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Adapting to the Challenge of Hospital-Based Care: The Evolving Role of Gastroenterology Hospitalists. Am J Gastroenterol 2022; 117:361-363. [PMID: 34904965 DOI: 10.14309/ajg.0000000000001585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 11/19/2021] [Indexed: 12/11/2022]
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Pierre-Louis RE, Pannikodu K, Madhoun M, Hartnett J, Rose S. Implementing a Neurohospitalist Program Improves Stroke Care Metrics and Patient Satisfaction Scores. Neurohospitalist 2022; 12:241-248. [PMID: 35419152 PMCID: PMC8995615 DOI: 10.1177/19418744211069272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective Compare the differences in health outcomes and patient satisfaction between a neurohospitalist model of care and a community-based neurologists model at a single community-based teaching hospital among in-patients diagnosed with a cerebrovascular accident (CVA). Methods Data was collected from the Stamford Hospital’s electronic medical records system. An assessment of patient health outcomes and satisfaction scores was conducted, comparing both discrete and continuous variables between the two time periods. An omnibus P-value of 0.05 ( P < 0.05) was considered statistically significant. Results The sample consisted of 341 patients between the two periods, pre-period n = 168 (49.3%) post-period n = 173 (50.7%). Door to lab and door to tPA times decreased significantly between pre- and post-periods ( P = 0.003 and P = 0.002, respectively) as did the number of MRIs ( P < 0.001). In addition, statistically significant increases were found between pre-period and post-period percentages, all increasing over time: stroke education ( P < 0.001), discharged on anticoagulant medication ( P < 0.001), and discharged on anti-thrombolytic medication ( P = 0.019). Patient satisfaction scores demonstrated mean gain across both periods for five of six items. Two items “Doctor’s Concern of my Questions/Worries” and “Skill of Doctors” demonstrated statistical significance ( P = 0.020 and P = 0.029, respectively). Conclusions The introduction of a neurohospitalist service at a community-based teaching hospital improved patient health outcomes on time to intervention, stroke education, discharge medications as well as patient satisfaction. Therefore, it may be beneficial for hospitals to implement a neurohospitalist model of care for their patients presenting with CVA.
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Affiliation(s)
| | - Kelly Pannikodu
- Office of Research, Stamford Hospital, Stamford, Connecticut, USA
| | - Maher Madhoun
- Department of Medicine, Stamford Hospital, Stamford, CT, USA
| | - Josette Hartnett
- Office of Research, Stamford Hospital, Stamford, Connecticut, USA
| | - Suzanne Rose
- Office of Research, Stamford Hospital, Stamford, Connecticut, USA
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Sood R, Annoni JM, Humm AM, Accolla E, Bill O, Toledo Sotomayor G, Niederhauser J, Medlin F. Distance Neurological Supervision Using Telestroke Does Not Increase Door-to-Needle Time in Acute Ischemic Stroke Management: The Experience of Two Regional Stroke Units. Front Neurol 2021; 12:616620. [PMID: 33815247 PMCID: PMC8017204 DOI: 10.3389/fneur.2021.616620] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/19/2021] [Indexed: 11/17/2022] Open
Abstract
Background and Aims: Timely administration of recombinant tissue plasminogen activator (r-tPA) improves clinical outcomes in acute ischemic stroke patients. This study aims to explore the influence of the systematic presence on site of a neurologist compared with telestroke management on door-to-needle time in acute ischemic stroke outside of working hours (OWH). Methods: This retrospective cohort study included all r-tPA-treated patients in the emergency rooms of two Swiss stroke units, Nyon Hospital [Groupement Hospitalier de l'Ouest Lémanique (GHOL)] and Fribourg Hospital [Hôpital de Fribourg (HFR)], between February 2014 and September 2018. Door-to-needle time was analyzed for patients admitted during working hours (WH' weekdays 08:00–18:00) and OWH (weekdays 18:00–08:00, weekends, and public holidays). The latter was compared between centers; OWH, every patient was evaluated prior to thrombolysis by a neurologist on site in GHOL, while HFR adopted distance neurological supervision with teleradiology, performed by telephone evaluation of relevant clinical information with online real-time access to brain imaging. Results: Data were analyzed for 157 patients in HFR and 101 patients in GHOL. No statistically significant differences in baseline characteristics were found for the 258 r-tPA-treated acute ischemic stroke patients, in terms of age, gender, cardiovascular risk factors (hypertension, diabetes, and atrial fibrillation), and pre-Modified Rankin Scale (pre-mRs) between centers, with the exception of smoking and anticoagulation status. Patients in HFR presented with more severe strokes {median National Institutes of Health Stroke Scale (NIHSS) [6 (SD 6.88) (GHOL), 8 (SD 6.98) (HFR), p = 0.005]}. No significant differences in baseline characteristics were found as per admission time independently of the center. Door-to-needle time was significantly longer in the HFR cohort when compared with GHOL, irrespective of admission time. Both centers demonstrated significantly longer median door-to-needle time OWH. However, analysis of the door-to-needle time differences between WH and OWH showed no significant interaction using robust ANCOVA WRS2 analysis (p = 0.952) and a Bayesian model (BF01 = 3.97). Conclusions: On-site systematic evaluation by a neurologist did not appear to influence door-to-needle time OWH, suggesting distance supervision may be time-efficient in thrombolysis. This supports existing prospective studies in hyperacute telestroke management. The relevance lies in optimizing resource use considering the increasing demand for emergency neurological management.
