Stroke Unit 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 roving stroke teams do not provide the same benefit as stroke units.

• 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.
• 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.
• 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.

1. Number of stroke patients treated on a stroke unit at any time during their in-patient 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 total time in hospital for an acute stroke event spent on a stroke unit.
4. Percentage increase in telehealth or telestroke coverage to remote communities to support organized stroke care across the continuum.

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.

• Canadian Stroke Strategy Guide to Stroke Unit Care
• National Stroke Nurses Council: Best Practice Nursing Care Across the Acute Stroke Continuum: Module 3

Stroke unit care carries with it some of the strongest evidence for improved outcomes available in the stroke research literature. The typical components of care described in the stroke unit trials are summarized as: a) assessment—medical evaluation and diagnostic testing (including CT scanning), early assessment of nursing and rehabilitation therapy needs; b) early management policies—early mobilization, prevention of complications (e.g. pressure area care, careful positioning and handling), treatment of hypoxia, hyperglycemia, fever and dehydration; and c) ongoing rehabilitation policies (coordinated interprofessional team care, early assessment of needs after discharge).²⁶⁶

The Stroke Unit Trialists’ systematic review(2009) included 31 randomized and quasi-randomized trials containing outcome information on 6936 patients comparing stroke unit care with alternative service.²⁶⁷ Of the 31 trials, 26 trials (n= 5592) compared stroke unit care with general wards. The alternative service was usual care provided on an acute medical ward without routine interprofessional input. Organized inpatient (stroke unit) care typically involved: a) coordinated interprofessional rehabilitation, b) staff with a specialist interest in stroke or rehabilitation, c) routine involvement of caregivers in the rehabilitation process, and d) regular programs of education and training. The core characteristics which were invariably included in the stroke unit setting were: interprofessional staffing i.e. medical, nursing and therapy staff (usually including physiotherapy, occupational therapy, speech therapy, social work); and coordinated interprofessional team care with meetings at least once per week. Stroke unit care showed reductions in the odds of death recorded at final (median one year) follow-up (odds ratio 0.86; 95% confidence interval 0.76 to 0.98; p=0.02), the odds of death or institutionalized care (0.82; 0.73 to 0.92; p=0.0006), and death or dependency (0.82; 0.73 to 0.92; p=0.001). The authors concluded that stroke patients receiving organized inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The benefits were most apparent in units based in a discrete ward. No systematic increase was observed in the length of inpatient stay.

A randomized study examined the frequency and timing of predefined medical complications in stroke patients (n= 489) treated in an acute comprehensive stroke unit and an early supported discharge service.²⁶⁸ During the first week, nearly 64 percent of patients experienced one or more complications, with the most common complications being: pain (23.9%), temperature ≥38°C (23.7%), progressing stroke (18.4%), urinary tract infection (16.0%), troponin T elevation without criteria of myocardial infarction (11.7%), chest infections (11.2%), non serious falls (7.4%), and myocardial infarction (4.5%). Stroke recurrence, seizure, deep vein thrombosis, pulmonary embolism, shoulder pain, serious falls, other infections, and pressure sores were each present in ≤2.5% of patients. During the 3 month follow-up, 82% of patients experienced at least one complication, the most common of which was pain (53.3%), followed by urinary tract infection (27.9%) and non serious falls (25.0%). The severity of stroke on admission was the most important risk factor for developing complications.

Within clinical trials, stroke patients allocated to receive organized inpatient (stroke unit) care are more likely to survive, return home, and regain independence than those allocated to conventional care. However, there are concerns that the benefits seen in clinical trials may not be replicated in routine practice. Seenan et al. (2007) carried out a systematic review of observational studies of stroke unit implementation, comparing the outcomes of stroke patients managed in a stroke unit versus non-stroke unit care.²⁶⁹The primary outcome was death within one year and poor outcome was recorded as institutional care or dependency. Twenty-five studies were eligible for review (18 provided data on case fatality or poor outcome). Stroke unit care was associated with significantly reduced odds of death (odds ratio=0.79, 95% CI=0.73 to 0.86; p

In a synthesis of evidence demonstrating the benefits of organized stroke care, Kalra and Langhorne (2007) 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.²⁷⁰ 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.

The use of standardized and validated tools for stroke severity and functional assessment enables sound decision-making and care planning. The Canadian Neurological Scale (CNS) was designed to monitor mentation and motor functions in stroke patients.²⁷¹ The CNS was initially validated by Cote et al (1989) and found to be internally consistent and to have a high level of interrater reliability.^271,272 Initial CNS scores were found to be a significant predictor of death, morbidity, and recovery of ADL. Patients with high initial CNS scores were at lower risk of poor outcomes at 6 months. This relationship held even after adjustments were made for other covariates.²⁷³

The NIH Stroke Scale (NIHSS) is another validated scale used in clinical practice.²⁷³ In the original validation study, interrater reliability for the scale was found to be high (mean kappa = 0.69), and test-retest reliability was also high (mean kappa = 0.66-0.77).²⁷⁴ Test-retest reliability did not differ significantly among a neurologist, a neurology house officer, a neurology nurse, or an emergency department nurse. The stroke scale validity was assessed by comparing the scale scores obtained prospectively on 65 acute stroke patients to the patients' infarction size as measured by computed tomography scan at 1 week and to the patients' clinical outcome as determined at three months. These correlations (scale-lesion size r = 0.68, scale-outcome r = 0.79) suggested acceptable examination and scale validity. Of the 15 test items, the most interrater reliable item (pupillary response) had low validity. Less reliable items such as upper or lower extremity motor function were more valid.

A more recent study assessed the reliability of both the CNS and the NIHSS at academic medical centres and community hospitals.²⁷⁴ The intra-class correlation coefficient for NIHSS and CNS, respectively, were 0.93 (95% CI, 0.82 to 1.00) and0.97 (95% CI, 0.90 to 1.00) for the AMC, 0.89 (95% CI, 0.75to 1.00) and 0.88 (95%, 0.73 to 1.00) for the community hospital with neurological services (CH1), and 0.48(95% CI, 0.26 to 0.70) and 0.78 (95% CI, 0.60 to 0.96) for the community hospitals without neurological services (CH2). More NIHSS items were missing at the CH2 (62%) versus the AMC (27%) and the CH1 (23%, P=0.0001). In comparison, 33 percent, zero percent, and eight percent of CNS items were missing from records from CH2, AMC, andCH1, respectively (P=0.0001). The study found that the levels of interrater agreement were almost perfect for retrospectively assigned NIHSS and CNS scores for patients initially evaluated by a neurologist at both an AMC and a CH. Levels of agreement for the CNS were substantial at CH2, but interrater agreement for the NIHSS was only moderate in this setting. The proportions of missing items are higher for the NIHSS than the CNS in each setting, particularly limiting its application in the hospital without acute neurological consultative services.