5.2.1 Stroke Unit Care
All patients with stroke who are admitted to hospital and who require rehabilitation should be treated in a comprehensive or rehabilitation stroke unit by an interprofessional team [Evidence Level A].
- Post–acute stroke care should be delivered in a setting in which rehabilitation care is formally coordinated and organized [Evidence Level A].
- All patients should be referred to a specialist rehabilitation team on a geographically defined unit as soon as possible after admission [Evidence Level A]. Paediatric acute and rehabilitation stroke care should be provided on a specialized paediatric unit [Evidence Level B].
- The interprofessional rehabilitation team should consist of a physician, nurse, physical therapist, occupational therapist, speech-language pathologist, psychologist, recreation therapist, patient, and family and/or caregivers [Evidence Level A]. For children, this should also include educators and child-life workers. This core interprofessional team should consist of appropriate levels of these disciplines, as identified by the Stroke Unit Trialists’ Collaboration [Evidence Level B].267
5.2.2 For all settings (hospital, clinic, community) where stroke rehabilitation is provided
Post–acute stroke care should be delivered by a variety of treatment disciplines, experienced in providing post-stroke care, to ensure consistency and reduce the risk of complications [Evidence Level C].
- The interprofessional rehabilitation team should assess patients within 24 to 48 hours of admission and develop a comprehensive individualized rehabilitation plan which reflects the severity of the stroke and the needs and goals of the stroke patient [Evidence Level C].
- Patients with moderate or severe stroke who are rehabilitation ready and have rehabilitation goals should be given an opportunity to participate in inpatient stroke rehabilitation [Evidence Level A].
- Stroke unit teams should conduct at least one formal interprofessional meeting per week to discuss the progress and problems, rehabilitation goals and discharge arrangements for patients on the unit [Evidence Level B]. Individualized rehabilitation plans should be regularly updated based on patient status reviews [Evidence Level C].
- Clinicians should use standardized, valid assessment tools to evaluate the patient’s stroke-related impairments and functional status [Evidence Level B].
- Where admission to a stroke rehabilitation unit is not possible, a less optimal solution is inpatient rehabilitation on a mixed rehabilitation unit (i.e., where interprofessional care is provided to patients disabled by a range of disorders including stroke) [Evidence Level B].
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.340 For every 100 patients receiving organized inpatient interprofessional rehabilitation, an extra five returned home in an independent state.340
- Timely access to specialized inpatient stroke rehabilitation services.
- An adequate number of geographically defined stroke units with critical mass of trained staff; interprofessional team care during the rehabilitation period following stroke.
- Stroke rehabilitation units adequately staffed with clinicians with expertise in stroke rehabilitation.
- 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 spend approximately 80 percent of their time with patients.
- 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).
- 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 (core).
- Number of stroke patients assessed by physical therapist, occupational therapist, speech–language pathologist and social workers during inpatient rehabilitation.
- Proportion of total time during inpatient rehabilitation following an acute stroke event that is spent on a stroke rehabilitation unit.
- Frequency, duration and intensity of therapies received from rehabilitation professionals while in an inpatient rehabilitation setting following stroke.
- 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.
- 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.
- Duration and intensity of services by rehabilitation professionals requires a chart review or consistent use of reliable workload measurement tools that are implemented locally or regionally.
- 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.
- Canadian Stroke Strategy Guide to the Implementation of Stroke Unit Care
- National Stroke Nurses Council: Best Practice Nursing Care Across the Acute Stroke Continuum: Module 4
The benefits of this approach are substantial and, compared with a general hospital ward, coordinated and organized rehabilitation care in a stroke unit has been shown to reduce hospitalization length of stay and to increase the stroke patient’s walking mobility, functional status and quality of life. Stroke patients should be admitted early to stroke rehabilitation units as this also enhances functional outcomes.28 Stroke is multifaceted and requires a wide range of rehabilitation health professionals. It is important that rehabilitation beds and resources are protected, to provide sufficient intensity of treatment during the inpatient rehabilitation phase. Mobile stroke teams that do not work in a geographically defined unit do not achieve the same benefits. 357-360 Evidence suggests that a specialized stroke rehabilitation unit is superior to a general rehabilitation unit; however, this may not be possible due to a lack of a critical mass of stroke patients in a smaller hospital.