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Affiliation(s)
- Radhika Sood
- Neurology Unit, Hôpital Fribourgeois, Fribourg, Switzerland
| | - Jean-Marie Annoni
- Neurology Unit, Hôpital Fribourgeois, Fribourg, Switzerland.,Department of Neurosciences, Fribourg University, Fribourg, Switzerland
| | - Andrea M Humm
- Neurology Unit, Hôpital Fribourgeois, Fribourg, Switzerland
| | - Ettore Accolla
- Neurology Unit, Hôpital Fribourgeois, Fribourg, Switzerland
| | - Olivier Bill
- Stroke Unit, Groupement Hospitalier de l'Ouest Lémanique, Nyon, Switzerland
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Aubert CE, Schnipper JL, Fankhauser N, Marques-Vidal P, Stirnemann J, Auerbach AD, Zimlichman E, Kripalani S, Vasilevskis EE, Robinson E, Metlay J, Fletcher GS, Limacher A, Donzé J. Association of patterns of multimorbidity with length of stay: A multinational observational study. Medicine (Baltimore) 2020; 99:e21650. [PMID: 32846776 PMCID: PMC7447409 DOI: 10.1097/md.0000000000021650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to identify the combinations of chronic comorbidities associated with length of stay (LOS) among multimorbid medical inpatients.Multinational retrospective cohort of 126,828 medical inpatients with multimorbidity, defined as ≥2 chronic diseases (data collection: 2010-2011). We categorized the chronic diseases into comorbidities using the Clinical Classification Software. We described the 20 combinations of comorbidities with the strongest association with prolonged LOS, defined as longer than or equal to country-specific LOS, and reported the difference in median LOS for those combinations. We also assessed the association between the number of diseases or body systems involved and prolonged LOS.The strongest association with prolonged LOS (odds ratio [OR] 7.25, 95% confidence interval [CI] 6.64-7.91, P < 0.001) and the highest difference in median LOS (13 days, 95% CI 12.8-13.2, P < 0.001) were found for the combination of diseases of white blood cells and hematological malignancy. Other comorbidities found in the 20 top combinations had ORs between 2.37 and 3.65 (all with P < 0.001) and a difference in median LOS of 2 to 5 days (all with P < 0.001), and included mostly neurological disorders and chronic ulcer of skin. Prolonged LOS was associated with the number of chronic diseases and particularly with the number of body systems involved (≥7 body systems: OR 21.50, 95% CI 19.94-23.18, P < 0.001).LOS was strongly associated with specific combinations of comorbidities and particularly with the number of body systems involved. Describing patterns of multimorbidity associated with LOS may help hospitals anticipate resource utilization and judiciously allocate services to shorten LOS.
