How do stroke units enhance stroke recovery?

Importance of stroke

Stroke is a global health problem. It is the leading cause of adult disability and the second leading cause of mortality worldwide [1]. Every year, stroke kills approximately 5.5 million people around the world [101]. It is a significant socioeconomic burden for all countries and responsible for up to 4% of the total healthcare costs [2,3].

Stroke unit concept & prehospital stroke management

Stroke has few effective treatments. Advances in the management of stroke patients in the last few years, including new diagnostic and therapeutic strategies, have allowed reduction of in-hospital lethality and achievement of better functional outcomes. One of the main improvements in stroke treatment was the establishment of the stroke unit concept. Stroke units are separate hospital-based wards with a multidisciplinary team specially trained to provide optimal and timely care in the acute phase of stroke. Goals of the stroke unit concept are improved diagnostic accuracy, systematic prevention of complications through specialized nursing care and appropriate monitoring, as well as early rehabilitation [4–6].

Thrombolysis has a potential benefit if the onset-to-needle time is within 3 h. The sooner that recombinant tissue plasminogen activator (rt-PA) is given to stroke patients, the greater the benefit, especially if started within 90 min from the onset of stroke symptoms [7]. Thrombolysis should be started in the CT scan room or in the vicinity of the scanner.

Many barriers, including both prehospital and in-hospital delays, within the patient pathway can prevent early administration of thrombolytic therapy in patients admitted with acute stroke [8]. To improve the efficacy of thrombolysis for acute stroke, the European Stroke Organization (ESO) guidelines recommend: educational programs to increase awareness of stroke at the population level (Class II, Level B); educational programs to increase stroke awareness among professionals (paramedics/emergency physicians; Class II, Level B); immediate emergency medical services contact and priority emergency medical services dispatch (Class II, Level B); priority transport with advance notification to the receiving hospital (outside and inside hospital; Class III, Level B); and suspected stroke victims should be transported without delay to the nearest medical center with a stroke unit that can provide ultra-early treatment (Class III, Level B) [9].

Stroke thrombolysis is in the process of moving from academic centers into community-based standard therapy. Telemedicine using bidirectional video-conferencing equipment to provide health services or to assist healthcare personnel at distant sites is a feasible, valid and reliable means of facilitating thrombolysis delivery to patients in distant or rural hospitals, where timely air or ground transportation is not feasible. The quality of treatment, complication rates and short- and long-term outcomes are similar for acute stroke patients treated with rt-PA via a telemedicine consultation at local hospitals and those treated in academic centers. The differences in using diagnostic procedures and in the application of thrombolytic treatment, physiotherapy, speech therapy and occupational therapy might contribute substantially to the better outcome in community hospitals with telemedical support from the academic hospitals [9–19].

It is recommended that in remote or rural areas helicopter transfer or telemedical support should be considered in order to improve access to treatment (Class II, Level B) [9].

Characteristics of stroke units

In-hospital delays can be decreased by the application of care pathways. ‘Care pathway’ care can be defined as a plan of care that aims to promote organized and efficient multidisciplinary patient care that is based on the best available evidence and guidelines for a specific condition [20]. Organized in-patient (stroke unit) care is a term used to describe the focusing of care for stroke patients in hospital under a multidisciplinary team (MDT) who are specialized in stroke management [21]. Stroke unit care is characterized by a coordinated MDT (i.e., medicine, nursing, physiotherapy, occupational therapy, speech and language therapy, and social work) operating within a discrete hospital ward dedicated exclusively to stroke patients, providing acute stroke patient care, preventing stroke complications and recurrence, accelerating mobilization and providing early rehabilitation therapy. The typical components of stroke unit care in stroke unit trials were [22]:

• • Medical assessment and diagnosis, including imaging (CT scan and MRI), selective investigations (carotid Doppler ultrasound and echocardiogram) and early assessment of nursing and therapy needs;

• • Early management, consisting of early mobilization, prevention of complications and treatment of hypoxia, hyperglycemia, pyrexia and dehydration;

• • Ongoing rehabilitation (early goal setting, early involvement of carers in rehabilitation and provision of information), involving coordinated MDT care (MDT meetings) and early assessment of needs after discharge.

In 2000, the Brain Attack Coalition (BAC) discussed the concept of stroke centers and proposed two types of centers: primary and comprehensive. A primary stroke center (PSC) has the necessary staffing, infrastructure and programs to stabilize and treat most acute stroke patients [23]. A comprehensive stroke center (CSC) is defined as a facility or system with the necessary personnel, infrastructure, expertise and programs to diagnose and treat stroke patients who require high-intensity medical and surgical care, specialized tests or interventional therapies. Stroke experts consider eight components as absolutely necessary for both CSCs and PSCs: MDT, stroke-trained nurses, 24-h brain CT scan availability, CT priority for stroke patients, extracranial Doppler sonography, automated electrocardiographic monitoring, intravenous rt-PA protocols 24 h a day and an in-house emergency department. An additional 11 components (in the fields of vascular surgery, neurosurgery, interventional radiology and clinical research) were considered as necessary in CSC [24].

Among European hospitals admitting acute stroke patients, 4.9% met the criteria for a CSC, 3.6% for a PSC (<10% optimal facilities), 40.2% for any hospital ward where general acute care is provided and more than 50 acute stroke patients are admitted each year, even if there is no stroke unit and 51.4% did not meet any of these levels. In 2005, 8.3% of stroke patients were treated in a CSC, 5.2% in a PSC and 44.1% in any hospital ward where general acute care is provided and more than 50 acute stroke patients are admitted each year, even if there is no stroke unit. There was no 24-h availability for brain CT scan in 25% of hospitals [25]. More than 40% of hospitals do not have the minimum facilities required to treat stroke patients.

