The impact of different care modes on the rehabilitation efficacy of acute ischemic stroke patients

Authors: Wenjuan Song, Shengyong Wu, Lei Shi, Xiaowei Luan, Jialiang Song, Jintao Lai, Cheng Wu, Fanfu Fang

Abstract

Objective

To explore the differences of the risk of complications, functional rehabilitation, and hospitalization expenses between the ischemic stroke patients cared by their families or orderlies.

Methods

This was a retrospective cohort study. We collected a total of 443 patients with ischemic stroke. According to the different types of nursing staff, they were divided into family caregiving group and orderly caregiving group. Propensity Score Weighting (PSW) method was used to balance the baseline; The weighted logistic regression model was used to analyze the risk of pulmonary, urinary tract infection, diarrhea, falls, and pressure ulcer in different groups of patients. The functional rehabilitation indicators, including the National Institutes of Health Stroke Scale (NIHSS) score, Barthel score, muscle strength grade and hospitalization cost before discharge, were compared between the two groups by means of independent samples t test or Wilcoxon rank sum test, depending on the distribution characteristics of the data. P value less than 0.05 was considered statistically significant.

Results

①There were no significant differences in the incidence of pulmonary, urinary tract infection, diarrhea and fall between the two groups. The family caregiving group had a lower risk of developing pressure ulcer. ②The proportion of patients with upper limb muscle strength of grade 3 or above in the family caregiving group (90.60%) was higher than that in the orderly caregiving group (82.26%). ③The hospitalization expenses of the family caregiving group, and the average daily hospitalization expenses were higher than those of the orderly caregiving group, respectively.

Conclusion

Family caregiving is a protective factor for pressure ulcer in ischemic stroke patients.The patients in the family caregiving group had better upper limb muscle strength.

Introduction

Stroke is the second leading cause of death and the third major cause of disability in the world [1]. Complications in stroke patients include infection, falls, stroke recurrence and progression, pain, thromboembolism, etc [2]. These complications can delay or hinder the recovery process, lead to greater functional impairment, and affect prognosis [3].The person with the most contact time and the closest contact with the patient is the patient’s caregivers. The quality of caregivers’ supports plays an important role in the rehabilitation of stroke patients.

Currently, the field of hospital nursing in China presents distinct developmental there exists a shortage in the total nursing workforce; meanwhile, the personnel structure shows a trend of rising educational attainment and younger age profile. In clinical practice, nurses are primarily responsible for ward rounds and professional nursing care, while the non-technical daily living assistance for patients has been gradually undertaken by hospital orderlies. Typically, hospital orderlies are stationed in medical institutions through a third-party dispatch mechanism, where the dispatch agencies sign cooperation agreements with hospitals. At present, with the arrival of an aging society in China, many patients from one-child family and empty-nest elderly people have limited family member, they need orderly to provide bedside rehabilitation assistance [4]. What are the differences between the two types of accompanying modes, family members and orderly, will they affect the patient’s recovery?

During the COVID-19 pandemic, different countries and regions have also implemented different visit restrictions [5]. Our hospital had a restricted visitation and bedside care policy in the inpatient ward. Only one regular caregiver was allowed to accompany and the previous dual support model of “family relative + orderlies” was changed to a single care model of one family relative or one orderly.The research group carried out a standardized retrospective cohort study to analyze the differences in complications, functional rehabilitation and hospitalization expenses of ischemic stroke patients under the two escort modes.

Materials and methods

Research objects

A total of 855 ischemic stroke patients admitted to the Cerebrovascular Center of Changhai Hospital from April 1, 2020 to December 31, 2021 were collected and screened, 443 among them met the inclusion criteria. According to the nursing records, the qualified patients during hospitalization were divided into the patients cared by their own family (family caregiving group) and those cared by orderly (orderly caregiving group). We collected the patients’ general conditions and disease information, such as gender, age, Body Mass Index (BMI), comorbidities, smoking history, excessive drinking, feeding methods, urethral catheterization, treatment approach, cause of disease, infarct foci size, clinical type, and the scale scores and inspection indicators at admission and discharge.

Patient enrollment

Inclusion criteria

Patients should meet the diagnostic criteria for ischemic stroke, with age ≥ 20 years, Glasgow Coma Scale (GCS) > 12 points [6], and National Institutes of Health Stroke Scale (NIHSS) ≤ 15 points [7]. The course of disease is within 1 to 7 days. The hospitalization time is 4 to 21 days. The patients should receive either conservative medication or thrombolytic therapy. During hospitalization, they should be accompanied by family or orderly who were not replaced, and they have not been transferred to other departments or the intensive care unit.

Exclusion criteria

Patients should not be complicated with cerebral hemorrhage, infectious diseases, organ failure, malignant tumor, gastrointestinal bleeding, intracranial tumor, traumatic brain injury, or arteriovenous malformation. Patients should not have the history of stroke or major trauma in the past 3 months. They should not have neurological or musculoskeletal diseases affecting functional recovery, or severe mental illness. They should not have pre-hospital infection, pressure ulcers, visuospatial defects, ataxia, Parkinson’s disease and other diseases are not allowed. Those who lack baseline data are also be excluded.

Outcome indicators

The primary outcome was the risk of hospital-based medical complications, including pulmonary [8], urinary tract infection [8], diarrhea [8], falls [9], pressure ulcer [10] and other complications. The secondary outcomes were NIHSS score before discharge, Barthel score [11] before discharge, muscle strengths of the upper and lower limbs before discharge, functional rehabilitation outcomes such as upper and lower limb muscle strength before discharge and hospitalization costs. Outcome indicators are collected through discharge summaries, progress notes, nursing records, and billing statements. The incidence of various complications is calculated as the proportion of patients who experience a specific complication relative to the total number of patients included in the study during the same period.

Statistical analysis

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