree that LOS is a major variable contributing to the acute
cost of stroke. The contributing percentage of LOS ranged
from 43%10 to 82%11 of the variation in total cost of acute
stroke.
This study shows that admitting acute MMS patients to an
ICU provides no outcome or cost benefits. For mild stroke
Discussion
This is the first study to our knowledge that addresses
outcomes and cost considerations in acute stroke patients
Briggs et al
Admission of Mild and Moderate Strokes
875
TABLE 6. Cost Differences Between Inhouse Placement at
Hospital A
Stroke Severity
ICU Admission
(n⫽23)
Ward Admission
(n⫽31)
P*
Mild (n⫽35)
Total ICU days
30
0
Total ward days
22
110
Total patients
Total room costs
9
26
$12 133
$2538
0.004
Avg MRIs/MRAs
0.22
0.46
0.218
Avg CTs
1.33
1.12
0.279
Moderate (n⫽19)
Total ICU days
70
6*
Total ward days
30
46
Total patients
Total room costs
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Correlation of presenting NIHSS score and discharge Rankin
scale score for 23 patients with moderate stroke admitted to the
ICU (squares, R2⫽0.273) and 16 with moderate stroke admitted
to the ward (circles, R2⫽0.09). There was no obvious “cutoff”
baseline NIHSS score that was predictive of better outcome
(lower Rankin) in ICU patients.
patients, significantly better discharge Rankin scores and
lower complication rates were found for patients admitted to
the ward versus patients placed in an ICU. Although not
significantly different, the LOS for mild stroke patients was
consistently lower when the patients were admitted to the
general ward. This shorter LOS, along with avoidance of ICU
costs, corresponds to significantly lower hospitalization costs.
Moderate strokes patients showed a non–statistically significant trend toward better outcomes when placed in an ICU
(Table 4). We suspect that there is a subgroup of moderate
stroke patients who fare better with ICU care. Because all
patients with NIHSS scores between 8 and 16 were included
under moderate strokes, it is possible that a subgroup of
patients would have better outcomes if admitted to an ICU.
However, on the basis of baseline NIHSS score alone, we
could not identify a subgroup of patients whose outcome was
clearly superior if admitted to the ICU instead of the ward.
There are several aspects of our study where bias could
have been introduced. First, the retrospective nature of our
study is susceptible to many biases and may limit some of the
conclusions. For example, bias could result from different
admission criteria used by different admitting physicians,
since there were no stroke treatment pathways implemented
at either hospital. Also, standards of practice other than triage
decisions may differ between hospital A and hospital B,
skewing our analysis. There may be other influencing factors
on ICU admission that may not have been captured by our
analysis, such the administration of tissue plasminogen activator being a factor for ICU admission. We believe that these
instances are minor and have little influence on the results. At
least at hospital A, minor imbalances in baseline demographics among MMS patients might have been expected to favor
better outcomes in the ICU, because younger patients with
fewer comorbidities were admitted to the ICU. Furthermore,
14
5
$17 286
$9360
Avg MRIs/MRAs
0.50
0.60
0.480
0.720
Avg CTs
1.86
1.60
0.676
Mild & Moderate
100
6
Total ward days
Total ICU days
52
156
Total patients
23
31
Total room costs
$15 270
$3638
0.004
Avg MRIs/MRAs
0.39
0.48
0.508
Avg CTs
1.65
1.19
0.0443
These days represent ICU days for patients transferred to the ICU from the
ward; values are number unless otherwise specified.
Total ICU days⫽sum of all days in the ICU for the patients during admission.
Total ward days⫽sum of all days on a general ward for the patients during
admission.
Total patients⫽the number of patients admitted to unit or ward, for each
respective stroke severity.
Total room costs⫽[(Total ICU days * $3200)⫹(Total ward days * $600)]/no.
of patients.
Avg MRIs/MRAs⫽sum of all MRIs done/no. of patients.
Avg CTs⫽sum of all CTs done/no. of patients.
*Significance levels are based on 2-tailed Student t test.
for each of the comorbidities, there were no important
differences between the ICU versus ward patients. For instance, for MMS the incidence of atrial fibrillation (24% to
ward versus 12% to ICU, P⫽0.422) or congestive heart
failure (12% to ICU versus 6% to ward, P⫽0.450) were
similar. This lack of significant difference also held true for
all other comorbidities (data not shown.)
Another consideration is that complications might be
detected more readily in the ICU because of more intensive
testing and observation of the patients. If greater scrutiny of
ICU patients were the major factor influencing complication
rates, we should have seen higher rates in ICU patients with
both mild and moderate stroke. However, higher complication rates were only seen in mild stroke patients. Overall, the
incidence of complications on the ward and the ICU were
small; only 25% of the total patients had 1 or more complications. The most common complication in the ICU was
pneumonia, followed by herniation and hemorrhagic conversion of an ischemic stroke. The latter 2 were mainly found in
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severe strokes. Hemorrhagic conversion of an ischemic stroke
had the same incidence rate on the ward as in the ICU. The
most common complication on the ward was repeat cerebrovascular accident, and the next most common was hemorrhagic conversion. Several of the complications in the ICU
were more a result of ICU care, such as line infections or
hematomas that resulted from lines being placed or pulled.
Other areas of bias include the use of 2 different methods
of case ascertainment required to collect data at the 2
hospitals. The 2 methods selected were used because they
turned out to be the best ways to capture all stroke cases
admitted through the ER at each hospital. Also, the study was
powered to detect outcome differences between the 2 hospitals. The study may have been underpowered to detect
differences in the analysis of hospital A alone. Finally, 2
investigators were used to assign NIHSS and Rankin scores,
which also allows for bias in interrater reliability.
As for limitations in our cost analysis, we used major cost
determinants rather than actual cost and performed an intrahospital rather than interhospital cost analysis. Length of stay
at hospital A may be artificially prolonged because of
economic placement delays caused by a relatively higher
number of underinsured patients, which raised the costs at
this hospital. Also, LOS may be affected by the patient’s
premorbid condition, availability of a caretaker, etc. It was
not our intention to represent costs as absolute values, but
rather as relative costs to be used in comparison analysis. As
such, we believe our conclusions were not greatly effected by
this cost-analysis limitation.
In conclusion, routinely admitting acute mild to moderate
stroke patients to an ICU provides no outcome or cost
benefits. Patients with mild strokes probably have better
results at lower cost if admitted to the ward. Considering that
MMS patients represent the majority of all stroke patients
(80% in our cohort), and that in 1993 $17 billion of an
estimated $30 billion annual cost for acute stroke was in
direct medical costs,12 whether a patient is admitted to an ICU
or to the general ward has a significant impact on the
economic burden of acute stroke.
Acknowledgments
Dr Felberg MD was supported by NIH training grant 1-T32NS07412-O1A1. We are grateful to Melinda A. Smith for her
support in statistical matters.
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Should Mild or Moderate Stroke Patients Be Admitted to an Intensive Care Unit?
Deborah E. Briggs, Robert A. Felberg, Marc D. Malkoff, Patti Bratina and James C. Grotta
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Stroke. 2001;32:871-876
doi: 10.1161/01.STR.32.4.871
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