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Stroke Rehabilitation Unit Care

2016 UPDATE
February 2016

The Canadian Stroke Best Practice Recommendations for Stroke Rehabilitation, 5th Edition (2015) is published in the International Journal of Stroke (IJS) and available freely online. To access the specific recommendations for Stroke Rehabilitation Unit Care, and all other sections of the Stroke Rehabilitation recommendations, please click on this URL which will take you to the recommendations online in the IJS: http://journals.sagepub.com/doi/pdf/10.1177/1747493016643553

For the French version of these recommendations, open the appendix at this link :  http://wso.sagepub.com/content/suppl/2016/04/18/1747493016643553.DC1/Stroke_Rehabilitation_2015_IJS_Manuscript_FINAL_FRENCH.pdf

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through www.strokebestpractices.ca, and not through the IJS.  Please click on the appropriate sections on our website below for this additional content.

 

Rationale

There is strong and compelling evidence in favour of admitting patients with moderate and severe stroke to a geographically defined stroke rehabilitation unit staffed by an interprofessional team. Death and disability are reduced when post-acute stroke patients receive coordinated, interprofessional evaluation and intervention on a stroke rehabilitation unit. For every 100 patients receiving organized inpatient interprofessional rehabilitation, an extra five return home in an independent state (Stroke Unit Trialists’ Collaboration, 1997).

 

 

 

System Implications

To ensure patients receive best practice stroke rehabilitation care, health systems funders and organizations must plan for:

  • Timely access to specialized inpatient stroke rehabilitation services.
  • An adequate number of geographically defined stroke rehabilitation units with a critical mass of trained staff with expertise in stroke rehabilitation; interprofessional team care during the rehabilitation period following stroke.
  • Resources to enable patient access to appropriate type and intensity of rehabilitation professionals throughout their stay (including weekends when required).
  • Protocols and strategies to prevent complications and the recurrence of stroke developed and communicated to all staff.
  • System and process changes to allow therapists to ensure effective therapist to patient rations in rehabilitation settings, with the goal of therapists spending approximately 80% of their time providing direct care to patients.

 

 

 

 

Performance Measures

  1. Number of stroke patients treated in a geographically defined stroke rehabilitation unit at any time during their inpatient rehabilitation phase following an acute stroke event (core).
  2. 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 requiring readmission to an acute care hospital for stroke-related causes; percentage of patients discharged back to the community who were residing in a community setting prior to their stroke (core).
  3. Number of stroke patients assessed by a physiotherapist, occupational therapist, speech–language pathologist, dietitian, and social workers during inpatient rehabilitation.
  4. Proportion of total time during inpatient rehabilitation following an acute stroke event that is spent on a stroke rehabilitation unit.
  5. Frequency, duration and intensity of therapies received from rehabilitation professionals while in an inpatient rehabilitation setting following stroke.
  6. Change in functional status measured with a standardized measurement tool, from time of admission to an inpatient rehabilitation unit for stroke patients to the time of discharge.

Measurement Notes

  • Performance measure 1: The denominator should be the total number of stroke patients admitted to inpatient rehabilitation.
  • Performance measure 2: Data should be correlated with stroke severity scores during analysis.
  • To determine the duration and intensity of services by rehabilitation professionals, a chart review is required or the availability of consistent use of reliable workload measurement tools that are implemented locally or regionally.

 

 

 

 

Implementation Resources and Knowledge Transfer Tools

Health Care Provider Information

Patient Information

 

 

 

 

Summary of the Evidence

Evidence Table 2: Stroke Rehabilitation Unit Care

The benefits of stroke unit care are substantial, both in terms of improving activities of daily living and reducing disabilities (Zhang et al. 2014). As compared to general rehabilitation units, coordinated and organized rehabilitation care in a stroke unit has been shown to reduce mortality and hospital length of stay and to increase functional independence and quality of life (Stroke Unit Trialists’ Collaboration, 2013; Foley et al., 2007). Within a stroke unit, 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 (Stroke Unit Trialists’ Collaboration, 2013; Foley et al. 2013; Zhang et al. 2014; Saposnik et al. 2011), and often within a geographically defined space (Langhorne & Pollock, 2002). Stroke units also typically include staff members who have a specialist interest in stroke, participate in routine team meetings and continuing education/training, and involve caregivers in the rehabilitation process (Langhorne & Pollock, 2002). In addition to professional services rendered, it is encouraged that patients and their caregivers alike engage in early active involvement in the rehabilitation process (Scottish Intercollegiate Guidelines Network, 2010).

The Stroke Unit Trialists’ Collaboration identified 28 randomized and quasi-randomized trials (n=5,855) comparing stroke unit care with an alternative, less organized form of care (e.g., general medical ward) (Stroke Unit Trialists’ Collaboration, 2013). At a median one-year follow-up, stroke unit care was associated with a significant reduction in death (OR=0.76, 95% CI 0.66 to 0.88, p=0.0001), death or institutionalization (OR=0.76, 95% CI 0.67 to 0.86, p=0.0001), and death or dependency (OR=0.80, 95% CI 0.67 to 0.97, p<0.00001), as compared to an alternative form of care. Moreover, stroke unit care was found to be beneficial regardless of sex, age, or stroke severity, with benefits maintained in follow-up studies 5-10 years post-stroke (Stroke Unit Trialists’ Collaboration, 2013).

Seenan and colleagues identified 25 (n=42,236) observational studies to explore the benefits of stroke unit care in clinical practice (Seenan et al., 2007). As in pooled analyses of clinical trials, stroke unit care provided in clinical practice was found to be associated with a significant reduction in the 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; I2=45.5%) within one-year of stroke. Similar findings were reported for a secondary analysis limited to multi-centered trials (OR=0.82, 95% CI 0.77 to 0.87, p<0.001; I2=0%) (Seenan et al., 2007).

In another systematic review and meta-analysis, Foley and colleagues identified 14 trials comparing stroke unit care to conventional care (Foley et al., 2007). Included studies were categorized on the basis of the model of care provided (i.e., acute care, combined acute/rehabilitation, or rehabilitation). Based on the pooled results of 5 studies, post-acute rehabilitation stroke units were found to be associated with reduced odds of death (OR=0.60, 95% CI 0.44 to 0.81, p<0.05) and death or dependency (OR=0.63, 95% CI 0.48 to 0.83, p<0.05). Similar findings were reported with respect to combined acute/rehabilitation stroke units (death: OR=0.71, 95% CI 0.54 to 0.94; death/dependency: OR=0.50, 95% CI 0.39 to 0.65). Although Foley et al. (2007) reported that stroke rehabilitation units do not have a significant impact on length of stay (weighted mean difference=-13.2, 95% CI -48.3 to 21.9, p>0.05), there is evidence that patients with moderately severe strokes treated in stroke rehabilitation units are more likely to be discharged home (75% v. 52%, p<0.001) and are less likely to require institutionalization (22% vs. 44%, p<0.001) (Kalra et al. 1993).