NOTES on this recommendation
- Outpatient rehabilitation includes day hospital, outpatient ambulatory care, and home-based rehabilitation.
All persons with acute stroke should be assessed to determine the severity of stroke and early rehabilitation needs.
- All patients admitted to hospital with acute stroke should have an initial assessment by rehabilitation professionals as soon as possible after admission [Evidence Level A], preferably within the first 24 to 48 hours [Evidence Level C].
- This initial assessment should include assessment of patient function; safety and risk; physical readiness and ability to learn and participate; and transition planning [Evidence Level C].
- All patients with acute stroke with any residual stroke-related impairments who are not admitted to hospital should undergo a comprehensive outpatient assessment(s) for functional impairment, which includes a cognitive evaluation, screening for depression, screening for fitness to drive, as well as functional assessments for potential rehabilitation treatment [Evidence Level A], preferably within 2 weeks [Evidence Level C].
- Clinicians should use standardized, valid assessment tools to evaluate the patient’s stroke-related impairments and functional status [Evidence Level C].
- The rehabilitation needs of survivors of a severe or moderate stroke should be reassessed weekly for the first month, and then at intervals as indicated by their health status [Evidence Level C].
The first interprofessional assessment after the stroke patient is admitted must identify the physical, cognitive, and communication complications from the stroke to help identify the likely discharge needs.
Early consultation with rehabilitation professionals contributes to reductions in complications from immobility such as joint contracture, falls, aspiration pneumonia, and deep vein thrombosis. There is evidence that an interprofessional approach bringing together clinicians with different skill sets is one of the factors that results in reduced deaths in specialized stroke units. Another key benefit of early consultation with rehabilitation professionals is early discharge planning for transition from acute care to specialized rehabilitation units or to the community.
Patients with milder strokes may have subtle cognitive difficulties that need to be followed; those with severe stroke initially may not be candidates for rehabilitation but still require follow-up because 40 to 50 percent may be able to return home following rehabilitation rather than requiring institutional care.28 Early assessment can reduce overall costs through improved outcomes and potentially reduced time to discharge.
To ensure patients receive timely stroke rehabilitation assessments, the acute care organization requires:
- An adequate complement of clinicians experienced in stroke and stroke rehabilitation.
- A clear process for patient referral to rehabilitation professionals after admission.
- An interprofessional team that is well resourced to provide prescribed levels of rehabilitation therapy.
- A defined geographic area or unit where individuals with stroke are ensured access to an experienced team.
- Standard expert consensus-based screening assessment tools and training.
- A process for timely referral to specialized stroke inpatient services in all centres (for example, electronic referral system and standardized assessment tools).
- Access to a follow-up clinic to ensure assessment of mild stroke-related difficulties and access to rehabilitation when required. For children, follow-up in their school environments.
- Development of stroke rehabilitation expertise in children’s hospitals and children’s treatment centres.
- Mechanisms to periodically re-evaluate those with severe stroke admitted to nursing homes or continuing care to ensure access to a trial of rehabilitation.
- Coordination and development of strong partnerships in the community to ensure access to comprehensive stroke rehabilitation. This is especially important in more rural and remote geographic locations where telehealth technologies should be optimized.
- Proportion of stroke patients with a rehabilitation assessment within 48 hours of hospital admission for acute ischemic stroke and within 5 days of admission for hemorrhagic stroke (core).
- Median time from hospital admission for stroke to initial rehabilitation assessment for each of the rehabilitation disciplines.
- Proportion of acute stroke patients discharged from acute care to inpatient rehabilitation (core).
- Percentage of stroke patients discharged to the community who receive a referral for outpatient rehabilitation before discharge from acute and/or inpatient rehabilitation hospital (either facility-based or community- based programs).
- Median length of time between referral for outpatient rehabilitation to admission to a community rehabilitation program.
- Length of time between referral for outpatient rehabilitation to commencement of therapy.
- Percentage of those with severe stroke reassessed for rehabilitation following initial assessment.
- Percentage of those with severe stroke admitted to inpatient rehabilitation.
- Percentage increase in Telehealth/Telestroke coverage to remote communities to support organized stroke care across the continuum and provide rehabilitation assessments for stroke patients.
- Referral information may be found through primary audit of inpatient charts (nurses’ notes, discharge summary notes, copies of referral forms) or through databases maintained by organizations that receive and process referrals. These community databases will vary in the amount of information included, and there may be challenges in accessing information contained in these databases.
- Most home care organizations monitor when the first service started but cannot determine easily the onset of rehabilitation therapy.
