Stroke Unit Care *NEW!

• It is recognized that not all hospitals are able to deliver all of the stroke unit  elements, and every hospital should be Taking Action to establish protocols and processes of care to implement as many elements as possible to achieve optimal stroke care delivery within their geographic location, hospital volumes and resource availability (human, equipment, funding). 
  Refer to Figure 1 in Chapter 4 Overview for Canadian Stroke Services Framework, in the Overview section of this chapter, and in the Taking Action Towards Optimal Stroke Care resource kit.
• Specialized care for patients with ischemic stroke, intracerebral hemorrhage (ICH), and transient ischemic attack (TIA) (care may be expanded in some institutions to include patients with subarachnoid hemorrhage [SAH] and other neurovascular conditions);
• Dedicated stroke team with broad expertise – including neurology, nursing neurosurgery, physiatry, rehabilitation professionals, pharmacists, and others;
• Consistent clustered model where all stroke patients are cared for on the same hospital ward with dedicated stroke beds by trained and experienced staff, including rehabilitation professionals;
• Access to 24/7 imaging and interventional neuroradiology expertise;
• Emergent neurovascular surgery access;
• Protocols in place for hyperacute and acute stroke management, and seamless transitions between stages of care (including pre-hospital, emergency department and inpatient care);
• Dysphagia screening protocols in place to assess all stroke patients without prolonged time delays prior to commencing oral nutrition and oral medications;
• Access to post-acute rehabilitation services, including inpatient, community-based, and/or early supported discharge (ESD) therapy;
• Discharge planning starting as soon as possible after admission, and anticipating discharge needs to facilitate smooth transitions;
• Daily/bi-weekly patient care rounds with interprofessional stroke team to conduct case reviews, discuss patient management issues, family concerns or needs, and discharge planning (discharge or transition to the next step in their care, timing, transition requirements);
• Patient and family education that is formal, coordinated, and addresses learning needs and responds to patient and family readiness;
• Provision of palliative care when required, ideally by a specialized palliative care team;
• Ongoing professional development for all staff – stroke knowledge, evidence-based best practices, skill building, orientation of trainees;
• Involvement in clinical research for stroke care.

Stroke unit care reduces the likelihood of death and disability by as much as 30 percent for men and women of any age with mild, moderate, or severe stroke. Stroke unit care is characterized by a coordinated interprofessional team approach for preventing stroke complications, preventing stroke recurrence, accelerating mobilization, and providing early rehabilitation therapy. Evidence suggests that stroke patients treated on acute stroke units have fewer complications, earlier mobilization, and pneumonia is recognized earlier. Patients should be treated in a geographically defined unit, as care through stroke pathways and by roving stroke teams do not provide the same benefit as stroke units.  Access to early rehabilitation is a key aspect of stroke unit care.  For patients with stroke, rehabilitation should start as early as possible and rehabilitation should be considered an intervention that can occur in any and all settings across the continuum of stroke care.

• Organized systems of stroke care including stroke units with a critical mass of trained staff (interprofessional team). If not feasible, then mechanisms for coordinating the care of stroke patients to ensure use of best practices and optimal outcomes.
• Protocols and mechanisms to enable the rapid transfer of stroke patients from the emergency department to an interprofessional stroke unit as soon as possible after arrival in hospital, ideally within the first three hours.
• Comprehensive and advanced stroke care centres should have leadership roles within their geographic regions and ensure specialized stroke care access is available to patients who may first appear at general healthcare facilities (usually remote or rural centres) and facilities with basic stroke services only.
• Telestroke services should be optimized to ensure access to specialized stroke care across the continuum to meet individual needs (including access to rehabilitation and stroke specialists).
• Information on geographic location of stroke units and other specialized stroke care models available to community service providers, to facilitate navigation to appropriate resources and to strengthen relationships between each sector along the stroke continuum of care.

1. Number of stroke patients who are admitted to hospital and treated on a specialized stroke unit at any time during their inpatient hospital stay for an acute stroke event (numerator) as a percentage of total number of stroke patients admitted to hospital (core). 
2. Percentage of patients discharged to their home or place of residence following an inpatient admission for stroke (core).
3. Proportion of stroke patients who die in hospital within 7 days and within 30 days of hospital admission for an index stroke (reported by stroke type) (core).
4. Proportion of total time in hospital for an acute stroke event spent on a stroke unit.
5. Percentage increase in telehealth or telestroke coverage to remote communities to support organized stroke care across the continuum.
   Refer to Canadian Stroke Quality and Performance Measurement Manual for detailed indicator definitions and calculation formulas.

