1.0 All patients with acute stroke should be assessed to determine the severity of stroke and early rehabilitation needs.
- All patients admitted to hospital with acute stroke should have an initial assessment, conducted by rehabilitation professionals, as soon as possible after admission [Evidence Level A].
- The core rehabilitation professional team should include physiatrists, or other physicians with expertise/core training in stroke rehabilitation, occupational therapists, physiotherapists, speech-language pathologists, nurses, social workers and dietitians [Evidence Level A]. The patient and family are also included as part of the core team [Evidence Level C].
- Additional team members may include recreation therapists, psychologists, vocational therapists, educational therapists, kinesiologists, rehabilitation therapy assistants, and pharmacists. [Evidence level C].
- All professional members of the rehabilitation team should have specialized training in stroke care and recovery [Evidence Level A].
- All professional team members should be trained in supported conversation to be able to interact with patients with communication limitations such as aphasia [Evidence Level B].
- Initial screening and assessment should ideally be commenced within 48 hours of admission by rehabilitation professionals in direct contact with the patient [Evidence Level C].
- Initial assessment may include: an evaluation of patient function, safety, physical readiness, and ability to learn and participate in rehabilitation therapies [Evidence Level C].
- It is reasonable to consider issues related to transition planning during the initial rehabilitation assessment [Evidence Level C].
- Assessments of impairment, functional activity limitations, role participation restrictions and environmental factors should be conducted using standardized, valid assessment tools [Evidence Level B]; tools should be adapted for use with patients who have communication differences or limitations where required [Evidence Level B]. Refer to Table 1: Stroke Rehabilitation Screening and Assessment Tools.
- For patients who do not initially meet criteria for rehabilitation, weekly reassessment of rehabilitation needs may be considered weekly during the first month, and at intervals as indicated by their health status thereafter [Evidence Level C]. Refer to Box One for more information.
- All patients 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 [Evidence level C].
- Priority screening areas, including evaluation of safety (cognition, fitness to drive), swallowing, communication and mobility, should be completed by a clinician with expertise in stroke rehabilitation where feasible before the patients leave the emergency department or in the primary care setting [Evidence Level C]. Refer to CSBPR Secondary Prevention of Stroke module.
- Additional screening of impairments, including onset of depression, cognitive ability, functional activity limitations, role participation restrictions, environmental factors and the presence of modifiable stroke risk factors (such as lifestyle behaviours) should be considered within two weeks of stroke onset [Evidence Level C].
- Once a patient with stroke has undergone assessments, a standardized approach is recommended to determine the appropriate setting for rehabilitation (inpatient, outpatient, community, and/or home-based settings) [Evidence Level C].
- This standardized criteria for admission to any rehabilitation setting is ideally communicated to all referring centres and services [Evidence Level C]. Refer to Box One for key elements of rehabilitation admission criteria
The goal of the first interdisciplinary assessment a patient receives after admission for stroke is to identify impairments in physical, functional, cognitive, and communication functioning which will guide decisions on rehabilitation services and therapies required, and potential discharge needs. Early consultation with rehabilitation professionals enhances the process of discharge planning, whether patients are going to transition from acute care to specialized rehabilitation units or back to the community.
People with stroke express that their experiences with inpatient rehabilitation admission and eligibility assessment reflect what is within these recommendations. However, people with stroke also discuss concerns about the potential for people to be excluded from inpatient rehabilitation based on the criteria presented. It is essential that people with stroke who do not meet the criteria for inpatient rehabilitation are appropriately referred to other services to meet post-stroke rehabilitation needs.
- Proportion of stroke patients 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 (core).
- 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).
- Proportion of acute stroke patients discharged from acute care to inpatient rehabilitation (core).
- Percentage of stroke patients discharged to the community who receive a referral for outpatient rehabilitation before discharge from acute and/or inpatient rehabilitation (either facility-based or community- based programs).
- Median length of time between referral for outpatient rehabilitation and admission to a facility-based or community rehabilitation program.
- Median length of time between referral for outpatient rehabilitation to commencement of therapy (Target is within 30 days).
- Percentage of those patients with severe stroke reassessed for rehabilitation following initial assessment within one month, 3 months and six months of index stroke event.
- Percentage of patients with severe stroke admitted to inpatient rehabilitation (as a change in patterns that may be directly result of implementation of endovascular thrombectomy).
- Percentage of Telehealth/Telestroke coverage to remote communities to support organized stroke care across the continuum, including providing rehabilitation assessments and therapies for stroke patients.
- Number of severe strokes and change in volume potentially as a direct result of EVT.
- Referral information may be found through primary audit of inpatient charts (nurses’ notes, discharge summary notes, copies of referral forms) or through databases maintained by organizations that receive and process referrals. These community databases will vary in the amount of information included, and there may be challenges in accessing information contained in these databases.
- Most home care organizations monitor when the first service started but cannot determine easily the onset of rehabilitation therapy.
- For Performance Measure 3, when analyzing these data consider also looking at appropriateness of referral and location of facility.
- Performance Measure 5, the timing being measured if from referral to acceptance into a program, and not specifically the start of therapy (Performance Measure 6 measures time to start of therapy).
- For Performance Measure 7, this reassessment should be done at all transition points and ideally at least monthly thereafter. This includes admission to complex care, long-term care or return to other community setting. The denominator will be a challenge and should be clearly identified and applied consistently by all groups who adopt this measure (e.g., denominator could be all severe stroke patients admitted to a long term care facility).
Health Care Provider Information
- Table 1: Stroke Rehabilitation Screening and Assessment Tools
- FIM® Instrument
- AlphaFIM® Instrument
- Modified Rankin Scale
- Evidence-Based Review of Stroke Rehabilitation (Triage Module)
- Aphasia United Best Practice Recommendations
- Aphasia Institute
- Stroke Engine
Information for People with Stroke, their Families and Caregivers
- Taking charge of your stroke recovery: Rehabilitation and recovery infographic
- Taking charge of your stroke recovery: Transitions and community participation infographic
- Post Stroke Checklist
- Living with Stroke Program
- Stroke Resources Directory
- Your Stroke Journey
- Stroke Engine
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery
- Taking charge of your stroke recovery: 2020 Virtual healthcare checklist infographic
Comprehensive assessment of a patient’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 patients who have more than one type of disability and who, require the services of two or more rehabilitation disciplines. Patients with a single disability can usually benefit from outpatient or community-based services, and generally do not require an interprofessional program. Hakkennes et al. (2013) surveyed 14 clinicians responsible for assessing the suitability of patients for inpatient rehabilitation. A questionnaire was administered to assess factors that were used to assess a patient’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. (2013) reported that 11.2% of veterans were selected for comprehensive-level rehabilitation. Patients 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 (Putman et al. 2007), the presence of pre-morbid cognitive disability, depression and severe behavioral problems were identified as factors where the probability of being admitted for inpatient rehabilitation was lowered.