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2018 UPDATE
June 2018

8.1 Patients admitted to hospital with an acute stroke or transient ischemic attack should be treated on an inpatient stroke unit [Evidence Level A] as soon as possible; ideally within 24 hours of hospital arrival [Evidence Level C].

  1. Patients should be admitted to a stroke unit which is a specialized, geographically defined hospital unit dedicated to the management of stroke patients [Evidence Level A].
    1. For facilities without a dedicated stroke unit, the facility must strive to focus care on the priority elements identified for comprehensive stroke care delivery (including clustering patients, interdisciplinary team, access to early rehabilitation, stroke care protocols, case rounds, patient education). Refer to?Box 8A: Optimal Acute Stroke Care for further information.
  2. The core interdisciplinary team on the stroke unit should consist of health care professionals with stroke expertise including physicians, nurses, occupational therapists, physiotherapists, speech-language pathologists, social workers, and clinical nutritionists (dietitians) [Evidence Level A].
    1. All stroke teams should include hospital pharmacists to promote patient safety, medication reconciliation, provide education to the team and patients/family regarding medication(s) (especially side effects, adverse effects, interactions), discussions regarding adherence, and discharge planning (such as special needs for patients, e.g., individual dosing packages) [Evidence Level B].
    2. Additional members of the interdisciplinary team may include discharge planners or case managers, (neuro) psychologists, palliative care specialists, recreation and vocational therapists, spiritual care providers, peer supporters and stroke recovery group liaisons [Evidence Level B].
  3. The interdisciplinary team should assess patients within 48 hours of admission to hospital and formulate a management plan [Evidence Level B].
    1. Clinicians should use standardized, valid assessment tools to evaluate the patient’s stroke-related impairments and functional status [Evidence Level B].
    2. Assessment components should include dysphagia, mood and cognition, mobility, functional assessment, temperature, nutrition, bowel and bladder function, skin breakdown, discharge planning, prevention therapies, venous thromboembolism prophylaxis [Evidence Level B]. Refer to?Section 9 of this module for further information.
    3. Alongside the initial and ongoing clinical assessments regarding functional status, a formal and individualized assessment to determine the type of ongoing post-acute rehabilitation services required should occur as soon as the status of the patient has stabilized, and within the first 72 hours post-stroke, using a standardized protocol (including tools such as the alpha-FIM) [Evidence Level B]. Refer to?Canadian Stroke Best Practice Recommendations Stroke Rehabilitation Module section 3 for further information.
  4. Any child admitted to hospital with stroke should be managed in a centre with pediatric stroke expertise when available; if there is no access to specialized pediatric services, children with stroke should be managed using standardized pediatric stroke protocols [Evidence Level B].

8.2 Management of Stroke that Occurs While Patient Already in Hospital:

  1. Hospital in-patients who experience a new stroke while hospitalized should undergo immediate assessment by a physician with stroke expertise, undergo neurovascular imaging without delay, and be assessed for eligibility for intravenous alteplase and/or endovascular thrombectomy [Evidence Level B]. Refer to sections 4 and 5 for additional information.
    1. All hospitals should have protocols in place for management of acute inpatient stroke and all staff trained on these protocols, especially in units with higher risk patients [Evidence Level C].

Box 8A: Optimal Acute Inpatient Stroke Care

The final, definitive version of this paper has been published in?International Journal of Stroke?by SAGE Publications Ltd. Copyright ? 2018 World Stroke Organization.
http://journals.sagepub.com/doi/full/10.1177/1747493018786616

Rationale

Stroke unit care reduces the likelihood of death and disability by as much as 30 percent for men and women of any age with mild, moderate, or severe stroke. Stroke unit care is characterized by a coordinated interdisciplinary team approach for preventing stroke complications, preventing stroke recurrence, accelerating mobilization, and providing early rehabilitation therapy. Evidence suggests that stroke patients treated on acute stroke units have fewer complications, earlier mobilization, and pneumonia is recognized earlier. Patients should be treated in a geographically defined unit, as care through stroke pathways and by roving stroke teams do not provide the same benefit as stroke units. Access to early rehabilitation is a key aspect of stroke unit care. For patients with stroke, rehabilitation should start as early as possible and rehabilitation should be considered an intervention that can occur in any and all settings across the continuum of stroke care.

