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NEW Stroke Rehabilitation Planning for Optimal Care Delivery
NEW Stroke Rehabilitation Planning for Optimal Care Delivery

1. Initial Stroke Rehabilitation Screening and Assessment

Note

These recommendations apply in inpatient and outpatient settings.

Recommendations and/or Clinical Considerations

1.0 All individuals with acute stroke should be assessed to determine the severity of stroke and early rehabilitation needs [Strong recommendation; Moderate quality of evidence].

  1. All individuals admitted to hospital with acute stroke should have an initial assessment, conducted by rehabilitation professionals, as soon as possible after admission [Strong recommendation; High quality of evidence]. 
    1. The core rehabilitation professional team should include physicians (i.e., physiatrist, neurologist, or other physicians with training in stroke rehabilitation), nurses, physiotherapists, occupational therapists, speech-language pathologists, social workers, and dietitians [Strong recommendation; High quality of evidence]. The individual with stroke, their family and caregivers should also be included as part of the core team [Strong recommendation; Moderate quality of evidence].
    2. Additional team members may include recreation therapists, psychologists, vocational therapists, kinesiologists, rehabilitation therapy assistants, vision specialists, and pharmacists [Strong recommendation; Low quality of evidence].
    3. All professional members of the rehabilitation team should have specialized training in stroke care and recovery [Strong recommendation; High quality of evidence].
    4. All professional team members should be trained in supported conversation to be able to interact with individuals with communication limitations such as aphasia [Strong recommendation; Moderate quality of evidence]. 
  2. Initial screening and assessment should ideally be commenced within 48 hours of admission by rehabilitation professionals in direct contact with the individual with stroke [Strong recommendation; Moderate quality of evidence]. 
    1. Initial assessment may include: an evaluation of an individual with stroke’s function, safety, physical, psychological and cognitive readiness, and ability to learn and participate in rehabilitation therapies [Strong recommendation; Low quality of evidence]. 
    2. Transition planning should be considered during the initial rehabilitation assessment [Strong recommendation; Moderate quality of evidence]. 
  3. Assessment of impairments, functional activity limitations, role participation restrictions and environmental factors should be conducted using standardized, valid assessment tools [Strong recommendation; Moderate quality of evidence].
    1. Assessment tools should be adapted for use with individuals who have communication differences or limitations where required [Strong recommendation; Moderate quality of evidence]. 
    2. Other limitations should also be taken into consideration, such as impaired vision, hearing and communication [Strong recommendation; Low quality of evidence].  
  4. For individuals with stroke who do not initially meet criteria for rehabilitation services, reassessment of rehabilitation needs should be considered as indicated by changes in health or functional status [Strong recommendation; Low quality of evidence]. Refer to Box 1 for additional information. 
  5. All individuals with stroke who present with acute stroke or TIA who are not admitted to hospital should be screened for the need to undergo a comprehensive rehabilitation assessment to determine the scope of deficits from index stroke event and any potential rehabilitation requirements [Strong recommendation; Low quality of evidence]. 
    1. Priority screening areas, including evaluation of safety (cognition, fitness to drive, social support), swallowing, communication, and mobility, should be completed by a clinician with expertise in stroke rehabilitation where feasible before the individual with stroke leaves the emergency department or in the primary care setting [Strong recommendation; Low quality of evidence]. Refer to CSBPR Secondary Prevention of Stroke module.13
    2. Additional screening of impairments, including onset of depression, cognitive changes, visual and other perceptual impairment, functional activity limitations, role participation restrictions, social and environmental factors and the presence of modifiable stroke risk factors (such as lifestyle behaviours) should be considered as soon as possible, and at least within two weeks of stroke onset [Strong recommendation; Low quality of evidence]. 
  6. Once an individual with stroke has undergone assessment, a standardized approach is recommended to determine the appropriate setting for rehabilitation (including inpatient rehabilitation, outpatient and community-based rehabilitation, and home-based rehabilitation.) [Strong recommendation; Low quality of evidence]. 
    1. Standardized criteria for admission to any rehabilitation setting is ideally communicated to all referring centres and services [Strong recommendation; Low quality of evidence]. Refer to Box 1 for Eligibility and Admission criteria for stroke rehabilitation.
Rationale +-

