Stroke units

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
   

• 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
   

The following are the standard requirements of a stroke unit:^1,2

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.

AHA/ASA Guidelines – recommendations on stroke centres¹

• 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 units²

• 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).