System Implications
  1. Organized systems of stroke care including stroke units with a critical mass of trained staff (interdisciplinary team). If not feasible, then mechanisms for coordinating the care of stroke patients to ensure use of best practices and optimal outcomes.
  2. Protocols and mechanisms to enable the rapid transfer of stroke patients from the Emergency Department to a specialized stroke unit as soon as possible after arrival in hospital, ideally within the first six hours.
  3. Comprehensive and advanced stroke care centres should have leadership roles within their geographic regions to ensure specialized stroke care access is available to patients who may first appear at general health care facilities (usually remote or rural centres) and facilities with basic stroke services only.
  4. Telestroke service infrastructure and utilization should be optimized to ensure access to specialized stroke care across the continuum to meet individual needs (including access to rehabilitation and stroke specialists) including the needs of northern, rural and remote residents in Canada.
  5. Information on geographic location of stroke units and other specialized stroke care models available to community service providers, to facilitate navigation to appropriate resources and to strengthen relationships between each sector along the stroke continuum of care.
Performance Measures
  1. Number of stroke patients who are admitted to hospital and treated on a specialized stroke unit at any time during their inpatient hospital stay for an acute stroke event (numerator) as a percentage of total number of stroke patients admitted to hospital (core).
  2. Percentage of patients discharged to their home or place of residence following an inpatient admission for stroke (core).
  3. Proportion of stroke patients who die in hospital within 7 days and within 30 days of hospital admission for an index stroke (reported by stroke type) (core).
  4. Proportion of total time in hospital for an acute stroke event spent on a stroke unit.
  5. Proportion of patients admitted to a stroke unit, who arrive in the stroke unit within 24 hours of Emergency Department arrival.
  6. Proportion of designated stroke unit beds that are filled with stroke patients (weekly average).
  7. Percentage increase in telehealth or telestroke coverage to remote communities to support organized stroke care across the continuum.

Refer to Canadian Stroke Quality and Performance Measurement Manual for detailed indicator definitions and calculation formulas.? www.strokebestpractices.ca/

Measurement Notes

    1. Performance measure 1: calculate for all cases, and then stratify by type of stroke.
    2. Definition of stroke unit varies widely from institution to institution. Where stroke units do not meet the criteria defined in the recommendation, then a hierarchy of other stroke care models could be considered: a) dedicated stroke unit; (b) designated area within a general nursing unit or neuro-unit where stroke patients are clustered; (c) mobile stroke team care; (d) managed on a general nursing unit by staff using stroke guidelines and protocols.
    3. Institutions collecting this data must note their operational definition of “stroke unit” to ensure standardization and validity when data is reported across institutions.
    4. Performance measure 5 – start time for assessing stroke unit admission within 24 hours should be Emergency Department triage time.
    5. Patient and family experience surveys should be in place to monitor care quality during inpatient stroke admissions
Implementation Resources and Knowledge Transfer Tools

Health Care Provider Information

Patient Information

Summary of the Evidence

Evidence Table and Reference List

It is now well-established that patients who receive stroke unit care are more likely to survive, return home, and regain independence compared to patients who receive less organized forms of care.? Stroke unit care is characterized by an experienced interdisciplinary stroke team, including physicians, nurses, physiotherapists, occupational therapists, speech therapists, among others, dedicated to the management of stroke patients, often located within a geographically defined space.? Other features of stroke units include staff members who have an interest in stroke, routine team meetings, continuing education/training, and involvement of caregivers in the rehabilitation process.? In an updated Cochrane Review, the Stroke Unit Trialists’ Collaboration (2013) identified 28 randomized and quasi-randomized trials (n=5,855) comparing stroke unit care with alternative, less organized care (e.g., an acute medical ward).? Compared to less organized forms of care, stroke unit care was associated with a significant reduction in the odds of death (OR= 0.81, 95% CI 0.69 to 0.94, p = 0.005), death or institutionalization (OR=0.78, 95% CI 0.68 to 0.89, p = 0.0003), and death or dependency (OR= 0.79, 95% CI 0.68 to 0.90, p = 0.0007) at a median follow-up period of one year.? Based on the results from a small number of trials, the authors also reported that the benefits of stroke unit care are maintained for periods up to 5 and 10 years post stroke.? Moreover, subgroup analyses demonstrated benefits of stroke unit care regardless of sex, age, or stroke severity.? Saposnik et al. (2011) investigated the differential impact of stroke unit care on four subtypes of ischemic stroke (cardioembolic, large artery disease, small vessel disease, or other) and reported that stroke unit care was associated with reduced 30-day mortality across all subtypes.

