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Section 5.3

Delivery of Inpatient Stroke Rehabilitation

All patients with stroke should begin rehabilitation therapy within an active and complex stimulating environment [Evidence Level C] as early as possible once medical stability is reached [Evidence Level A].

  1. Patients should receive the intensity and duration of clinically relevant therapy defined in their individualized rehabilitation plan and appropriate to their needs and tolerance levels [Evidence Level A].
  2. Stroke patients should receive, through an individualized treatment plan, a minimum of three hours of direct task-specific therapy by the interprofessional stroke team for a minimum of five days per week [Evidence Level A].
  3. The team should promote the practice of skills gained in therapy into the patient’s daily routine in a consistent manner [Evidence Level A].
  4. Therapy should include repetitive and intense use of novel tasks that challenge the patient to acquire necessary motor skills to use the involved limb during functional tasks and activities [Evidence Level A].
  5. Stroke unit teams should conduct at least one formal interprofessional meeting per week at which patient problems are identified, rehabilitation goals set, progress monitored and support after discharge planned [Evidence Level B].
  6. The care management plan should include a pre-discharge needs assessment to ensure a smooth transition from rehabilitation back to the community. Elements of discharge planning should include a home visit by a healthcare professional, ideally before discharge, to assess home environment and suitability for safe discharge, determine equipment needs and home modifications, and begin caregiver training for how the patient will manage activities of daily living and instrumental activities of daily living in their environment [Evidence Level C].
    Rationale

    A number of important elements must be present on inpatient stroke rehabilitation units to obtain benefits. These include adequate intensity of therapy, task-oriented training, excellent team coordination and early discharge planning. Both animal and human research suggests that the earlier rehabilitation starts, the better the outcome. In fact, people who start rehabilitation later may never recover as much as those who start early. Early-intensive rehabilitation care for both acute and subacute stroke patients improves arm and leg motor recovery, walking mobility and functional status, including independence in self-care and participation in leisure activities. It is important that the rehabilitation be tailored to the tasks that need to be retrained and developed. Another vital component is the need for all of the professionals involved to work together as a coordinated, specialized team, meeting regularly to discuss the rehabilitation goals and progress. Early discharge planning, including home assessment and caregiver training, identifies potential barriers to discharge and promotes efficient transition back to the community.

    System Implications
    • Timely access to specialized, interprofessional stroke rehabilitation services, regardless of geographic location of patients’ home community.
    • A critical mass of trained healthcare providers functioning as a coordinated interprofessional team during the rehabilitation period following stroke.
    • Adequate clinician resources to provide the recommended intensity of individualized therapies for stroke patients.
    • Establishment of protocols and partnerships between inpatient rehabilitation and community care providers to ensure safe and efficient transitions between hospital and community. Particular considerations should be made for patients residing in more rural or remote locations.
    • Optimization of strategies to prevent the recurrence of stroke.
    • Stroke rehabilitation support initiatives for caregivers.
    • Process for patients and caregivers to re-access the rehabilitation system as required.
    Performance Measures
    1. Median length of time from stroke admission to an acute care hospital to assessment of rehabilitation potential by a rehabilitation healthcare professional.
    2. Median length of time between stroke onset and admission to stroke inpatient rehabilitation.
    3. Number or percentage of patients admitted to a stroke unit — either a combined acute care and rehabilitation unit or a rehabilitation stroke unit in an inpatient rehabilitation facility — at any time during their hospital stay (acute and/or rehabilitation) (core).
    4. Final discharge disposition for stroke patients following inpatient rehabilitation: percentage discharged to their original place of residence, percentage discharged to a long-term care facility or nursing home, percentage discharged to supportive housing or assisted living (core).
    5. Percentage of patients requiring readmission to an acute care hospital for stroke-related causes (core).
    6. Median length of time spent on a stroke unit during inpatient rehabilitation.
    7. Median number of days spent in “alternate level of care” in an acute care setting before arrival in inpatient rehabilitation setting.
    8. Change (improvement) in functional status scores using a standardized assessment tool from admission to an inpatient rehabilitation program to discharge.
    9. Total number of days spent in inpatient rehabilitation, by stroke type.
    10. Number of patients screened for cognitive impairment using valid screening tool during inpatient rehabilitation.
    11. Time from stroke onset to mobilization: sitting, standing upright, walking with or without assistance.
    12. Median number of days spent in alternate level of care or inpatient rehabilitation while waiting for return to home or placement in a residential or long-term care setting.

