Stroke units

Strokes are medical emergencies that require prompt and effective treatment to achieve an optimal outcome for the patient. By bringing together the specialities, techniques and equipment needed for the management of strokes into one unit, clinicians are better placed to deal with these medical emergencies. This section looks at the benefits of these specialist stroke units as well as what is needed for their implementation.

 

Broadly, the benefits of stroke units are as follows:1-5

  • Improved quality of care
  • Facilitated patient access to thrombolysis and specialised stroke care
  • Timely evaluation
  • Improved early survival across age groups
  • More cost effective than care on other hospital wards/teams
  • Reduced incidence of post-stroke complications, such as urinary tract infections, pneumonia, and death.

Stroke units have been shown to have a clear effect on the survival of patients compared with those admitted to a conventional ward as can be seen in the survival curves below:

  • Compared with conventional-ward care, stroke-unit care was associated with a reduced probability of death or being disabled at the end of follow-up (odds ratio 0·81, 95% CI 0·72-0·91; p=0·0001).4
  • The potential benefit was significant across all age ranges and clinical characteristics, except for unconsciousness.4
  • The difference in survival between the two groups was most pronounced during the first month after admission.4
  • Data from a 2009 study show that the benefit in terms of 30-day fatality is consistent across age groups and that the more intense the stroke care is, the better the outcome.5

References

  1. Jarman. Acute stroke units and early CT scans are linked to lower in-hospital mortality rates. BMJ. 2004 Feb 14; 328(7436): 369.
  2. Rajan et al. Implementing a mobile stroke unit program in the United States: why, how, and how much? AMA Neurol. 2015 Feb;72(2):229-34.
  3. Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev. 2013 Sep 11;(9):CD000197.
  4. Candelise et al. Stroke-unit care for acute stroke patients: an observational follow-up study. Lancet. 2007 Jan 27;369(9558):299-305.
  5. Saposnik et al. Do all age groups benefit from organized inpatient stroke care? Stroke. 2009 Oct;40(10):3321-7
  • Patients admitted to a stroke unit are more likely to receive specialist treatments.1-10
  • A report from the Swedish stroke register looking at stroke patient admissions from 2003 to 2008 showed that in 2008, patients admitted to a stroke unit were 5 times more likely to receive thrombolysis than those admitted to general wards.8
  • This study also found that stroke patients were also more likely to receive thrombolysis if they were admitted to a university hospital rather than a specialist, non-university hospital or a community hospital. Furthermore, stroke patients were also more likely to receive thrombolysis if they were admitted to a neurology department rather than a general department within a university hospital.8
  • A study from a specialist stroke centre in the Netherlands showed that after initiation of an Acute Brain Care (ABC) unit the door-to-needle (iv thrombolysis) time was reduced from a median of 86 minutes to 26 minutes. Because more patients could be treated within the 3-hour (later 4.5 hour) time-window, the number of patients treated at the ABC unit almost doubled in the first year.9

A German study10 has also demonstrated the benefits of a specialist stroke unit comprising six beds. Prior to the introduction of this unit in 2007, patients with stroke were treated on the intensive care unit. Stroke admission rates and thrombolysis- related times were assessed during the whole period.

  • The number of patients with thrombolysis increased from 24 in 2005-2006 (4.8% of all admitted patients with ischaemic stroke) to 95 in 2007-2008 (12.8%).10
  • Door-to-needle time was significantly reduced from 62.2 ±36.1 to 38.5 ± 22.2 min (p <0.001).10
  • Door-to-CT time remained unchanged at 10.3 ±9.5 to 10.4 ± 13.9 min (p=0.974), whereas CNT improved from 45.7 ±23.1 to 28.3 ± 20.3 min (p=0.001).10