To determine if the benefits of stroke unit care demonstrated in clinical trials can be replicated in routine clinical practice, Seenan et al. (2007) conducted a systematic review of 25 observational studies (n=42,236) comparing stroke unit care to non-stroke unit care. Stroke unit care was associated with a reduction in the risk of death (OR=0.79, 95% CI 0.73 to 0.86, p<0.001) and of death or poor outcome (OR=0.87, 95% CI=0.80 to 0.95; p=0.002) within one-year of stroke.? Similar findings were reported for the outcome of death at one year in a secondary analysis limited to multi-centered trials (OR=0.82, 95% CI 0.77 to 0.87, p<0.001).?

In-hospital Stroke
Estimates of persons who experience a stroke while already hospitalized for other conditions range from 4% to 17% (as cited by Cumbler et al. 2014). Many of these patients have pre-existing stroke risk including hypertension, diabetes, cardiac diseases, and dyslipidemia (Vera et al. 2011). These in-hospital strokes often occur following cardiac and orthopedic procedures, usually within 7 days of surgery. There is evidence to suggest that, compared with persons who suffer a stroke in the community, patients who experience an in-hospital stroke have more severe strokes, worse outcomes and do not receive care in as timely a fashion. Of 15,815 consecutive patients included in the J-MUSIC registry, (Kimura et al 2006), 694 (4.4%) experienced an in-hospital ischemic stroke. The mean admission NIHSS score was significantly higher for patients with in-hospital stroke (14.6 vs. 8.1, p<0.0001). In-hospital stroke was an independent predictor of severe stroke, defined as NIHSS score ≥11 (OR=3.27, 95% CI 2.7-3.88, p<0.0001). Significantly more in-hospital stroke patients died both in hospital (19.2% vs. 6.8%, p<0.0001) and within 28 days (12.1% vs. 4.8%, p<0.0001). Farooq et al. (2008) compared the outcomes of 177 patients who experienced an in-hospital stroke and 2,566 who were admitted from the community to 15 hospitals in a single state over a 6-month period.? In-hospital case fatality was significantly higher among in-hospital patients (14.6% vs. 6.9%, p=0.04). The distribution of mRS scores was shifter towards poorer outcomes for the in-hospital group (p<0.001) and fewer in-hospital stroke patients were discharged home (22.9% vs. 52.2%, p<0.01).

One of the largest studies to examine quality of care received and stroke outcome included 21,349 patients who experienced an in-hospital ischemic stroke and were admitted to 1,280 hospitals participating in the Get with the Guideline Stroke registry from 2006-2012, and 928,885 patients admitted to hospitals from the community during the same time frame (Cumbler et al. 2014). In-hospital stroke patients were significantly less likely to meet 7 achievement standards (t-PA within 3 hours, early antithrombotics, DVT prophylaxis, antithrombotics/anticoagulants on discharge, statin meds), and were less likely to receive a dysphagia screen or receive t-PA within 3.5-4.5 hours, but were more likely to receive a referral for rehabilitation and to receive intensive statin therapy.? When quality/achievement measures were combined, in-hospital stroke patients were less likely to receive investigations/care for which they were eligible (82.6% vs. 92.8%, p<0.0001). In-hospital stroke patients also experienced worse outcomes. They were less likely to be independent in ambulation at discharge (adj OR=0.42, 95% CI 0.39-0.45, p<0.001), to be discharged home (adj OR=0.37, 95% CI 0.35-0.39, p<0.001) and the odds of in-hospital mortality were significantly higher (adj OR=2.72, 95% CI 2.57-2.88, p<0.001). Although a higher percentage of patients with in-hospital stroke received thrombolytic therapy with t-PA (11% vs. 6.6%), fewer received the treatment within 3-hours (31.6% vs. 73.4%, p<0.0001).