Early rehabilitation assessment is vital to evaluate specific functional impairments resulting from stroke, such as mobility, speech, cognitive, or swallowing difficulties. By identifying these deficits early, clinicians can create a personalized rehabilitation plan that targets individual needs. Early assessment also helps to inform decision making regarding the level of rehabilitation services that will likely we required following discharge from an acute care service and can also aid in the process of discharge planning from acute care, regardless of the eventual discharge destination. For individuals with stroke who do not initially meet the criteria for inpatient rehabilitation, both ongoing reassessments are appropriate referrals to other services are important to ensure post-stroke rehabilitation needs and goals are optimized.

Individuals with stroke stressed that access to rehabilitation screening and assessment should be provided to all individuals who experience a stroke. The first few days or weeks in the hospital after experiencing a stroke can be confusing and overwhelming, and individuals with stroke valued the opportunity to ask questions to healthcare providers during initial assessments, as well as when healthcare providers communicated with the family early on following stroke, with appropriate consent. 

Individuals with stroke, their families and caregivers face challenges in advocating for themselves as well as retaining information during the initial period following stroke, especially when speech and sensory function is affected by the stroke. They valued receiving information in multiple formats – written and verbal - as well as information being repeated.

System Implications +-

To ensure that individuals who experience stroke receive timely stroke rehabilitation assessments, interventions and management, interdisciplinary teams need to have the education, infrastructure and resources required. These may include the following components established at a systems level:

  1. An adequate complement of interdisciplinary healthcare providers with training and experience in stroke and stroke rehabilitation.
  2. A process for timely referral to specialized stroke inpatient services in all centres (e.g., electronic referral system and standardized assessment tools).
  3. Availability and accessibility of the appropriate type and level of rehabilitation services and resources across geographic regions, including inpatient rehabilitation, outpatient and community-based rehabilitation, and home-based rehabilitation (including in supportive living). 
  4. Availability of early supported discharge (ESD) programs and criteria for the individual with stroke who is an appropriate candidate.
  5. A clear efficient referral process for individuals with stroke to access rehabilitation professionals and programs after acute management, and if not acutely admitted, from community settings such as primary care.
  6. Standards for time from receipt of referral to decision regarding intake to rehabilitation (suggest 24-48 hours).
  7. Rehabilitation professionals knowledgeable about stroke should be responsible for reviewing intake applications.
  8. Processes in place to ensure family members and caregivers are included as part of the rehabilitation process, including decisions regarding type and location of rehabilitation where appropriate and with the individual with stroke’s consent.
  9. An interdisciplinary team that is resourced to provide prescribed levels of rehabilitation therapy.
  10. A defined geographic area or unit where individuals with stroke are assured access to an experienced team.
  11. Standardized, validated, and expert consensus-based screening assessment tools and training.
  12. Access to a follow-up clinic for secondary stroke prevention to ensure assessment of mild stroke-related difficulties and referral to rehabilitation services and programs when deficits and issues are identified that are amenable to rehabilitation. 
  13. Mechanisms to reevaluate individuals who do not initially meet criteria for rehabilitation to ensure that they have access to rehabilitation as appropriate, if the individual with stroke meets defined rehabilitation criteria.
  14. Mechanisms to periodically re-evaluate those individuals who are admitted to long-term care, complex continuing care, or other settings to ensure that they have access to rehabilitation as appropriate, if the individual with stroke meets defined rehabilitation criteria.
  15. Coordination and development of strong partnerships in the community, and adequate resources to ensure access to comprehensive stroke rehabilitation. This is especially important in more rural and remote geographic locations where virtual care technologies should be optimized.
Performance Measures +-