Measurement Notes

• Performance measure 1: calculate for all cases, and then stratify by type of stroke.
• Definition of stroke unit varies widely from institution to institution. Where stroke units do not meet the criteria defined in the recommendation, then a hierarchy of other stroke care models could be considered: a) dedicated stroke unit; (b) designated area within a general nursing unit or neuro-unit where stroke patients are clustered; (c) mobile stroke team care; (d) managed on a general nursing unit by staff using stroke guidelines and protocols.
• Institutions collecting this data must note their operational definition of “stroke unit” to ensure standardization and validity when data is reported across institutions.
• Patient and family experience surveys should be in place to monitor care quality during inpatient stroke admissions

• Canadian Stroke Best Practices Patient Order Set for Admission to Inpatient Stroke Care
• Canadian Stroke Best Practices Table 3.3A Screening and Assessment Tools for Acute Stroke
• Canadian Stroke Best Practices Table 3.3B Recommended Laboratory Investigations for Acute Stroke and Transient Ischemic Attack
• HSF Stroke Nurses Assessment Pocket Cards
• Canadian Stroke Best Practices Implementation guide: Taking Action Towards Optimal Stroke Care
• RNAO Stroke Assessment Across the Continuum of Care (2005)

Stroke patients who receive stroke unit care are more likely to survive, return home, and regain independence as compared to patients who receive less organized conventional care (Stroke Unit Trialists' Collaboration, 2009).  Stroke units are characterized as hospital units in which care is provided by an experienced interprofessional stroke team (including physicians, nurses, physiotherapists, occupational therapists, speech therapists, etc.) dedicated to the management of stroke patients, often within a geographically defined space.(Langhorne & Pollock, 2002)  Stroke units also typically involve staff members who have a specialist interest in stroke, participate in routine team meeting and continuing education/training, engage in interprofessional rehabilitation, and involve caregivers in the rehabilitation process. (Langhorne & Pollock, 2002)

In a Cochrane Review, the Stroke Unit Trialists’ Collaboration identified 31 randomized and quasi-randomized trials (n=6,936) comparing stroke unit care with alternative, less organized care (e.g., an acute medical ward)(Stroke Unit Trialists' Collaboration, 2009).  As compared to treatment in a less organized unit, stroke unit care was associated with a significant reduction in death (OR=0.82, 95% CI 0.73 to 0.92, p=0.001), death or institutionalization (OR=0.81, 95% CI 0.74 to 0.90, p<0.001), and death or dependency (OR=0.79, 95% CI 0.71 to 0.88, p<0.001) at a median follow-up period of one year.  Based on the results from three trials, the authors also reported that the benefits of stroke unit care are maintained for periods up to 5 and 10 years post-stroke.  Moreover, subgroup analyses demonstrated benefits of stroke unit care regardless of sex, age, or stroke severity (Stroke Unit Trialists' Collaboration, 2009).  In a more recent study, Saposnik et al. investigated the differential impact of stroke unit care on four subtypes of ischemic stroke and reported that stroke unit care is associated with reduced 30-day mortality across all four subtypes (Saposnik et al., 2011).

Seenan and colleagues conducted a systematic review of observational studies to determine if the benefits of stroke unit care described in clinical trials are replicated in clinical practice (Seenan et al., 2007).  Twenty-five observational studies (n=42,236) comparing stroke unit care to non-stroke unit care were identified for inclusion, although only 18 provided data on case fatality or poor outcome.  The authors reported that stroke unit care was associated with significantly reduced odds of death (odds ratio=0.79, 95% CI=0.73 to 0.86; p<0.001) and of death or poor outcome (odds ratio=0.87, 95% CI=0.80 to 0.95; p=0.002) within one-year of stroke.  Although the analyses were subject to significant heterogeneity, similar findings were reported for the outcome of death at one year in a secondary analysis limited to multi-centered trials, which did not suffer from significant heterogeneity (OR=0.82, 95% CI 0.77 to 0.87, p<0.001) (Seenan et al., 2007).  Although observational studies are associated with a greater risk of bias than RCTs, it is noteworthy that the benefit of stroke unit care observed in observational studies of clinical practice is comparable to that observed in clinical trials.

In a synthesis of evidence demonstrating the benefits of organized stroke care, Kalra and Langhorne noted that an important challenge for stroke units is a conceptual shift in the philosophy of stroke care from being predominantly engaged with patient-oriented interventions to a strategy in which the patient and the caregiver are seen as a combined focus for intervention, with the objective of empowering and equipping caregivers to be competent facilitators of activities of daily living when caring for disabled patients after stroke (Kalra & Langhorne, 2007).  Research has consistently shown that better outcomes are associated with comprehensive and early processes of stroke-specific assessments, particularly assessments for swallowing and aspiration risk, early detection and management of infections, maintenance of hydration and nutrition, early mobilization, clear goals for function, and communication with patients and their families (Kalra & Langhorne, 2007).

Evidence Table 4.1 and References