Previous Section 1. Initial Stroke Rehabilitation Screening and Assessment Next Section 3. Delivery of Inpatient Stroke Rehabilitation
NEW Stroke Rehabilitation Planning for Optimal Care Delivery
NEW Stroke Rehabilitation Planning for Optimal Care Delivery

2. Stroke Rehabilitation Unit

Note

Applicable for all stroke rehabilitation settings (acute care hospital, inpatient rehabilitation, outpatient clinic, community-based services and programs, including long-term and complex continuing care settings).

Recommendations and/or Clinical Considerations
2.1 Stroke Rehabilitation Team
  1. Stroke rehabilitation should be delivered by an interdisciplinary team of health professionals, with expertise and training in providing post-stroke care, regardless of where services are provided, to ensure consistency, promote optimal recovery, and reduce the risk of complications [Strong recommendation; Moderate quality of evidence]. 
  2. The interdisciplinary rehabilitation team should assess individuals with stroke within 48 hours of admission and together with the individual and their family develop and document a comprehensive individualized rehabilitation plan which reflects the severity of the stroke, the needs and goals of the individual, the best available research evidence, and clinical judgment [Strong recommendation; Low quality of evidence].
  3. Stroke unit teams should conduct at least one formal interdisciplinary meeting per week to identify ongoing or new rehabilitation problems, set goals, monitor progress, and plan discharge for individuals with stroke on the unit [Strong recommendation; Moderate quality of evidence]. 
  4. Individualized rehabilitation plans should be regularly updated based on review of health status and stroke recovery progress [Strong recommendation; Low quality of evidence]. 
  5. Clinicians should use standardized, valid assessment tools when appropriate to support treatment and care planning [Strong recommendation; Low quality of evidence].
  6. Verbal and written information should be tailored to the individual’s cognitive, sensory, and communication abilities [Strong recommendation; Moderate quality of evidence]. Refer to Knowledge Translation and Implementation Resource sections and Stroke Engine for additional information on Stroke Rehabilitation Screening and Assessment Tools.
2.2 Stroke Rehabilitation Unit
  1. All individuals who require inpatient rehabilitation following stroke should be treated on a specialized stroke rehabilitation unit [Strong recommendation; High quality of evidence], characterized by the following elements: 
    1. Rehabilitation care is formally coordinated and organized [Strong recommendation; High quality of evidence]. 
    2. The rehabilitation unit is geographically defined [Strong recommendation; High quality of evidence]. 
    3. The rehabilitation unit is staffed by an interdisciplinary rehabilitation team with expertise/core training in stroke rehabilitation consisting of 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].   
    4. Additional members of the interdisciplinary team may include pharmacists, stroke navigators, neuropsychologists, psychologists, palliative care specialists, recreation therapists, vocational therapists, kinesiologists, rehabilitation therapy assistants, spiritual care providers, vision specialists, sexual health specialists, music or art therapists, peer supporters, stroke recovery group liaisons, and other consulting services based on individual needs [Strong recommendation; Low quality of evidence]. 
    5. Individuals who have experienced a stroke, their families and caregivers should have early and active involvement in the rehabilitation process [Strong recommendation; Moderate quality of evidence]. 
    6. Transition and discharge planning should be initiated on admission to the unit [Strong Recommendation; Low quality of evidence]. Refer to Section 7 for additional information on care planning. 
    7. Education for individuals with stroke, their families and caregivers, is an integral part of stroke rehabilitation care that should be included throughout rehabilitation interactions [Strong recommendation; High quality of evidence].  Refer to the CSBPR Stroke Systems of Care module, Section 5 for additional information on education following stroke.
    8. All team members should be trained and capable of interacting with individuals with communication limitations such as aphasia, by using supported conversation techniques [Strong recommendation; Moderate quality of evidence]. Refer to Part Two, Section 7 Language and Communication for additional information.
  2. Individuals who have experienced a moderate or severe stroke, who are ready for rehabilitation and have goals amenable to rehabilitation, should be given an opportunity to participate in inpatient stroke rehabilitation [Strong recommendation; High quality of evidence]. 
  3. Where admission to a dedicated stroke rehabilitation unit is not possible, inpatient rehabilitation provided on a general rehabilitation unit should be considered as an alternative (i.e., where interdisciplinary care is provided to individuals with stroke disabled by a range of disorders including stroke) [Strong recommendation; Low quality of evidence].
    1. Individuals with stroke treated on general rehabilitation units should receive equivalent rehabilitation intensity and principles as individuals treated on dedicated stroke rehabilitation units, as described in section 3 [Strong recommendation; Moderate quality of evidence].