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Affiliation(s)
- Carole E. Aubert
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey L. Schnipper
- BWH Hospitalist Service, Division of General Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Niklaus Fankhauser
- CTU Bern, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Pedro Marques-Vidal
- Division of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Jérôme Stirnemann
- Department of Internal Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Andrew D. Auerbach
- Division of Hospital Medicine, University of California, San Francisco, CA
| | | | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health Vanderbilt University, Nashville, TN
- Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, TN
| | - Eduard E. Vasilevskis
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health Vanderbilt University, Nashville, TN
- VA Tennessee Valley, Geriatric Research, Education and Clinical Center, Nashville, TN
| | | | - Joshua Metlay
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Grant S. Fletcher
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Andreas Limacher
- CTU Bern, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Jacques Donzé
- Harvard Medical School, Boston, MA
- Division of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
- Department of Internal Medicine, Neuchâtel Hospital Network, Neuchâtel, Switzerland
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Aubert CE, Fankhauser N, Marques-Vidal P, Stirnemann J, Aujesky D, Limacher A, Donzé J. Multimorbidity and healthcare resource utilization in Switzerland: a multicentre cohort study. BMC Health Serv Res 2019; 19:708. [PMID: 31623664 PMCID: PMC6798375 DOI: 10.1186/s12913-019-4575-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 09/30/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Multimorbidity is associated with higher healthcare resource utilization, but we lack data on the association of specific combinations of comorbidities with healthcare resource utilization. We aimed to identify the combinations of comorbidities associated with high healthcare resource utilization among multimorbid medical inpatients. METHODS We performed a multicentre retrospective cohort study including 33,871 multimorbid (≥2 chronic diseases) medical inpatients discharged from three Swiss hospitals in 2010-2011. Healthcare resource utilization was measured as 30-day potentially avoidable readmission (PAR), prolonged length of stay (LOS) and difference in median LOS. We identified the combinations of chronic comorbidities associated with the highest healthcare resource utilization and quantified this association using regression techniques. RESULTS Three-fourths of the combinations with the strongest association with PAR included chronic kidney disease. Acute and unspecified renal failure combined with solid malignancy was most strongly associated with PAR (OR 2.64, 95%CI 1.79;3.90). Miscellaneous mental health disorders combined with mood disorders was the most strongly associated with LOS (difference in median LOS: 17 days) and prolonged LOS (OR 10.77, 95%CI 8.38;13.84). The number of chronic diseases was strongly associated with prolonged LOS (OR 9.07, 95%CI 8.04;10.24 for ≥10 chronic diseases), and to a lesser extent with PAR (OR 2.16, 95%CI 1.75;2.65 for ≥10 chronic diseases). CONCLUSIONS Multimorbidity appears to have a higher impact on LOS than on PAR. Combinations of comorbidities most strongly associated with healthcare utilization included kidney disorders for PAR, and mental health disorders for LOS.
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Affiliation(s)
- Carole E Aubert
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland. .,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.
| | | | - Pedro Marques-Vidal
- Department of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Jérôme Stirnemann
- Department of Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland
| | | | - Jacques Donzé
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland.,Division of General Medicine, BWH Hospitalist Service, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Internal Medicine, Hôpital neuchâtelois, Neuchâtel, Switzerland
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Quimby AE, Shamy MCF, Rothwell DM, Liu EY, Dowlatshahi D, Stotts G. A Novel Neuroscience Intermediate-Level Care Unit Model: Retrospective Analysis of Impact on Patient Flow and Safety. Neurohospitalist 2016; 7:83-90. [PMID: 28400902 DOI: 10.1177/1941874416672558] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE Neurointensive care units have been shown to improve patient outcomes across a variety of neurological and neurosurgical conditions. However, the efficacy of less resource-intensive intermediate-level care units to deliver similar care has not been well studied. The purpose of this study is to evaluate the impact of neurocritical specialist comanagement on patient flow and safety in a neuroscience intermediate-level care unit. METHODS Our intervention consisted of the addition of a physician with critical care experience as well as training in neurology, anesthesiology, or intensive care to a neuroscience intermediate-level care unit to comanage patients alongside neurology and neurosurgery staff during weekday daytime hours. A retrospective analysis was performed on prospectively collected data pertaining to all patients admitted to the unit over a 3-year period, 1 year before our intervention and 2 years after. Patient statistics including wait times to admission, length of stay (LOS), and mortality were reviewed. RESULTS Following the intervention, there were significant reductions in wait times to unit admission from both the emergency department and postanesthetic care unit, as well as reductions in the average LOS. No significant safety concerns were identified. CONCLUSION This study has demonstrated that the optimization of a neuroscience intermediate-level care unit involving comanagement of patients by a neurocritical specialist can reduce wait times to admission and lengths of stay, with preserved safety outcomes.
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Affiliation(s)
- Alexandra E Quimby
- Department of Otolaryngology-Head & Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Michel C F Shamy
- Division of Neurology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Deanna M Rothwell
- The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Erin Y Liu
- The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Division of Neurology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Grant Stotts
- Division of Neurology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada
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Sipilä J, Ruuskanen JO, Rautava P, Kytö V. Effect of the summer holiday season on ischaemic stroke care in Finland. J Neurol Sci 2016; 367:363-4. [PMID: 27423621 DOI: 10.1016/j.jns.2016.06.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 06/20/2016] [Accepted: 06/22/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Jussi Sipilä
- North Karelia Central Hospital, Joensuu, Finland; Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland; Department of Neurology, University of Turku, Turku, Finland.
