Article

OBJECTIVE: To test the role of hospital-acquired symptomatic urinary tract
infection (SUTI) as an independent predictor of discharge disposition in the
acute stroke patient. STUDY DESIGN: A retrospective study of data collected from
a stroke registry service. The registry is maintained by the Specialized Programs
of Translational Research in Acute Stroke Data Core. The Specialized Programs of
Translational Research in Acute Stroke is a national network of 8 centers that
perform early phase clinical projects, share data, and promote new approaches to
therapy for acute stroke. SETTING: A single university-based hospital.
PARTICIPANTS: We performed a data query of the fields of interest from our
university-based stroke registry, a collection of 200 variables collected
prospectively for each patient admitted to the stroke service between July 2004
and October 2009, with discharge disposition of home, inpatient rehabilitation,
skilled nursing facility, or long-term acute care. MAIN OUTCOME MEASURES:
Baseline demographics, including age, gender, ethnicity, and National Institutes
of Health Stroke Scale (NIHSS) score, were collected. Cerebrovascular disease
risk factors were used for independent risk assessment. Interaction terms were
created between SUTI and known covariates, such as age, NIHSS, serum creatinine
level, history of stroke, and urinary incontinence. Because patients who share
discharge disposition tend to have similar length of hospitalization, we analyzed
the effect of SUTI on the median length of stay for a correlation. Days in the
intensive care unit and death were used to evaluate morbidity and mortality. By
using multivariate logistic regression, the data were analyzed for differences in
poststroke disposition among patients with SUTI. RESULTS: Of 4971 patients
admitted to the University of Texas at Houston Stroke Service, 2089 were
discharged to home, 1029 to inpatient rehabilitation, 659 to a skilled nursing
facility, and 226 to a long-term acute care facility. Patients with an SUTI were
57% less likely to be discharged home compared with the other levels of care (P <
.0001; odds ratio 0.430 [95% confidence interval 0.303-0.609]). When considering
inpatient rehabilitation versus skilled nursing facility, patients with SUTI were
38% less likely to be discharged to inpatient rehabilitation (P < .0058; odds
ratio 0.626 [95% confidence interval, 0.449-0.873]). We performed interaction
analyses for SUTI and age, NIHSS, urinary incontinence, serum creatinine level,
and history of stroke. We noted an interaction between SUTI and NIHSS for
discharge disposition to a skilled nursing facility versus a long-term acute care
facility. For patients with SUTI, a 1-unit increase in NIHSS results in a 10.6%
increase in the likelihood of stroke rehabilitation in a long-term acute care
facility compared with 5.6% increased likelihood for patients without SUTI (P =
.0370). CONCLUSIONS: Acute stroke patients with hospital-acquired SUTI are less
likely to be discharged home. In our analysis, if poststroke care is necessary,
then patients with SUTI are more likely to receive inpatient stroke
rehabilitation at the level of care suggestive of lower functional status. For
every point increase in NIHSS, stroke patients with SUTI are 10.6% more likely to
require continued rehabilitation care in a long-term acute care facility versus a
skilled nursing facility compared with 5.6% for patients without SUTI. The
combination of premorbid urinary incontinence and urinary tract infection has no
additional impact on discharge disposition. This study is limited by its
retrospective nature and the undetermined role of psychosocial factors related to
discharge. Prospective studies are warranted on the efficacy of early catheter
discontinuation, identification of new-onset urinary incontinence, use of
genitourinary barriers, and catheter care every shift as variables that can
decrease the risk of infection. The information obtained from prospective studies
will have an impact on resource use that is of prime importance in the current
health care climate.
CI - Copyright (c) 2013 American Academy of Physical Medicine and Rehabilitation.
Published by Elsevier Inc. All rights reserved.

Langue : ANGLAIS