Langhorne and Duncan conducted a systematic review of a subset of the studies identified by the Stroke Unit Trialists’ Collaboration, those dealing with post-acute rehabilitation stroke services.340 They defined intervention as “organized inpatient interprofessional rehabilitation commencing at least one week after stroke” and sought randomized trials that compared this model of care with an alternative. In a heterogeneous group of nine trials (six involving stroke rehabilitation units and three involving general rehabilitation wards) that recruited a total of 1437 patients, organized inpatient interprofessional rehabilitation was associated with a reduced odds of death (OR 0.66, 95% CI 0.49–0.88; p < 0.01), death or institutionalization (OR 0.70, 95% CI 0.56–0.88; p < 0.001) and death or dependency (OR 0.65, 95% CI 0.50–0.85; p < 0.001), which was consistent across a variety of trial subgroups. This review of post–acute stroke care concluded there could be substantial benefit from organized inpatient interprofessional rehabilitation in the post-acute period, which is both statistically significant and clinically important.
The Stroke Unit Trialists’ Collaboration determined that comprehensive units, rehabilitation stroke units and mixed assessment– rehabilitation units all tended to be more effective than care in a general medical ward.267 Apparent benefits were seen in units with acute admission policies as well as those with delayed admission policies and in units that could offer a period of rehabilitation lasting several weeks. Both the Cochrane review and a subsequent meta-analysis showed that care provided on a dedicated ward is superior to care provided by a mobile stroke team. 340, 352
Teasell and collaborators 28 concluded from another metaanalysis that there is strong (Level A) evidence that combined acute and rehabilitation stroke units are associated with a reduction in the odds of combined death or dependency (OR 0.56), length of stay in hospital and the need for long-term institutionalization (OR 0.55), but not with reductions in mortality alone.
Stroke rehabilitation units, which admit patients from a different ward or facility following acute stroke, help to improve functional outcomes compared with standard care. Based on the results from meta-analyses, there is strong (Level A) evidence that specialized, interprofessional rehabilitation provided in the subacute phase of stroke is associated with reductions in mortality (OR 0.60) and the combined outcome of death or dependency (OR 0.63).28 Patients treated on a stroke rehabilitation unit are more likely to be discharged home and less likely to require institutionalization. Kalra and Eade reported that a larger percentage of patients who were treated in a stroke rehabilitation unit were discharged home (47% v. 19% on a general medical ward, p < 0.01). 353 Kalra and coworkers reported that patients with moderate stroke re receiving stroke unit care were less likely to require long-term care (22% v. 44%).354
A systematic review by the Ottawa Panel showed that stroke unit rehabilitation reduced length of stay and significantly improved functional status (including an increase in the proportion of patients able to walk long distances independently at the end of six weeks of treatment) and enhanced quality of life. 27 That review also showed that stroke unit rehabilitation was superior to home care.
There is strong evidence that subgroups of patients will benefit from subacute rehabilitation in different ways. Patients with more severe strokes have reduced mortality and those with moderate strokes experience improved functional outcomes. 28
The proportions of patients who had experienced death, death or institutionalization, and death or dependency at the end of scheduled follow-up were similar between studies that compared mobile stroke teams with general medical ward care. There was strong evidence that mobile stroke teams do not reduce mortality (OR 1.13, 95% CI 0.83–1.55), the combined outcome of death or dependency (OR 0.97 95% CI 0.72–1.32), the need for institutionalization (OR 1.23, 95% CI 0.70–2.17) or the length of hospital stay (OR 7.0, 95% CI –1.73 to 15.73).28 Patients receiving mobile stroke team care fared significantly poorer than patients who had been managed on a comprehensive stroke unit. Although the total number of patients included in the review was relatively small, the authors concluded that mobile stroke team care did not have a major impact on clinically important outcomes.