System indicators:

  1. Proportion of individuals with stroke who are admitted to inpatient rehabilitation following an acute stroke event.
  2. Proportion of individuals with stroke living in remote communities with access to rehabilitation assessments and therapies to support stroke recovery, both in-person and virtually.
  3. Proportion of individuals with mild, moderate and severe stroke admitted to inpatient or community stroke rehabilitation, by age and sex.
  4. Distribution of discharge disposition locations following inpatient rehabilitation.
  5. 30-day acute ischemic stroke mortality during acute care and or inpatient rehabilitation hospital stay (Aligns to Accreditation Canada).

Process indicators:

  1. Proportion of individuals with stroke with a rehabilitation assessment within 48 hours of hospital admission for acute stroke by at least one stroke rehabilitation specialist, as appropriate to patient needs (aligns to Accreditation Canada).
  2. Median time from hospital admission for stroke to initial rehabilitation assessment for each of the rehabilitation disciplines (Target is within 48 hours of hospital admission).
  3. Proportion of individuals with mild, moderate and severe stroke discharged to the community who receive a referral for outpatient rehabilitation prior to leaving acute and/or inpatient rehabilitation setting (either facility-based or community- based programs).
  4. Median length of time between referral for outpatient rehabilitation to first appointment with the rehabilitation services (Target is within 30 days).
  5. Proportion of individuals with severe stroke reassessed for rehabilitation following initial assessment within one month, 3 months and six months of index stroke event.

Patient-oriented indicators   

  1. Self-reported quality of life at 6 months and one year following stroke (using a validated QoL tool) (ICHOM).
  2. Occurrence of new stroke within 90 days of discharge from stroke admission (ICHOM).
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 or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Healthcare Provider Information

Resources for Individuals with Stroke, Families and Caregivers

Summary of the Evidence +-

Evidence Table and Reference List

Comprehensive assessment of an individual with stroke’s cognitive and functional status conducted within the first few days following a stroke is essential to guide the development of individualized care plans. These assessments should be conducted using a standardized approach with validated tools.  Areas of evaluation should include 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).  

Admission to an interprofessional program should be limited to individuals with stroke who have more than one type of disability and who require the services of two or more rehabilitation disciplines. Individuals with stroke with a single disability can usually benefit from outpatient or community-based services, and generally do not require an interprofessional program. Hakkennes et al. 14 surveyed 14 clinicians responsible for assessing the suitability of individuals with stroke for inpatient rehabilitation. A questionnaire was administered to assess factors that were used to assess an individual with stroke’s suitability for rehabilitation. Potentially relevant items included 15 patient-related factors (e.g. age, pre-morbid mobility) and 2 organization factors (bed availability and funding source). Using data from 8,783 Veterans admitted to a Veterans Affairs Medical Center with a primary diagnosis of stroke, Stineman et al.15 reported that 11.2% of veterans were selected for comprehensive-level rehabilitation. Individuals with stroke at the lowest grades of physical independence and the middle cognitive stages had significantly higher odds of admission to a comprehensive rehabilitation unit. Other independent factors associated with higher odds of admission for comprehensive rehabilitation included patients who were age <70 years, married, living at home pre-stroke and the presence of a comprehensive rehabilitation unit at admitting hospital. In the CERISE study,16 consultants were surveyed to identify medical and nonmedical factors that influenced the decision to admit an individual with stroke for stroke rehabilitation. The presence of pre-morbid cognitive disability, depression and severe behavioral problems were identified as factors reduced the likelihood of admission.

Sex & Gender Considerations

Although no literature exists on the topic, an effective initial assessment should consider the sex- and gender-related differences to tailor rehabilitation interventions appropriately, ensuring that both physical and psychological aspects of recovery are addressed in an individualized manner.

Stroke Resources
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