BMJ No. 7047 Volume 312 Saturday 29 June 1996
Abstract
Objectives - To determine the short and long term
outcome of patients admitted to hospital after initially successful
resuscitation from cardiac arrest out of hospital.
Design - Review of ambulance and hospital records.
Follow up of mortality by 'flagging' with the registrar general.
Cox proportional hazards analysis of predictors of mortality in
patients discharged alive from hospital.
Setting - Scottish Ambulance Service and acute
hospitals throughout Scotland.
Subjects - 1476 patients admitted to a hospital ward,
of whom 680 (46%) were discharged alive.
Main outcome measures - Survival to hospital
discharge, neurological status at discharge, time to death, and cause
of death after discharge.
Results - The median duration of hospital stay was 10
days (interquartile range 8-15) in patients discharged alive and 1
(1-4) day in those dying in hospital. Neurological status at discharge
in survivors was normal or mildly impaired in 605 (89%), moderately
impaired in 58 (8.5%), and severely impaired in 13 (2%); one patient
was comatose. Direct discharge to home occurred in 622 (91%) cases.
The 680 discharged survivors were followed up for a median of 25 (range
0-68) months. There were 176 deaths, of which 81 were sudden cardiac
deaths, 55 were non-sudden cardiac deaths, and 40 were due to other
causes. The product limit estimate of 4 year survival after discharge
was 68%. The independent predictors of mortality on follow up were
increased age, treatment for heart failure, and cardiac arrest not due
to definite myocardial infarction.
Conclusion - About 40% of initial survivors of
resuscitation out of hospital are discharged home without major
neurological disability. Patients at high risk of subsequent cardiac
death can be identified and may benefit from further cardiological
evaluation.
Department of Medical Cardiology,
Stuart M Cobbe, professor of medical cardiology
Robertson Centre for Biostatistics,
Ian Ford, professor of statistics
Scottish Ambulance Service,
Andrew K Marsden, consultant medical director
Correspondence to:Professor Cobbe.
Survival of 1476 patients initially resuscitated from out of
hospital cardiac arrest
Stuart M Cobbe, Kirsty Dalziel, Ian Ford, Andrew K Marsden
Glasgow Royal Infirmary,
Glasgow G31 2ER
Kirsty Dalziel, research statistician
University of Glasgow,
Glasgow G12 8QQ
Edinburgh EH10 5UU
Prospective evaluation of eligibility for thrombolytic therapy
in acute myocardial infarction
John K French, Barbara F Williams, Hamish H Hart,
Susan Wyatt, June E Poole, Christine Ingram, Christopher J Ellis, Miles
G Williams, Harvey D White
Abstract
Objective - To determine the proportion of patients presenting with acute myocardial infarction who are eligible for thrombolytic therapy.
Design - Cohort follow up study.
Setting - The four coronary care units in Auckland, New Zealand.
Subjects - All 3014 patients presenting to the units with suspected myocardial infarction in 1993.
Main outcome measures - Eligibility for reperfusion
with thrombolytic therapy (presentation within 12 hours of the onset of
ischaemic chest pain with ST elevation equal to or greater than 2 mm in leads V1-V3, ST
elevation
Results - 948 patients had definite myocardial
infarction, 124 probable myocardial infarction, and nine ST elevation
but no infarction; 1274 patients had unstable angina and 659 chest pain
of other causes. Of patients with definite or probable myocardial
infarction, 576 (53.3%) were eligible for reperfusion, 39 had definite
contraindications to thrombolysis (risk of bleeding). Hence 49.7% of
patients (537/1081) were eligible for thrombolysis and 43.5% (470)
received this treatment. Hospital mortality among patients eligible for
reperfusion was 11.7% (55/470 cases) among those who received
thrombolysis and 17.0% (18/106) among those who did not.
Conclusions - On current criteria about half of
patients admitted to coronary care units with definite or probable
myocardial infarction are eligible for thrombolytic therapy. Few
eligible patients have definite contraindications to thrombolytic
therapy. Mortality for all community admissions for myocardial
infarction remains high.
Coronary Care Unit,
John K French, cardiologist
Coronary Care Unit,
Hamish H Hart, physician
Coronary Care Unit, Middlemore Hospital,
June E Poole, rehabilitation nurse
Coronary Care Unit, Auckland Hospital,
Christine Ingram, charge nurse
Correspondence to: Dr John French,
Abstract
Objective - To evaluate whether specialist nurse
visits enhance the social integration and perceived health of patients
with stroke or alleviate stress in carers in longer term stroke care.
