From the Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, United Kingdom (L.P., A.H.).
Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (E.W.).
Stroke. 2018 Sep;49(9):2155-2162. doi: 10.1161/STROKEAHA.118.021518.
Background and Purpose- Well-organized stroke care is associated with better patient outcomes, but the most important organizational factors are unknown. Methods- Data were extracted from the Sentinel Stroke National Audit Programme of adults with acute stroke treated in stroke hospitals in England and Wales between April 2013 and March 2015. Multilevel models with random intercepts for hospitals were used to estimate the association of each variable with 30-day mortality to estimate the impact of admission to differently organized hospitals. Results- Of the 143 578 patients with acute stroke admitted to 154 hospitals, 14.4% died within 30 days of admission. In adjusted analyses, admission to hospitals with higher ratios of nurses trained in swallow screening was associated with reduced odds of death ( P=0.004), and admission to hospitals with daily physician ward rounds was associated with 10% lower odds of mortality compared with less-frequent ward rounds (95% CI, 0.82-0.98; P=0.013). Number of stroke admissions and overall ratio of registered nurses on duty at weekends were not found to be independently associated with mortality after adjustment for other factors. Conclusions- If these associations are causal, an extra 1332 deaths annually in England and Wales could be saved by hospitals providing care associated with a ratio of nurses trained in swallow screening of at least 3 per 10 beds and daily stroke physician ward rounds.
背景与目的- 组织完善的卒中护理与更好的患者预后相关，但最重要的组织因素尚不清楚。方法- 数据来自 2013 年 4 月至 2015 年 3 月期间在英格兰和威尔士的卒中医院治疗的急性卒中成年患者的 Sentinel Stroke 国家审计计划。采用带有医院随机截距的多水平模型来估计每个变量与 30 天死亡率的相关性，以评估不同组织卒中医院的影响。结果- 在 154 家医院收治的 143578 例急性卒中患者中，有 14.4%的患者在入院后 30 天内死亡。在调整分析中，与接受护士接受吞咽筛查培训比例较高的医院相比，接受护士接受吞咽筛查培训比例较低的医院的死亡风险更高（P=0.004），与较少的每周例行巡房相比，每天进行医师巡房的医院的死亡风险降低了 10%（95%CI，0.82-0.98；P=0.013）。在调整其他因素后，卒中入院人数和周末注册护士总数与死亡率之间未发现独立相关性。结论- 如果这些关联是因果关系的，那么通过为患者提供与至少每 10 张床位 3 名接受吞咽筛查培训的护士比例和每天卒中医师巡房相关的护理，英国和威尔士每年可额外减少 1332 例死亡。
