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NEW Acute Stroke Management

8. Acute Stroke Unit Care

2022 update

Recommendations and/or Clinical Considerations
8.1 Recommendations

8.1 Patients admitted to hospital with an acute stroke or transient ischemic attack (TIA) should be treated on an inpatient stroke unit [Strong recommendation; High quality of evidence] as soon as possible; ideally within 24 hours of hospital arrival [Strong recommendation; Low quality of evidence]. 

  1. All efforts should be made to admit patients to an acute stroke unit, which is a specialized, geographically defined hospital unit dedicated to the management of patients with stroke [Strong recommendation; High quality of evidence].
    1. Facilities without a dedicated stroke unit must strive to focus care on the priority elements for comprehensive stroke care delivery, including clustering patients, having an interdisciplinary team, providing access to early rehabilitation, using stroke care protocols, conducting case rounds, and providing patient education [Strong recommendation; Moderate quality of evidence]. 

      Note: Stroke unit care is the gold standard for care following acute stroke. Alternate models may be discussed with system planners and should only be considered if it is not possible to create or access a stroke unit. Refer to Box 8A Optimal Acute Inpatient Stroke Care for additional information. 
  2. The core interdisciplinary stroke team should consist of healthcare professionals with stroke expertise including physicians, nurses, occupational therapists, physiotherapists, speech-language pathologists, social workers, dietitians, patients, and family members [Strong recommendation; High quality of evidence], who are ideally available seven days a week [Strong recommendation; Low quality of evidence]. 
    1. All interdisciplinary stroke teams should include hospital pharmacists to promote patient safety; conduct medication reconciliation; provide education to the team and patients and families about medications and their side effects, adverse effects, and interactions; promote adherence; and participate in discharge planning which could include addressing special needs for patients, such as individual dosing packages [Strong recommendation; Moderate quality of evidence].
    2. Additional members of the interdisciplinary team may include discharge planners or case managers, (neuro)psychologists, palliative care specialists, recreation and vocational therapists, spiritual care providers, peer supporters, and stroke recovery group liaisons [Strong recommendation; Moderate quality of evidence]. 
    3. The patient and family should be included as part of the core team [Strong recommendation; Low quality of evidence]. 
    4. All professional members of the interdisciplinary stroke team should have specialized training in stroke care and recovery [Strong recommendation; Moderate quality of evidence]. 
  3. The interdisciplinary stroke team should assess all patients as soon as possible after admission to hospital, and ideally within 48 hours, and formulate a management plan [Strong recommendation; High quality of evidence].
  4. Assessments of impairment, functional activity limitations, role participation restrictions, and environmental factors should be conducted using standardized, valid assessment tools [Strong recommendation; Moderate quality of evidence].
    1. Patients should be assessed for areas such as dysphagia, mood and cognition, mobility, functional assessment, temperature, nutrition, bowel and bladder function, skin breakdown, vision, apraxia, neglect, and perception [Strong recommendation; Moderate quality of evidence]. Refer to Section 9 Inpatient Prevention and Management of Complications Following Stroke for additional information.
    2. Patients should have a formal and individualized assessment to determine the type of ongoing post-acute rehabilitation services they require as soon as their status has stabilized, and within the first 72 hours post-stroke, using a standardized protocol [Strong recommendation; Moderate quality of evidence]. Refer to CSBPR Rehabilitation and Recovery Following Stroke module Section 3 for additional information.
    3. Tools should be adapted for use with patients who have communication differences or limitations as required [Strong recommendation; Moderate quality of evidence]. 
  5. Discharge planning discussions, prevention therapies, and venous thromboembolism prophylaxis should be initiated soon after arrival on the acute stroke unit [Strong recommendation; Moderate quality of evidence]. Refer to Section 9 Inpatient Prevention and Management of Complications Following Stroke for additional information.
8.2 Management of Stroke Occurring While Patient is Already in Hospital
  1. Patients who experience onset of signs and symptoms of a new acute stroke while already in hospital should have an immediate assessment by a physician with stroke expertise, undergo neurovascular imaging without delay, and be assessed for eligibility for intravenous thrombolytics and/or endovascular thrombectomy [Strong recommendation; Moderate quality of evidence]. Refer to Section 4 Emergency Department Evaluation and Management of Patients with TIA and Acute Stroke, and Section 5 Acute Ischemic Stroke Treatment, for additional information.
  2. All hospitals should have protocols to manage acute inpatient stroke, and all staff should be familiar with these protocols, especially in units with higher risk patients [Strong recommendation; Moderate quality of evidence].
8.3 Virtual Inpatient Stroke Care
  1. Virtual stroke care modalities should be considered to support optimal in-hospital stroke care when patients cannot be transferred to an acute stroke unit (i.e., virtual stroke unit care) including support for medical decision-making and rehabilitation treatment [Conditional recommendation; Low quality of evidence]. Refer to the CSBPR Virtual Stroke Care Implementation Toolkit for additional information.
  2. Virtual care technology should be available to provide education to admitted patients and to staff working with patients, and to allow patients to access programs available at other locations if not available on-site, when safe to do so [Conditional recommendation; Low quality of evidence].
Rationale +-