References

  1. Norrving B, et al. Organized stroke care. Stroke 2006;37:326-328.
  2. Duncan PW, et al. Adherence to postacute rehabilitation guidelines is associated with functional recovery in stroke. Stroke 2002;33:167-178.
  3. Gropen TI, et al. Quality improvement in acute stroke: the New York State Stroke Center Designation Project. Neurology 2006;67:88-93.
  4. Stradling D, et al. Stroke care delivery before vs after JCAHO stroke center certification. Neurology 2007;68:469-470.
  5. Saposnik G, et al. Hospital volume and stroke outcome: does it matter? Neurology 2007;69:1142-1151.
  6. Candelise L, et al. Stroke-unit care for acute stroke patients: an observational follow-up study. Lancet 2007;369:299-305.
  7. Saposnik G, et al. Do all age groups benefit from organized inpatient stroke care? Stroke 2009;40: 3321-3327.
  8. Eriksson M, et al. Dissemination of thrombolysis for acute ischemic stroke across a nation: experiences from the Swedish stroke register, 2003 to 2008. Stroke 2010;41:1115-1122.
  9. Roos YB, et al. The acute brain care unit (ABC-Unit): the initiation of a multidisciplinary treatment protocol and special unit for IV thrombolysis in stroke reduces the median door-to-needle time to 26 minutes. Presented at the European Stroke Conference, Hamburg, Germany, May 26, 2011. Abstract.
  10. Etgen T, et al. Multimodal strategy in the successful implementation of a stroke unit community hospital. Acta Neurol Scand 2011;123(6):390-395.

The following are the standard requirements of a stroke unit:

Emergency needs for stroke patients

  • Multidisciplinary stroke team led by an experienced neurologist
  • Cerebral imaging and laboratory services available 24 hours a day, 7 days a week
  • Ability to perform rapid Doppler ultrasound, magnetic resonance imaging (MRI) and conventional angiography
  • Access to neurosurgical facilities

Organisation of a stroke unit

  • A stroke unit is only useful when at least 200 patients are admitted on a yearly basis.
  • It should consist of at least four beds, each equipped with non-invasive computer-assisted monitoring for cardiac arrhythmia detection, arterial blood pressure assessment and oxygen saturation measurements.
  • Four stroke beds require two nurses in the early morning, two in the afternoon and one during the night in an eight-hour rotation system.
  • The physiotherapist, the occupational therapist and the speech therapist should be involved as soon as possible to start early rehabilitation.
  • Each patient admitted to the unit should have a stroke protocol and checklist including laboratory investigations, medical and nursing procedures, monitoring and therapy applications, neurological rehabilitation programme, family involvement, support and education, and discharge planning.

Early neurological rehabilitation

  • This starts with a good positioning of the patient in bed. Patients should be placed in an upright position with support of the paretic arm and with the legs in a straight position as soon as possible.
  • Later, balance in a sitting position on the edge of the bed should be tested.
  • The speech therapist must assist in the evaluation and treatment of dysphagia and aphasia as early as possible.
  • Special attention is required for the evaluation of sensory and visual neglect.
  • Well-organised acute and intermediate rehabilitation after stroke can provide patients with the best functional results attainable on the basis of our current scientific understanding.

Nursing care plan

  • The nursing care plan should consist of assistance in the activities of daily living, hygiene, mobilisation, control of liquid balance and feeding, mouth care and skin necrosis prevention.
  • The monitoring of vital parameters such as oxygen arterial saturation, breathing, aerosols and aspiration are mandatory.
  • Blood pressure and ECG changes should be continuously followed-up.
  • Changes in neurological status must also be followed up regularly using stroke scales.
  • Changes in levels of consciousness also need to be assessed by the nurses.

References

  1. Leys D, et al. The main components of stroke unit care: results of a European expert survey. Cerebrovasc Dis 2007;23:344-352.
  2. Knecht S, et al. Rehabilitation after stroke. Dtsch Arztebl Int 2011;108(36):600-606.

AHA/ASA Guidelines – recommendations on stroke centres

  • Creation of primary stroke centres is strongly recommended (Class I, LOE B)
  • Development of comprehensive stroke centres is recommended (Class I, LOE C)
  • Certification of stroke centres by an external body (e.g. Joint Commission on the Accreditation of Healthcare Organisations) is encouraged (Class I, LOE B)
  • Patients with suspected stroke should bypass hospitals without stroke resources and go to the closest facility capable of treating acute stroke (Class I, LOE B).

ESO Guidelines: recommendations for stroke services and stroke units

  • All stroke patients should be treated in a stroke unit (Class I, Level A)
  • Acute stroke patients should have access to high technology medical and surgical stroke care when required (Class III, Level B)
  • The development of clinical networks, including telemedicine, is recommended to expand access to high technology specialist stroke care (Class II, Level B)

References

  1. Adams HP Jr, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007;38:1655-1711
  2. ESO Guidelines 2009 Update. www.eso-stroke.org