    Measurement notes

    • Some acute care hospitals provide combined acute and rehabilitation stroke units, where patients progress to “rehabilitation status” and may not actually move or change locations. This information could be found in patient records through primary chart audit.
    • Many performance measures require primary chart audit of inpatient rehabilitation records. Documentation quality by rehabilitation staff may create concerns about data availability and data quality.
    • The Canadian Institute for Health Information has a database known as the National Rehabilitation Reporting System. This database includes data on all inpatient rehabilitation encounters to designated rehabilitation beds. It is mandated in some provinces to submit data to the National Rehabilitation Reporting System; in other provinces, it is optional. The National Rehabilitation Reporting System has information on over 80 percent of all inpatient rehabilitation encounters in Canada and can distinguish stroke cases from other rehabilitation patients by diagnosis.
    • Duration or intensity of services by rehabilitation professionals requires a chart review or consistent use of reliable workload measurement tools implemented locally or regionally.
    • For performance measure 2, efforts should be made to collect information on reasons for delay, if any, in admission to inpatient rehabilitation from acute care. These may include such issues as bed availability, patient health status and other aspects of the referral and transfer process. This information may provide direction on areas to target quality improvement initiatives.
    Summary of the Evidence

    Importance of adequate intensity of inpatient rehabilitation

    A review by Cifu and Stewart found four studies of moderate quality that reported a positive correlation between early onset of rehabilitation interventions following stroke and improved functional outcomes. 345 The authors noted that early onset of rehabilitation was strongly associated with improved functional outcomes.

    Ottenbacher and Jannell conducted a meta-analysis including 36 studies with 3717 stroke survivors and demonstrated a positive correlation between early intervention of rehabilitation and improved functional outcome.346 According to the Evidence-Based Review of Stroke Rehabilitation, the intensity of rehabilitation needs to be considered.28 De Wit and colleagues studied four European countries (Belgium, United Kingdom, Switzerland and Germany) and found that gross and functional recovery were better for patients in the German and Swiss centres.355 In an earlier study of the same centres, it was reported that German and Swiss patients received more therapy per day in comparison with patients in the other centres. 356

    The Evidence-Based Review of Stroke Rehabilitation (EBRSR) concluded that there was strong evidence that greater intensities of physiotherapy and occupational therapy resulted in improved functional outcomes after stroke.28 The authors highlighted, however, that the overall beneficial effect of intensified therapy was modest and positive benefits may not hold over time.

    The EBRSR indicates that the weight of evidence suggests that more intensive therapy is associated with greater rehabilitation gains. However, the European Stroke Organization’s 2008 Guidelines for the Management of Ischemic Stroke and Transient Ischemic Attack have indicated that currently available data do not allow for recommendations on minimal or maximum therapy times.29 Nevertheless, the current standard of care at publicly-funded stroke rehabilitation facilities in the United States is to provide at least three hours of therapy. Failure to do so results in a loss of reimbursement.”361

     

    Important elements of inpatient stroke Rehabilitation

    The Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation include various types of physical rehabilitation techniques used for management of patients following a stroke event.27 Evidence was identified and synthesized, serving as the basis for the 147 recommendations put forward by the panel. The final recommendations supported the use of therapeutic exercise, task-oriented training, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation after stroke. For patients with subacute stroke, clinically important benefit was demonstrated for enhanced upper-limb treatment (Evidence Level

    A), 362 enhanced physiotherapy (Evidence Level A)363, 364 and enhanced occupational therapy (Evidence Level A).365-368 Effective discharge planning is essential for the successful reintegration of individuals living with stroke into the community and should be considered at all transition points along the continuum of stroke care. Discharge planning is an important aspect of stroke care allowing optimization of patient participation and independence, as well as aiding with caregiver needs and concerns. 16