| | - Jori O Ruuskanen
- Turku University Hospital, Turku, Finland, and Department of Neurology, University of Turku, Turku, Finland
| | - Päivi Rautava
- Department of Public Health, University of Turku, and Turku Clinical Research Centre, Turku University Hospital, Turku, Finland
| | - Ville Kytö
- Heart Center, Turku University Hospital, Turku, Finland, and Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
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Klein JP. The academic neurohospitalist: Building a successful career and practice. Ann Neurol 2015; 78:515-9. [PMID: 26179680 DOI: 10.1002/ana.24483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 07/03/2015] [Accepted: 07/12/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Joshua P Klein
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Velez-Ruiz N, Khan J, Greene JG. Defining the role of the academic neurohospitalist in residency education. Neurohospitalist 2014; 4:127-32. [PMID: 24982716 DOI: 10.1177/1941874414530722] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We sought to better understand the potential impact of the burgeoning neurohospitalist model of inpatient care on education of neurology residents and to better define possible roles for "neurohospitalists" in residency education. METHOD We designed a brief qualitative open-ended survey directed toward academic leaders in neurology and distributed it by e-mail to every academic neurology department in the United States and Canada. RESULTS Of 83 respondents, 36 (43%) had an active neurohospitalist program and only 10% felt certain they would not have 1 within the next 5 years. All respondents expected to have residents continue to be involved with inpatient care. The main perceived advantage for resident education associated with neurohospitalists was inpatient care expertise, and the main expected disadvantage was decreased exposure to subspecialty attendings. The majority anticipated positive impact on all Accreditation Council for Graduate Medical Education core competencies predominantly based on neurohospitalists' expertise in the inpatient setting. CONCLUSION The majority of academic neurology departments are expected to have a neurohospitalist program within the next 5 years. There are several perceived advantages and disadvantages to such a program for education of neurology residents. In general, the impact of these programs is expected to improve resident education. Regardless of expectations, neurohospitalists will likely play a prominent role in the education of the next generation of neurologists.
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Affiliation(s)
- Naymee Velez-Ruiz
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jaffar Khan
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - James G Greene
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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Bhatt A, Shatila A. Neurohospitalists Improve Door-to-Needle Times for Patients With Ischemic Stroke Receiving Intravenous tPA. Neurohospitalist 2013; 2:119-22. [PMID: 23983875 DOI: 10.1177/1941874412445098] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE It is unknown whether neurohospitalist evaluation improves door-to-needle times (DNT) in patients with acute ischemic stroke.The purpose of this study is to determine the impact of neurohospitalist evaluation on DNT for patients with ischemic stroke receiving intravenous tissue plasminogen activator (tPA) presenting within 4.5 hours of symptom onset. METHODS We retrospectively identified consecutive patients with ischemic stroke who received tPA between 0 and 4.5 hours. We determined and compared DNT for nonneurohospitalists versus neurohospitalists for a 26-month period from 2009 to 2011. Our main outcome measure was percentage of patients receiving tPA within 60 minutes. RESULTS Overall, out of the 107 consecutive ischemic stroke patients (mean age 67 years) who received intravenous tPA within 4.5 hours, 60 patients were evaluated by nonneurohospitalists (community and locums neurologists) and 47 patients were evaluated by neurohospitalists. Mean ± standard deviation (SD) DNT with patients treated by nonneurohospitalists (93 ± 24 minutes) were significantly longer than the DNT treated by neurohospitalists (68 ± 18 minutes). Twenty-four patients (51%) treated by neurohospitalists had DNT less than or equal to 60 minutes, while 9 patients (15%) treated by nonneurohospitalists had DNT less than or equal to 60 minutes. Multivariate analysis showed that neurohospitalist evaluation (odds ratio [OR] 5.4, confidence interval [CI] 2.2-13.6, P = .022) was the only independent factor associated with patients receiving tPA within 60 minutes. CONCLUSION Neurohospitialist evaluation is associated with faster DNT in patients with ischemic stroke. Neurohospitalist evaluation could be a part of a multidimensional initiative to improve the timeliness of tPA administration.
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Affiliation(s)
- Archit Bhatt
- Spectrum Health Neurosciences, Neurohospitalist Program, Grand Rapids, MI, USA
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Abstract
Akin to the rapid growth in hospitalist medicine seen in the prior decade, there has been a recent explosion in the need for neurohospitalists. Factors driving this demand include nationally mandated quality and safety measures, the increasing complexity and age of the hospitalized patient, and diminished training in diagnosis and management of neurological illnesses for internal medicine residents. The role of the neurohospitalist is varied and may include not only providing neurological care to hospitalized patients but also serving as a leader in an institution's push to meet quality and safety measures. Close collaboration with intensivists, vascular neurologists, and outpatient neurologists is both a challenge and essential for successful delivery of care both during hospitalization and after discharge. Future challenges facing neurohospitalists include defining its relationship to other fields, instituting a pathway for certification, and conducting research to guide the development of evidence-based practice and quality measures.
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