- FIM® Instrument
- Evidence-Based Review of Stroke Rehabilitation (Triage Module): www.ebrsr.com/uploads/Module_4_triage_final.pdf
- The Certificate of Stroke Rehabilitation Program: University of Alberta Department Rehabilitation Medicine
- Certificate in Advanced Neuroscience-Stroke Care: Ryerson University
Comprehensive stroke care delivery in the early days and weeks following an acute stroke has been shown to have significant positive impact on stroke outcomes.333Comprehensive assessments of a stroke patient’s cognitive and functional status in the first few days following a stroke are essential to developing individualized plans of care and recovery. The World Health Organization’s International Classification of Functioning (ICF) model is commonly used by healthcare professionals to guide assessment and treatment of stroke patients in the acute and post acute phases of care.334The ICF considers three perspectives: the body, the individual and societal perspectives. It also includes the two components of body function and structure and activity and participation, all within the context of one’s environment. Early rehabilitation assessments for stroke, as well as goal setting and treatment planning should incorporate aspects of the ICF model during the short and long term recovery of stroke patients.335, 336
Definition of functional assessment: Standardized or non-standardized method of evaluating a person’s ability to perform basic self-care activities (such as dressing, grooming, personal hygiene, feeding, functional mobility and communication) and instrumental activities of daily living (including meal preparation, home management, communication activities, financial management, shopping and community living skills). Ability to interact socially may also be a component of a functional assessment.
Benefits of early stroke rehabilitation assessment: A screening examination for rehabilitation should be performed as soon as the patient's medical and neurological condition permits, by a person experienced in rehabilitation.337 The screening examination should incorporate medical information, neurological examination, use of a well-standardized disability (e.g., activities of daily living) instrument and a mental status-screening test. Asberg and Nydevik (1991) felt that the optimal timing for stroke rehab assessment was five to seven days post-stroke onset, although recent trends have been towards decreasing that time, since onset.338
The EBRSR reports threshold criteria for admission to a comprehensive rehabilitation program should include medical stability, the presence of a functional deficit, the ability to learn, and enough physical endurance to sit unsupported for at least one hour and to participate actively in rehabilitation.337 Admission to an interprofessional program should be limited to patients who have more than one type of disability and who therefore require the services of two or more rehabilitation disciplines. Patients with a single disability can benefit from individual services, but generally, do not require an interprofessional program.337
One randomized controlled trial published in 2001 addressed both acute and rehabilitative care and sought to quantify the differences between staff interventions in a stroke unit versus staff interventions on a general ward supported by a stroke specialist team.339 Observations were made daily for the first week of acute care but only weekly during the postacute phase. During the observation period, the stroke unit patients were monitored more frequently and received better supportive care, including early initiation of feeding.339,340 Evidence is also emerging for the rehabilitative effects of swallowing therapy after stroke.341-343 Swallowing interventions including diet modifications, swallowing therapy and compensatory swallowing strategies should be implemented as soon as possible by a trained swallowing specialist who is able to complete a full clinical and instrumental assessment.344
Reviews by Cifu and Stewart (1999) and Ottenbacher and Jannell (1993) reported a positive correlation between early rehabilitation interventions and improved functional outcomes.345, 346 However, it is not evident whether the relationship is causal. One prospective comparative trial by Paolucci et al. (2000) looked at the outcomes of stroke patients admitted to rehabilitation at differing times following stroke.347 They found that those stroke patients who received rehabilitation early did better functionally than those whose rehabilitation was delayed.
Specialized nursing care promotes early recognition of complications and management of skin, bowel and bladder problems. Research suggests that physical therapy will promote better recovery through early mobilization of the patient and management of any lung problems caused by immobility. Occupational therapists focus on improving activities that are meaningful to the patient (self-care, productivity and leisure activities) by reducing stroke-related impairments. Assessment of patient’s discharge environment addresses suitability for discharge home, need for equipment and/or home modification for function and safety. Speech–language pathologists assess swallowing difficulties and provide swallowing therapy and compensatory techniques. The speech–language pathologist is also able to assess the degree of difficulty with communication and initiate appropriate therapy. Augmentative or alternative communication devices will be introduced if necessary. Medical specialists in physical medicine and rehabilitation address complications such as pain, spasticity (increased resistance in the muscles), and bowel and bladder incontinence. Neuropsychology, social work and other allied health professionals may help with the cognitive and psychosocial sequelae of stroke.348
Interpretation of early rehabilitation assessments relies on the use of standardized assessment tools. In Canada, the FIM® Instrument is widely used within inpatient rehabilitation settings, and less consistent in the inpatient acute care setting.349Ween et al. (1996) prospectively analyzed 536 consecutive stroke rehabilitation admissions to try and identify the influence of preselected factors on functional improvement and discharge destination.350 Patients with an admission FIM above 80 almost always went home after rehabilitation and so it was recommended that patients with early functional independence measure (FIM) scores greater than 80 (the mildly disabled) are best managed at home as long as appropriate supports are in place. Conversely, patients admitted to rehabilitation with a FIM score of less than 40 almost always required long-term care in a nursing home facility. It was recommended that those with FIM scores less than 40 (the more severely disabled) should likely go to a slower paced or less intensive rehab facility, or a decision should be postponed at the time of initial assessment and reassessed weekly. An admission score of 60 or more was associated with a larger FIM improvement, but the absence of a committed caregiver at home increased the risk of nursing home discharge. Therefore, it was recommended that intensive rehabilitation units are most likely to be effective with moderately severe stroke patients with early FIM scores between 40-80. These patients are generally able to participate fully, show substantial improvement during rehabilitation and have a high probability of discharge home.351