Stroke unit care is characterized by a coordinated interdisciplinary team comprising physicians, nurses, physiotherapists, occupational therapists, speech- language pathologists, and pharmacists, among others. They have a special interest and expertise in stroke care and are dedicated to the management of patients recovering from stroke. Staff on these units tend to have greater expertise, better nursing care is provided, and patients are mobilized sooner. As a result, patients treated on stroke units experience fewer complications and receive rehabilitation therapies earlier. Typically, patients have better outcomes compared with those treated on less specialized units. Stroke unit care is associated with reductions in the likelihood of death, death and disability, and death or the need for institutionalization by approximately 25%. For every 100 participants receiving care on a stroke unit, there would be 2 extra people who survived, 6 more living at home, and 6 more living independently (SUTC, Cochrane Database of Systematic Reviews 2020, Issue 4. Art. No.: CD000197).

People with lived experience expressed the value of including family and other caregivers as early as possible in helping the person with stroke through their recovery process. They provided examples such as having a list or cheat sheet of activities that families and caregivers can complete with the person with stroke, as a way to provide support. 

People with lived experience valued the ability to be aware of and track the stroke patient’s progress while the patient was on the acute stroke unit. They discussed that at times, patients may not realize the progress they’ve made, particularly when spending more time in bed and potentially losing track of days. They shared instances where family members, informal caregivers, and healthcare providers provided this type of support by using videos, notes, and voice memos to document and communicate the patient’s progress. 

People with lived experience also discussed their experience transitioning from acute care to another setting. They valued being a part of the conversation and receiving explanations about transition planning out of acute care and understanding their transition date plan. Recognizing that transitions can look very different depending on the person’s circumstances, people with lived experience stressed the importance of having healthcare providers explain available services to support their recovery, regardless of transition destination, as well as the importance of receiving education and preparation about the transition plan, including next steps such as rehabilitation, stroke prevention clinic, and activities that can be done while wait for rehabilitation. While people with lived experience emphasized the value in having someone in the role of a stroke patient navigator and/or care coordinator, to support the patient and their family throughout their journey, they recognized that this is not always available.

System Implications +-

To ensure people experiencing a stroke receive timely stroke assessments, interventions and management, interdisciplinary teams need to have the infrastructure and resources required. These may include the following components established at a systems level.

  1. Organized systems of stroke care including stroke units with a critical mass of trained staff (interdisciplinary team). Availability of Health Human Resources to appropriately staff stroke units and provide recommended best practice service (e.g., 7 days/week) and promote optimal outcomes. 
  2. Protocols and mechanisms to enable the rapid transfer of patients with stroke from the emergency department to a specialized stroke unit as soon as possible after arrival in hospital, ideally within the first six hours.
  3. Comprehensive and advanced stroke care centres with leadership roles within their geographic regions, to ensure specialized stroke care access is available to patients who may first appear at general healthcare facilities (usually remote or rural centres) and facilities with basic stroke services only.
  4. Telestroke service infrastructure and utilization optimized to ensure access to specialized stroke care across the continuum to meet individual needs (including access to rehabilitation and stroke specialists) including the needs of northern, rural, and remote residents in Canada.
  5. Information on geographic location of stroke units, rehabilitation, and home care services, 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.
  6. Efforts to facilitate building and maintaining of stroke expertise among staff to provide appropriate and evidence-based best practice care to patients with stroke. The interprofessional healthcare team members should have stroke-specific knowledge, skills, and expertise, and access regular education to maintain competency. 
Performance Measures +-

System Indicators:

  1. Proportion of designated stroke unit beds that are filled with patients with stroke (weekly average).
  2. Percentage increase in virtual stroke care coverage to remote communities to support organized stroke care across the continuum.

Process Indicators:

  1. Number of patients with stroke who are admitted to hospital and treated on a specialized stroke unit at any time during their inpatient hospital stay for an acute stroke event (numerator) as a percentage of total number of patients with stroke admitted to hospital. 
  2. Proportion of patients admitted to the stroke unit who arrive in the stroke unit within 24 hours of emergency department arrival.
  3. Proportion of patients admitted to the stroke unit who have a rehabilitation assessment within 48 hours of admission.
  4. Proportion of patients with stroke discharged to their home or previous place of residence following an inpatient admission for stroke. 
  5. Proportion of patients with stroke discharged to inpatient rehabilitation following an inpatient admission for stroke. 
  6. Proportion of total time in hospital for an acute stroke event that is spent on an acute stroke unit.
  7. Length of stay for patients with stroke admitted to hospital.

Patient-oriented outcome and experience indicators:

  1. Proportion of patients with stroke who die in hospital within 7 days and within 30 days of hospital admission for an index stroke (reported by stroke type).
  2. Functional outcome scores at 30 and 90 days following acute hospital discharge, using validated tools, for patients with stroke treated on an acute stroke unit compared to those not treated on an acute stroke unit.

