The objective of this study was to conduct a randomized, parallel-group clinical trial assessed the efficacy of a health-enhancing physical activity program (exercise and education) on vascular risk factors and aerobic fitness in patients who have experienced a transient ischemic attack (TIA) or nondisabling stroke. Sixty patients (69 ± 11 years) completed a baseline (BL) vascular risk stratification and aerobic fitness examination (cycle test) within 2 weeks of symptom onset. Subjects were then randomized to either an 8-week, twice weekly exercise program or to a usual-care control (CON) group. Postintervention (PI) assessments were completed immediately after the intervention and at 3-month follow-up. A series of primary (systolic blood pressure [SBP]) and secondary (vascular risk factors like total cholesterol [TC], high-density lipoproteins, etc.; Framingham risk score; peak oxygen uptake) outcome measures were assessed. Significantly greater reductions in SBP (mean change ± SD; −10.4 ± 9.2 mm Hg) and TC (−.53 ± .90 mmol/L) were observed between BL and PI assessments for the exercise group compared with the CON group (−1.9 ± 15.4 mm Hg and −.08 ± .59 mmol/L, respectively) ( P P > .05). Significant improvements in aerobic fitness were also observed and maintained at the 3-month follow-up assessment after regular exercise participation ( P

Effects of Early Exercise Engagement on Vascular Risk in Patients with Transient Ischemic Attack and Nondisabling Stroke

After the implementation of the multidisciplinary geriatric hip fracture clinical pathway in 2007, the hospital length of stay and the clinical outcomes improves. Moreover, the cost of manpower for each hip fracture decreases. It proves that this care model is cost-effective. The objective of this study is to compare the clinical outcomes and the cost of manpower before and after the implementation of the multidisciplinary geriatric hip fracture clinical pathway (GHFCP). The hip fracture data from 2006 was compared with the data of four consecutive years since 2008. The efficiency of the program is assessed using the hospital length of stay. The clinical outcomes include mortality rates and complication rates are compared. Cost of manpower was also analysed. After the implementation of the GHFCP, the preoperative length of stay shortened significantly from 5.8 days in 2006 to 1.3 days in 2011. The total length of stay in both acute and rehabilitation hospitals were also shortened by 6.1 days and 14.2 days, respectively. The postoperative pneumonia rate also decreased from 1.25 to 0.25%. The short- and long-term mortalities also showed a general improvement. Despite allied health manpower was increased to meet the increased workload, the shortened length of stay accounted for a mark decrease in cost of manpower per hip fracture case. This study proves that the GHFCP shortened the geriatric hip fracture patients’ length of stay and improves the clinical outcomes. It is also cost-effective which proves better care is less costly.

The effectiveness of a multidisciplinary hip fracture care model in improving the clinical outcome and the average cost of manpower.

https://espace.library.uq.edu.au/view/UQ:353016/UQ353616_OA.pdf

Identifying outcomes associated with co-managed care models for patients who have sustained a hip fracture: an integrative literature review

Individuals with TIA were successfully recruited and retained into a RCT. A different approach is required to study interventions in Maori, Pacific Islanders, Asian and Indian populations. If the exercise intervention improves vascular risk factors and reduces recurrent vascular events, it could be applied to a large number of people who suffer a TIA or non-disabling stroke.

Health-enhancing physical activity programme (HEPAP) for transient ischaemic attack and non-disabling stroke: recruitment and compliance.

Background: Early carotid endarterectomy (CEA) after stroke or transient ischaemic attack is the proposed standard of care to prevent recurrent ischaemic events in selected patients The aim of this study was to investigate if this standard is achieved in a tertiary vascular unit



Methods:  This was a clinical audit CEAs performed from 1 January 2006 to 31 December 2008 at Christchurch hospital were identified The value stream from initial presentation to surgery was mapped in two phases (phase 1; 2006–2007 and phase 2; 2008) Patients who had carotid intervention for asymptomatic carotid lesions were excluded



Results:  The relevant patient journey was documented in 81 patients (55 phase 1; 26 phase 2) Median time from initial presentation to carotid ultrasound was 5 days in phase 1 and 6 days in phase 2 Time from presentation to vascular surgery review was 22 days in phase 1 and 13 days in phase 2 Time from presentation to CEA significantly reduced from 83 to 32 days between phases (P < 0005)



Conclusions:  There has been a significant decrease in time from presentation to operation between phase 1 and 2 The most significant change is reduced delay between vascular surgery review and CEA There has been no improvement in urgency of referral for imaging or surgical review This part of the patient journey is a target for improvement

Patient flow to carotid endarterectomy: hastening the patient journey.