Section 2.2 Clinical Considerations

  1. Considering the high prevalence of comorbidities and complex medical needs in individuals with stroke, team members should incorporate the use of healthcare professionals who can manage the medical needs of individuals undergoing stroke rehabilitation. 
Rationale +-

There is a large and rigorous body of evidence to indicate that individuals who have sustained a stroke with residual impairment and disability will experience a better outcome if admitted to a specialized stroke rehabilitation unit or facility, as soon as they are “rehab ready”. Data from the latest update of the Stroke Unit Trialists 17 indicate that at 12 months, an extra two people are estimated to survive for every 100 receiving stroke unit care, an extra 6 will be living at home, and an extra 6 will be independent in daily activities. Key elements of a stroke rehabilitation unit include a geographically defined space or beds, which is staffed by an interdisciplinary team, whose practice is dominated by individuals recovering from stroke. 

Individuals with stroke spoke to the importance of access to a specialized stroke rehabilitation unit with a dedicated stroke rehabilitation team with expertise and training in providing stroke care. If admission to a dedicated stroke rehabilitation unit is not possible, they felt strongly that individuals with stroke should still have access to stroke rehabilitation and recovery that is equivalent to the care received on a specialized stroke rehabilitation unit. They also spoke to the importance of an interdisciplinary team, and communication and collaboration between healthcare team members to ensure their care was coordinated and seamless. They highlighted the importance of clear information and education, including information on the role of each healthcare team member and who to go to for questions, and the importance of information privacy and sensitivity.

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. Timely access to specialized inpatient stroke rehabilitation services.
  2. An adequate number of geographically defined stroke rehabilitation units with a critical mass of trained staff with expertise in stroke rehabilitation interdisciplinary team care during the rehabilitation period following stroke.
  3. Resources to enable the individual with stroke access to appropriate type and intensity of rehabilitation professionals throughout their stay (including weekends when required).
  4. Referral process in place to connect individual with stroke, family and caregivers to appropriate support services such as the local Indigenous Health Office, if available.
  5. To prevent complications and the recurrence of stroke, protocols and strategies should be developed and communicated to all staff.
  6. System and process changes to enable therapists to ensure effective therapist-to-individual with stroke ratios in rehabilitation settings, with the goal of therapists spending approximately 80% of their time providing direct care to individuals with stroke. 
  7. Processes in place to monitor, review and update rehabilitation goals and initiation of discharge planning, ensuring flexibility and adaptability.
  8. The interdisciplinary rehabilitation team and health systems leaders and planners should follow evidence-based best practices as defined by current consensus-based clinical practice guidelines.
Performance Measures +-

System indicators:

  1. [Access] Proportion of individuals with acute stroke transferred from acute inpatient unit to rehabilitation inpatient unit (aligns to Accreditation Canada).
  2. Proportion of individuals within a stroke region who access an inpatient stroke rehabilitation unit as part of their episode of care for a stroke event.
  3. Median length of time from stroke rehabilitation referral to and admission to stroke inpatient rehabilitation.
  4. Proportion of individuals with stroke who are discharged from acute care without rehabilitation referrals in place.
  5. Number or proportion of individuals with stroke admitted to a stroke unit — either a combined acute care and rehabilitation unit or a rehabilitation stroke unit in an inpatient rehabilitation facility — at any time during their hospital stay (acute and/or rehabilitation).