Design - Stratified randomised controlled trial; both
groups assessed at time of recruitment and at 3, 6, and 12 months.
Setting - Patients with disability related to new
stroke who lived in their own homes in the Bradford Metropolitan
District.
Subjects - 240 patients aged 60 years or over,
randomly allocated to control group (n
Intervention - Visits by specialist outreach nurses
over 12 months to provide information, advice, and support; minimum of
six visits during the first six months. The control group received no
visits.
Main outcome measures - The Barthel index (functional
ability), the Frenchay activities index (social activity), the
Nottingham health profile (perceived health status). Stress among
carers was indicated by the general health questionnaire-28 (28 items).
The nurses recorded their interventions in trial diaries.
Results - There were no significant differences in
perceived health, social activities, or stress among carers between the
treatment and control groups at any of the assessments points. A
subgroup of mildly disabled patients with stroke (Barthel index 15-19)
had an improved social outcome at six months (Frenchay activities
index, median difference 3 (95% confidence interval 0 to 6;
P
Conclusions - The specialist nurse intervention
resulted in a small improvement in social activities only for the
mildly disabled patients. No proved strategy yet exists that can be
recommended to address the psychosocial difficulties of patients with
stroke and their families.
Department of Health Care for
the Elderly,
Anne
Forster, research physiotherapist
Correspondence to:Dr
Forster.
Abstract
Objective - To compare the outcome and cost of care for leg ulcers in community
leg ulcer clinics in Stockport District Health Authority with Trafford District
Health Authority as a control.
Design - Detailed cost and efficacy studies conducted prospectively over a
three month period in both districts both before and one year after the
introduction of five leg ulcer clinics in Stockport.
Setting - Two large district health authorities of broad socioeconomic
mix and total population of
540,000.
Patients - All patients receiving treatment for an active leg ulcer,
irrespective of the profession or location of their carer.
Main outcome measures - The proportion of ulcerated limbs completely
healed within three months and total cost of leg ulcer care.
Results - The introduction of community clinics in Stockport improved healing
of leg ulcers from 66/252 (26%) in 1993 to 99/233 (42%) in 1994 (P<0.001)
compared with in Trafford, where 47/203 (23%) healed in 1993 and only 43/213
(20%) in 1994. This improved result in Stockport was achieved while the annual
expenditure on care of leg ulcers was reduced from £409,991 to only £253,371.
In the same year the cost of leg ulcer care inTrafford increased from £556,039
to £673,318.
Conclusion - In the first year after the introduction of community clinics,
before most patients in Stockport had access to these clinics, healing of leg
ulcers was already improved whereas costs were reduced.
University Department of Surgery,
Deborah A Simon, research nurse speciahst
Stockport District Health
Authority Community
Unit,
Julia Walsh, community research sister
Trafford District Health
Authority Community
Unit,
Chris Lane, community
research sister
Correspondence to:
Professor McCollum
BMJ 1996;312:1645-51
Green Lane Hospital,
Auckland,
New Zealand
Barbara F Williams, research nurse
Harvey D White, director of coronary care and cardiovascular research
North Shore Hospital,
Auckland
Susan Wyatt, research nurse
Auckland
Miles G Williams, cardiologist
Auckland
Christopher J Ellis, cardiologist
Cardiology Department,
Green Lane Hospital,
Epsom,
Auckland 1003,
New Zealand.
Specialist nurse support for patients with stroke in the
community: a randomised controlled trial
Anne Forster, John Young
St Luke's Hospital,
Bradford BD5 0NA
John Young,
consultant physician
Community leg ulcer clinics: a comparative study in two health
authorities
Deborah A Simon, Louise Freak, Annette Kinsella, Julia Walsh, Chris Lane, Louise
Groarke, Charles McCollum
University Hospital of South
Manchester,
West Didsbury,
Manchester M20 8LR
Louise Freak, research nurse specialist
Annette Kinsella, data manager
Louise Groarke, research nurse specialist
Charles McCoIIum, professor of surgery
Fourth Floor
Maternity Unit,
Stepping
Hill Hospital,
Stockport
SK2 7JE
Basford House,
Stretford Memorial
Hospital,
Manchester
M16 ODU