Optimizing Discharge Planning Clinical Predictors of Longer Stay After Recombinant Tissue Plasminogen Activator for Acute Stroke Gustavo Saposnik, MD, MSc; Fiona Webster, MA; Chris O’Callaghan, BAppSc; Vladimir Hachinski, MD, DSc, FRCPC Background and Purpose—The length of stay (LOS) is the main cost-determining factor for inpatients with acute stroke. Although studies have identified variables associated with LOS, few have analyzed predictors of longer stay after receiving thrombolytic therapy for acute stroke. Methods—We studied all consecutive acute stroke patients receiving intravenous recombinant tissue plasminogen activator (rtPA) admitted to the London Health Sciences Center, in London, Ontario, Canada, from 1999 to 2003. Longer stay was defined as LOS 7 days after admission. Demographic as well as baseline clinical, laboratory, and imaging variables were analyzed to identify predictors of LOS. Significant variables were entered into a multivariate logistic regression analysis. Results—Among 216 acute stroke patients receiving rtPA, the median LOS was 6 days. LOS was 7 days in 102 (49%) patients. Age 70 (odds ratio [OR], 2.2; 95% CI, 1.2 to 4.0), lack of improvement at 24 hours (OR, 2.5; 95% CI, 1.4 to 4.4), prestroke modified Rankin Scale 2 (OR, 2.4; 95% CI, 1.2 to 4.9), baseline National Institutes of Health Stroke Scale score 15 (OR, 9.4; 95% CI, 3.2 to 27.6), cortical involvement (OR, 2.2; 95% CI, 1.2 to 3.9), and new infarction on the control computed tomography (CT; OR, 2.8; 95% CI, 1.4 to 5.9) were independent predictors of longer stay. Conclusions—Lack of improvement at 24 hours after rtPA, cortical involvement, and new infarction on the 24-hour CT scan are relevant variables that can independently affect the LOS. These new variables may be useful for establishing policy in relation to the organization and planning of the health care system. (Stroke. 2005;36:147-150.) Key Words: complications  hospitalization  outcome  prognosis  stroke  thrombolytic therapy  tissue plasminogen activator T he length of stay (LOS) is the main cost-determining factor during hospitalization. 1 The average LOS for stroke varies among different countries, which may reflect the impact of the differences in health care system organization. For example, the LOS in the United States 2 for patients with acute ischemic stroke ranges from 6 to 11 days compared with much longer hospitalizations (17 to 26 days) in Canada, 3 Europe, 4 and Asia. 5 Information that can predict longer LOS in stroke patients will be useful for clinical and systems management, for example, as a marker for discharge plan- ning, resource utilization, and cost implications. 6 Few articles identify clinical factors associated with longer hospitalization in stroke patients who receive thrombolytic therapy. 7,8 Most articles concerning LOS take into account the perspective of the administrators, are focused on costs, and do not neces- sarily consider the clinical relevance of findings. 5 The aim of the present study was to determine clinical predictors for longer hospitalization in stroke patients after receiving recombinant tissue plasminogen activator (rtPA). We hypothesized that (1) baseline clinical, imaging, or laboratory factors are associated with LOS; and (2) these factors are different from those described previously in the prethrombolytic period or in patients not receiving rtPA. Patients and Methods We analyzed all consecutive acute stroke patients who received rtPA. All patients were admitted to the London Health Sciences Center, University Campus (LHSC-UC) in London between January 1999 and March 2003. London is the largest city in Southwestern Ontario, with a population of 336 540 inhabitants (432 450 in the metropolitan area). It has 2 academic medical centers with 24-hour access to computed tomography (CT) and MRI. These academic hospitals are a referral center for a large part of Ontario. In addition to serving the local population, LHSC-UC receives acute stroke referrals from 33 rural hospitals from 7 counties. Hospital charac- teristics, population served, and catchment area were outlined in previous articles. 9,10 Demographic variables, stroke severity at ad- mission and at 24 hours, functional status at admission, comorbidity, and outcomes were prospectively collected. Time of symptom onset Received September 1, 2004; final revision received October 13, 2004; accepted October 19, 2004. From the Stroke Program, Department of Clinical Neurological Sciences and Southwestern Ontario Coordinated Stroke Strategy, London Health Science Center, The University of Western Ontario, London, Ontario. Correspondence to Dr Gustavo Saposnik, 339 Windermere Rd, Stroke Service, Office 7-GE5, London Health Sciences Center, London, ON –N6A 5A5, Canada. E-mail gsaposni@uwo.ca © 2004 American Heart Association, Inc. Stroke is available at http://www.strokeaha.org DOI: 10.1161/01.STR.0000150492.12838.66 147 by guest on December 25, 2016 http://stroke.ahajournals.org/ Downloaded from