Evaluation of stroke unit activity

Indicators for quality of acute stroke care are mean length of hospital stay, diagnostic procedures performed, provision of treatment and discharge destination. These indicators are significantly better for patients treated in a stroke unit. Subgroup analysis of these indicators, based on patient characteristics of age, gender, stroke subtype and severity, is also performed [18,26].

Owing to higher resource use of personnel and diagnostic procedures, acute stroke unit care is approximately 16% more costly than treatment on regular neurological wards. Daily costs declined exponentially during the length of stay, with the maximum decrease within the first 10 days [27].

The total cost of care of all stroke patients treated in the department of neurology of the Helsinki University Central Hospital (Finland) was €11.3 million. Savings incurred by thrombolysis and acute stroke care of all stroke patients in the department of neurology, owing to reduced need for chronic institutional care, were €14.4 million in 2007 (Kaste M, Unpublished Data). Stroke unit treatment tends to decrease post-acute in-patient care costs because of the better outcome and higher level of independency at discharge [27].

The Mobile Stroke Team (MST) provides special multidisciplinary assessment, therapy and support for people who have suffered a stroke admitted to hospitals without an acute stroke unit. Compared with care in general wards, stroke team care improved some aspects of the process of care, but clinical outcomes were similar. Stroke team patients were significantly less likely to survive, return home or regain independence than those treated in a comprehensive stroke unit. Most aspects of the process of care were also poorer than in the stroke unit. Thus, the role of peripatetic mobile stroke teams remains unclear [28].

Benefits of stroke units

Nonselected stroke patients treated by a coordinated MDT in a stroke unit were able to leave the hospital earlier, went straight home more often and were more often independent in the activities of daily life at 1-year follow-up. Patients treated by well-organized management were able to leave hospital, on average, 16 days earlier than those treated routinely; out of every 100 patients, 13 more were able to return to their home at hospital discharge and 17 more were totally independent in their life at 1-year follow-up compared with those treated routinely [29].

An observational, controlled follow-up study compared the long-term outcome of acute stroke patients (n = 11,572) hospitalized within 48 h of the onset of symptoms and admitted to a stroke unit (n = 4936) with those treated in conventional wards (n = 6636). The primary outcome was mortality or disability (Rankin score > 2) after 2 years. Patients who received stroke unit care were less likely to have died or disabled than the controls by the end of follow-up (odds ratio [OR]: 0.81; 95% confidence interval [CI]: 0·72–0·91; p = 0.0001). The possible benefit of stroke unit care was also evident for in-hospital case fatality (OR: 0.78), long-term mortality (OR: 0.79) and for the likelihood of not being at home 2 years after hospital discharge (OR: 0.85). Survival of patients treated in stroke units was significantly higher than that of controls. The difference in survival between the two groups was most pronounced during the first month after admission [30].

For patients with primary intracranial hemorrhage receiving organized in-patient (stroke unit) care the 30-day and 1-year mortality rates were reduced compared with those treated in general medical wards (69 vs 52%) [31].

Comparing the outcome (i.e., returning and living at home, institutionalization and death) of acute stroke patients in different types of stroke units (CSC, PSC and general ward) at 1-year follow-up has shown that stroke patients managed in organized stroke units have a lower case fatality and disability, and are more likely to return home (outcome: CSC > PSC > general ward), compared with those managed in general wards, which proves that resourcing improves outcome [26,29].

The impact of stroke unit care is important at the community level because the incidence of stroke is high, approximately 2400 cases per year (80% being ischemic) in a Western population of 1 million inhabitants [32]. The evidence of benefit is most clear for units that can provide several weeks of rehabilitation if required. The benefits of a stroke unit were seen in units that admitted patients directly from the community or took over their care within 2 weeks of admission to hospital. For every 33 patients treated in a stroke unit there is one extra survivor, and for every 20 patients one extra patient is discharged back to their own home [33].

A high level of evidence was provided by a Cochrane review of the benefits of stroke rehabilitation in an organized hospital stroke unit, which demonstrated an 18% reduction in mortality, a 25% reduction in death or dependence and a 24% reduction in death or need for institutional care in patients treated in a stroke unit compared with a general medical ward. These benefits were seen for old and young patients, male or female and those with mild, moderate or severe stroke [18,26,33,34]. Stroke care provided by an organized and dedicated team, and the use of stroke care maps, lead to shorter hospital stays, fewer complications and a better functional outcome [29,35–37].

The 2008 ESO – Guidelines for Management of Ischaemic Stroke document recommends that: all stroke patients should be treated in a stroke unit (Class I, Level A); healthcare systems ensure that acute stroke patients have access to high-technology medical and surgical stroke care when required (Class III, Level B); and the development of clinical networks, including telemedicine, to expand access to high technology specialist stroke care (Class II, Level B) [9].

Importance of the ‘stroke chain’

The success of a stroke unit depends on the stroke chain, which includes awareness campaigns for public education to recognize stroke warning symptoms, well-organized transfer (<3 h) of stroke patients to a hospital with a stroke unit (possibility of thrombolysis), in-hospital pathways (CT scan priority for stroke patients, as well as thrombolysis) and stroke unit care with early and ongoing rehabilitation.

The strength of the chain is determined by the weakest element.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.