Informed Consent for Intravenous Tissue Plasminogen Activator in New York State Designated Stroke Centers.

OBJECTIVE: Our objective was to assess informed consent procedures for intravenous tissue plasminogen activator in acute stroke among New York State (NYS) Department of Health (DOH) designated stroke centers. METHODS: A 13-question survey stratified by 0- to 3-hour and 3.0- to 4.5-hour treatment windows was used to determine the type of consent or if no consent was required. RESULTS: Of the 117 hospitals, 111 responded (95%). All 111 hospitals provided treatment within the 3-hour window, whereas 97 (87%) provided treatment beyond the 3-hour window (P < .001). For hospitals that did provide treatment, there was a difference between the percentages of hospitals requiring consent (verbal or written) within 3 hours (82%) and beyond 3 hours (92%) (P = .04). Of the hospitals requiring consent, there was a difference in the type of consent: 31 of 91 (34%) required written consent within the 3-hour window, whereas 57 of 89 (64%) required written consent beyond the 3-hour window (P < .001). Within both treatment windows, 98% accepted a health-care proxy or surrogate in lieu of the patient. Of the hospitals with less than 500 beds, 11 of 81 (14%) did not require consent within the 3-hour treatment window, compared to hospitals with 500 or more beds where 9 of 30 (30%) did not require consent within the 3-hour treatment window (P < .05). Beyond the 3-hour treatment window, hospitals with more than 500 beds required written consent-2-fold increase "compared to less than 3 hour window" (P < .05). Fifty-five percent of the hospitals were academic, whereas 45% were nonacademic. Academic status was not related to the type of consent in either window. CONCLUSIONS: Significant variability exists in the types of informed consent based on hospital bed size and treatment windows across NYS DOH designated stroke centers.

Designated Stroke Center Status and Hospital Characteristics as Predictors of In-Hospital Mortality among Hemorrhagic Stroke Patients in New York, 2008-2012.

BACKGROUND: Although designated stroke centers (DSCs) improve the quality of care and clinical outcomes for ischemic stroke patients, less is known about the benefits of DSCs for patients with intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). HYPOTHESIS: Compared to non-DSCs, hospitals with the DSC status have lower in-hospital mortality rates for hemorrhagic stroke patients. We believed these effects would sustain over a period of time after adjusting for hospital-level characteristics, including hospital size, urban location, and teaching status. METHODS AND RESULTS: We evaluated ICH (International Classification of Diseases, Ninth Revision; ICD-9: 431) and SAH (ICD-9: 430) hospitalizations documented in the 2008-2012 New York State Department of Health Statewide Planning and Research Cooperative System inpatient sample database. Generalized estimating equation logistic regression was used to evaluate the association between DSC status and in-hospital mortality. We calculated ORs and 95% CIs adjusted for clustering of patients within facilities, other hospital characteristics, and individual level characteristics. Planned secondary analyses explored other hospital characteristics associated with in-hospital mortality. In 6,352 ICH and 3,369 SAH patients in the study sample, in-hospital mortality was higher among those with ICH compared to SAH (23.7 vs. 18.5%). Unadjusted analyses revealed that DSC status was related with reduced mortality for both ICH (OR 0.7, 95% CI 0.5-0.8) and SAH patients (OR 0.4, 95% CI 0.3-0.7). DSC remained a significant predictor of lower in-hospital mortality for SAH patients (OR 0.6, 95% CI 0.3-0.9) but not for ICH patients (OR 0.8, 95% CI 0.6-1.0) after adjusting for patient demographic characteristics, comorbidities, hospital size, teaching status and location. CONCLUSIONS: Admission to a DSC was independently associated with reduced in-hospital mortality for SAH patients but not for those with ICH. Other patient and hospital characteristics may explain the benefits of DSC status on outcomes after ICH. For conditions with clear treatments such as ischemic stroke and SAH, being treated in a DSC improves outcomes, but this trend was not observed in those with strokes, in those who did not have clear treatment guidelines. Identifying hospital-level factors associated with ICH and SAH represents a means to identify and improve gaps in stroke systems of care.

Factors associated with potentially preventable hospitalization in nursing home residents in New York State: a survey of directors of nursing.

OBJECTIVES: To describe characteristics of New York State nursing homes and identify factors associated with potentially preventable hospitalization in nursing home residents. DESIGN: Cross-sectional survey. SETTING: Randomly selected nursing homes in New York State. PARTICIPANTS: One hundred forty-seven directors of nursing (DONs). MEASUREMENTS: Data were collected using a Web-based survey completed in January 2008. Variables included specific aspects of facility environment, nurse and aide services, resource availability, perceived determinants of hospitalization, and nursing home practice. Stepwise multivariate linear regression examined the associations between perceived determinants and potentially preventable hospitalization. RESULTS: Factors associated with potentially preventable hospitalization included presence of nursing staff trained to communicate effectively with physicians (P<.001); easy access to urgent laboratory results in less than 4 hours on weekends (P=.03); that physicians attempt to treat patients within the nursing home and admit to the hospital as a last resort (P<.001); higher reported proportion of residents enrolled in managed care plans for regular medical care (P=.04); higher perceived likelihood that illness will cause death (P=.03); perceived inadequate access by physicians to residents' and prior medical history, laboratory results, and electrocardiograms (ECGs) (P=.02), as reported by DONs. CONCLUSION: Efficient and effective care depends on continuity of communication between nurses and physicians and adequate access to patients' medical history, laboratory results, and ECGs. The following operational strategies may help institutions reduce potentially preventable hospitalizations: ensure effective communication between nursing staff and physicians regarding patients' condition; provide physicians with easy access to stat laboratory results in less than 4 hours on weekends and adequate access to the patient's medical history, laboratory results, and ECGs; and motivate physicians to treat residents within the nursing home whenever possible.

Preventable hospitalization among nursing home residents: varying views between medical directors and directors of nursing regarding determinants.

OBJECTIVE: To compare the perception of the determinants of preventable hospitalization among nursing home residents by surveying medical directors (MDs) and directors of nursing (DONs). METHODS: A survey (N = 52) was completed in January 2008. Data included resource availability, determinants of hospitalization, and nursing home practice. Multivariate linear regression examined the associations between potential determinants and preventable hospitalization. RESULTS: Four significant determinants perceived by MDs to influence preventable hospitalization: MD/nurse practitioner (NP) access by pager, family preferences, access to medical history and lab/ electrocardiograph (EKG) reports, and physicians better paid to manage acutely ill residents (R(2) = .58). None of these factors were echoed by DONs (R(2) = .15). Whereas DONs perceived stat lab results on weekends were associated with increased hospitalization (p = .03), MDs did not (p = .28). CONCLUSIONS: Our analysis showed that communication and consensus are important factors in the hospital transfer decision and that the discord in perceptions among MDs and DONs may complicate interventions to reduce preventable hospitalization.