Process indicators:

  1. Number of individuals with stroke assessed by each of the following disciplines during inpatient rehabilitation: physiatrist, physiotherapist, occupational therapist, speech–language pathologist, dietitian, psychologist and social worker.
  2. Proportion of individuals with stroke requiring readmission to an acute care hospital for stroke-related causes during inpatient rehabilitation. 
  3. Proportion of total time spent on a stroke rehabilitation unit during inpatient stay for stroke rehabilitation.
  4. Frequency and duration of each therapy received from rehabilitation professionals while in an inpatient rehabilitation setting following stroke.
  5. Median total number of days spent in inpatient rehabilitation, by stroke type.
  6. Median active and total length of stay on an inpatient stroke rehabilitation unit (aligns with Accreditation Canada).
  7. Final discharge disposition for individuals with stroke following inpatient rehabilitation: 
    1. proportion discharged to their original place of residence prior to stroke (including those residing in LTC prior to stroke);
    2. proportion discharged to a long-term care facility or nursing home; 
    3. proportion requiring readmission to an acute care hospital for stroke-related and non-stroke related causes; 
    4. proportion of individuals with stroke discharged back to the community who were residing in a community setting prior to their stroke (excluding those residing in LTC prior to stroke). 

Patient-oriented indicators:   

  1. Change in functional status measured with a standardized measurement tool, from time of admission to an inpatient rehabilitation unit for individuals with stroke to the time of discharge.
  2. Self-reported quality of life at 6 months and one year following stroke (using a validated QoL tool) (ICHOM).
  3. Report 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

It is now well-established that individuals with stroke who receive stroke unit care are more likely to survive, return home, and regain independence compared to individuals who receive less organized forms of care. Stroke unit care is characterized by an experienced interprofessional stroke team, including physicians, nurses, physiotherapists, occupational therapists, and speech therapists, among others, dedicated to the management of individuals 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.

In an updated 2020 Cochrane Review, the Stroke Unit Trialists’ Collaboration17 identified 29 randomized and quasi-randomized trials (n=5,902) comparing stroke unit care with alternative, less organized care (general medical wards, mixed rehabilitation ward and a mobile stroke team). In this update, a single trial with 49 participants was added since the last update in 2013. The inclusion of a network meta-analysis (NMA) is also featured in this update. Twenty-three trials incorporated rehabilitation lasting several weeks, if required; 17 of these units admitted participants acutely, and 8 after a delay of one or two weeks. Overall, compared with alternative services, stroke units were associated with significant reductions, ranging from 23% to 25%, in the odds of a poor outcome (mRS 3-6 at the end of follow-up or the need for institutional care), death, death or institutional care, and death or disability, all of which were supported by moderate quality of evidence.  At 12 months, an extra two people are estimated to survive for every 100 receiving stroke unit care, an extra 6 will be living at home, and an extra 6 will be independent in daily activities. The benefit of stroke unit care was independent of sex, age stroke type and severity. In the NMA, compared with a general ward, the odds of a poor outcome were reduced significantly with a stroke unit (Odds Ratio [OR]=0.74, 95% CI 0.62-0.89), and mixed rehab ward (OR=0.70, 95% CI 0.52-0.95), but not compared with a mobile stroke team (OR=0.88, 95% CI 0.58-1.34). For the outcome of death at the end of scheduled follow-up, only a stroke ward was associated with a significant reduction (OR=0.62, 95% CI 0.47-0.82) compared with a general ward. Given that this review has been updated several times since 1997 with largely similar conclusions and there are few new trials being published, the focus of future research may shift to the examination of specific components of care or care process whereby stroke unit care is superior to other models. 

To determine if the benefits of stroke unit care demonstrated in clinical trials can be replicated in routine clinical practice, Seenan et al.19 conducted a systematic review of 25 observational studies (n=42,236) comparing stroke unit care to non-stroke unit care. In most cases, studies compared acute stroke units with conventional 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 one-year of stroke. Similar findings were reported for the outcome of death at one year in a secondary analysis limited to multi-centered trials (OR=0.82, 95% CI 0.77 to 0.87, p<0.001).

Sex & Gender Considerations

In the Stroke Unit Trialists’ Collaboration (SUTC) 2020 Cochrane review,17 the benefits of receiving care on a stroke rehabilitation unit were found to be independent of sex, age stroke type and severity.

Stroke Resources
Previous Section 1. Initial Stroke Rehabilitation Screening and Assessment Next Section 3. Delivery of Inpatient Stroke Rehabilitation