Background The process of care of older patients with fractured neck of femur at Auckland City Hospital has recently changed with selected patients "fast-tracked" as soon as possible postoperatively to a specialised Older People's Health (OPH) ward. Aims The aims of this study were: to evaluate patient characteristics; to analyse process of care; to compare outcomes in those "fast-tracked" patients with those receiving usual care; and to compare this information with previous data from Auckland City Hospital and other centres in New Zealand. Method Prospective case record audit of patients with fractured neck of femur aged 65 years and over admitted under Orthopaedics over a 4-month period. Results 115 patients were audited; mean age was 84 years, 77% were female. Inpatient mortality was 5%. Twenty-four percent of patients had surgery within 24 hours of admission. Of those who did not have surgery within 24 hours, 39% were awaiting operating theatre availability. Median overall length of stay (LOS) was 27 days. Eighty-four percent of patients were transferred to Older Peoples Health. Considering all patients, 70% of those living at home pre-fracture returned home on discharge. However, only 26% of those in Rest Home returned to Rest Home. Overall, 35% of patients were discharged to a higher level of care. Forty-four percent of the group were able to walk unaided prior to hip fracture, but only 1% on discharge. Forty-three patients were "fast-tracked" to Older Peoples Health. Their median overall LOS was 23 days compared to 28 days for those receiving usual care. This was due to the shorter time in Orthopaedics. Thirty-three percent of this group went to a higher level of care on discharge compared to 35% in the group that received usual care. Conclusions Many patients experience a delay to surgery for non-medical reasons. The percentage transferred to Older Peoples Health is high. Fast-tracking to Older Peoples Health shortens overall length of stay due to fewer days in Orthopaedics. Many patients require a higher level of care after hip fracture, particularly if already resident in Rest Home. Demographics and inpatient mortality are comparable, but total length of stay is longer than similar New Zealand studies due to a longer length of stay in Older Peoples Health. Review of previous data from Auckland City Hospital and from other New Zealand centres shows significant variability in process of care for older patients with hip fracture.

Auckland City Hospital's ortho-geriatric service: an audit of patients aged over 65 with fractured neck of femur.

BACKGROUND: We conducted an audit of transient ischaemic attack (TIA) services in New Zealand to determine how current practice compares to best practice recommendations. METHODS: A brief written questionnaire was sent to all district health boards (DHBs) concerning service provision, clinical management and clinical audit activity related to patients with TIA. RESULTS: Questionnaires were completed by all 21 DHBs. In 18 of 21 (71%) DHBs, most TIA patients were managed by acute services; 3 (14%) DHBs routinely admit most patients and 15 (72%) see most patients in hospital emergency departments or acute assessment units. Three (14%) DHBs see most TIA patients in outpatient clinics, with a usual wait to be seen of more than 1 week. Delays of more than a week were common for carotid ultrasound scans (10 DHBs, 48%) and carotid endarterectomy when indicated (16 DHBs, 76%). Only 4 (19%) DHBs had audited TIA management at a patient level and 3 (14%) at a service level. CONCLUSIONS: There are major discrepancies between current management of TIA patients and best practice recommendations in national and international guidelines. Significant regional variations in models of care and access to investigations exist. The provision of dedicated appropriately resourced TIA services within an organised stroke service should be seen as a priority.

Transient ischaemic attack services in New Zealand.

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Auckland City Hospital's ortho-geriatric service: an audit of patients aged over 65 with fractured neck of femur.

Transient ischaemic attack services in New Zealand.