Stroke severity is the predominant predictor of discharge destination

An article in the July issue of the Archives of Neurology reports that increasing stroke severity, as measured by the National Institutes of Health Stroke Scale, increases the likelihood that stroke patients who are treated with the rt-PA clot-dissolving drug will be discharged to rehabilitation or nursing homes, rather than to their own homes.

A stroke is a sudden and often severe problem in the nervous system, usually caused either by blood flow to part of the brain being obstructed (blood clot) or by bleeding into the brain. The National Stroke Association recently reported that three quarters of a million Americans will have a stroke or brain attack this year.

The National Institutes of Health Stroke Scale (NIHSS) is a widely used quantitative measure of stroke-related neurological deficit that includes items to assess level of consciousness, gaze, visual fields, facial palsy, motor strength, ataxia (wobbliness), sensation, language, dysarthria (slurred speech), and extinction or inattention.

Daniel J. Schlegel, M.D., of the University of Pennsylvania Medical Center, Philadelphia, and colleagues conducted a study to determine whether the NIHSS score predicts disposition in stroke patients treated with thrombolysis (administration of medication to dissolve a clot). The study included 546 patients from three countries with acute ischemic stroke, who were treated with recombinant tissue plasminogen activator (rt-PA), a powerful "clot-buster" that is infused through the vein. Medical records were reviewed for demographic information, vascular risk factors, location of stroke, initial NIHSS score, acute hospital disposition, and complications of symptomatic or asymptomatic intracerebral hemorrhage (ICH; bleeding within the brain tissue).

Of the 546 patients included in the study, 44 percent were discharged to home, 42 percent to rehabilitation, and 14 percent to a nursing facility.

"This study demonstrates that stroke severity, as measured by the NIHSS, is the predominant predictor of discharge destination after initial hospitalization for patients with acute ischemic stroke treated with intravenous rt-PA," the authors report.

Analysis showed that increasing NIHSS score was a robust and independent predictor of discharge to rehabilitation or nursing facilities, roughly doubling for each five-point increment.

The authors also found that symptomatic ICH was a devastating complication. "Patients who developed symptomatic ICH were never discharged to home," they write. But asymptomatic ICH had no significant independent effect on disposition.

"This multinational community and academic center-based study reinforces the usefulness of the NIHSS score as a predictor of disposition after stroke," the authors write. "The NIHSS score can predict discharge disposition when thrombolysis is used, although possibly with less precision than in patients not given this treatment."

The authors suggest that future studies should search for other variables rapidly available at admission like the NIHSS score, that could improve prediction of disposition after acute care.

"In addition, simulations or decision analyses could be performed to assess whether cost savings may be realized by using the NIHSS score to initiate early planning for disposition immediately on admission," they conclude.