    Refer to Canadian Stroke Quality and Performance Measurement Manual for detailed indicator definitions and calculation formulas.

Measurement Notes

  1. Calculate for all cases, and then stratify by type of stroke where appropriate.
  2. Definition of stroke unit varies among institutions. Where stroke units do not meet the criteria defined in the Section 8 recommendations; 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 patients with stroke are clustered; (c) mobile stroke team care; or (d) managed on a general nursing unit by staff using stroke guidelines and protocols. 
  3. Institutions collecting these data must note their operational definition of “stroke unit” to ensure standardization and validity when data is reported across institutions.
  4. Performance measure 6: Start time for assessing stroke unit admission within 24 hours should be emergency department triage time.
  5. Patient and family experience surveys should be in place to monitor care quality during inpatient stroke admissions.
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices writing group. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Healthcare Provider Information

Information for people with lived experience of stroke, including family, friends and caregivers

Summary of the Evidence +-

Evidence Table and Reference List

Sex and Gender Considerations Reference List

It is well-established that patients who receive stroke unit care are more likely to survive, return home, and regain independence compared to patients who receive less organized forms of care. Stroke unit care is characterized by an experienced interprofessional stroke team, including physicians, nurses, physiotherapists, occupational therapists, speech therapists, among others, who are dedicated to the management of patients with stroke, often located within a geographically defined space. Other features of stroke units include staff members who have an interest in stroke, routine team meetings, continuing education/training, and involvement of caregivers in the rehabilitation process (Langhorne et al., 2020). In an updated Cochrane Review (2020), the Stroke Unit Trialists’ Collaboration identified 29 randomized and quasi-randomized trials (5,902 participants) comparing stroke unit care with alternative, less organized care (e.g., an acute medical ward). Compared to less organized forms of care, stroke unit care was associated with a significant reduction in the odds of death (OR= 0.76, 95% CI 0.66 to 0.88), a poor outcome (OR=0.77, 95% CI 0.69 to 0.87), and death or dependency (OR= 0.75, 95% CI 0.66 to 0.85) at a median follow-up of one year. Based on the results from a small number of trials, the authors also reported that the benefits of stroke unit care are maintained for periods up to 5- and 10-years post-stroke. Moreover, subgroup analyses demonstrated benefits of stroke unit care regardless of sex, age, or stroke severity. Saposnik et al. (2011) investigated the differential impact of stroke unit care on four subtypes of ischemic stroke (cardioembolic, large artery disease, small vessel disease, or other) and reported that stroke unit care was associated with reduced 30-day mortality across all subtypes.

To determine if the benefits of stroke unit care demonstrated in clinical trials can be replicated in routine clinical practice, Seenan et al. (2007) conducted a systematic review of 25 observational studies (n=42,236) comparing stroke unit care to non-stroke unit care. Stroke unit care was associated with a reduction in the risk of death (OR=0.79, 95% CI 0.73 to 0.86, p<0.001) and of death or poor outcome (OR=0.87, 95% CI=0.80 to 0.95; p=0.002) within 1 year of stroke. Similar findings were reported for the outcome of death at one year in a secondary analysis limited to multi-centred trials (OR=0.82, 95% CI 0.77 to 0.87, p<0.001). 

In-hospital Stroke

Estimates of persons who experience a stroke while already hospitalized for other conditions range from 4% to 17% (as cited by Cumbler et al., 2014). Many of these patients have pre-existing stroke risk including hypertension, diabetes, cardiac diseases, and dyslipidemia. These in-hospital strokes often occur following cardiac and orthopedic procedures, usually within 7 days of surgery. There is evidence to suggest that, compared with persons who suffer a stroke in the community, patients who experience an in-hospital stroke have more severe strokes, worse outcomes, and do not receive care in as timely a fashion (Kimura et al., 2006; Farooq et al., 2006). Comparing the outcomes of over 250,000 patients who experienced a stroke with in-hospital (3.0%) or out-of-hospital onset, Akbik et al. (2020) reported patients with in-hospital stroke were significantly less likely to be treated with intravenous thrombolysis within 60 minutes of onset (adjusted OR=0.45, 95% CI, 0.42-0.48), were 22% less likely to be independent ambulators at discharge, and had an increased likelihood of in-hospital mortality or discharge to hospice (adjusted OR= 1.39; 95% CI, 1.29-1.50). Similar treatment delays and outcomes were reported for patients treated for in-hospital stroke with EVT.

Sex and Gender Considerations

In none of the major trials of stroke unit care was sex considered as a potential effect modifier. However, in a systematic review (Carcel et al. 2019) including data from 5 acute randomized controlled trials examining sex differences on stroke outcomes, among the findings was that women were more likely to be admitted a stroke unit (OR=1.17, 95% CI 1.01–1.34), compared with men.

Stroke Resources