Clinical Guidelines for Acute Stroke Management - Living on the EDge

1 ORGANISATION OF SERVICES
1 Organisation of Services
6Section
1.1 <strong>Stroke</strong> unit care
The organisation of hospital services to provide stroke
unit care is the single most important recommendation
<strong>for</strong> acute stroke management. <strong>Stroke</strong> unit care should
be the highest priority <strong>for</strong> clinicians and administrators
to consider. There is overwhelming evidence that
stroke unit care significantly reduces death and
disability after stroke compared with conventional care
in general wards <strong>for</strong> all people with stroke. 6
Models of stroke care described in the literature
include:
> acute stroke ward: acute unit in a discrete ward;
> comprehensive stroke unit care: combined acute
and rehabilitation unit in a discrete ward;
> stroke rehabilitation unit: a discrete rehabilitation unit
<strong>for</strong> people with stroke, who are transferred from
acute care 1-2 weeks post stroke;
> mixed rehabilitation ward: rehabilitation provided on
a ward managing a general caseload.
In Australia, most stroke units established to date have
a primary focus on early (acute) care and early aspects
of rehabilitation, with varying degrees of intensity and
follow-up. However, the evidence <strong>for</strong> stroke unit care is
clearest <strong>for</strong> units that can provide several weeks of
rehabilitation (on a comprehensive stroke unit or stroke
rehabilitation unit).
6, 18, 19
The stroke units that have been shown to deliver
highly effective stroke care share a number of
characteristics, including:
> location in a geographically discrete unit;
> comprehensive assessments;
> a coordinated interdisciplinary team;
> early mobilisation and avoidance of bed rest;
> staff who have a special interest in the management
of stroke, and access to ongoing professional
education and training;
> clear communication, with regular team meetings
to discuss management (including discharge
planning) and other meetings as needed
(e.g. family conferences);
> active encouragement of people with stroke and
their carers/family members to be involved in the
rehabilitation process.
6, 18
A mobile stroke team has been suggested as one
strategy to improve processes of care <strong>for</strong> hospitals
that do not currently have a dedicated stroke unit. 20
One robust systematic review found no clear benefit
<strong>for</strong> mobile stroke teams. The only significant benefit
related to a process outcome (documented OT
assessment) with non significant trends reported <strong>for</strong>
improved patient outcomes. 21 Mobile stroke teams are
generally not more effective than care on a general
ward but are inferior to care on a stroke unit. 21 Hence
based on best available data mobile stroke teams are
not the answer to regional hospitals or metropolitan
hospitals without a stroke unit. In such situations it is
recommended that a small (2-4 bed) geographically
based stroke unit be established as part of a larger
general ward. In larger hospitals, a comprehensive
stroke unit is considered the best model <strong>for</strong> acute
stroke patients. 19 Mobile stroke teams should only be
developed if part of a <strong>for</strong>mal randomised controlled
trial to establish an Australian evidence base.
Finally there is evidence that all patients should be
admitted to a stroke unit in a hospital rather than avoid
admission to hospital (“hospital at home”). Evidence
from one robust systematic review found that hospital
at home services had similar outcomes to general
ward care but noted that general wards are inferior to
stroke unit care. 22 A subsequent study confirmed that
stroke unit care is indeed superior to general hospital
ward care and hospital at home services provided by
a specialist stroke team. 23 Currently hospital at home
services are not a common model used in Australia
and hence ef<strong>for</strong>ts should be focused on providing
organised inpatient stroke unit care.
CONSUMER
1.1 STROKE UNIT CARE GRADE LEVEL RATING
a) All people with stroke should be admitted to hospital and be A Level I 6, 19 9.3/10
treated in a comprehensive stroke unit with an interdisciplinary team.
b) Smaller hospitals should consider models of stroke unit care that
adhere as closely as possible to the criteria <strong>for</strong> stroke unit care. B Level I 6, 21 –
Where possible, patients should receive care on geographically
discrete units.