Stroke UnitsStroke Units

Southern NeurologySouthern Neurology

Definition of a stroke unitDefinition of a stroke unit

A stroke unit can be defined as a unit with A stroke unit can be defined as a unit with dedicated stroke beds and a dedicated stroke beds and a multidisciplinary team that provides 24-multidisciplinary team that provides 24-hour care for acute stroke patients admitted hour care for acute stroke patients admitted to hospital. to hospital.

Meta-analysis of Acute Stroke Unit Care vs Meta-analysis of Acute Stroke Unit Care vs Admission to General Medical WardAdmission to General Medical Ward

(“Western” populations)(“Western” populations)After median 1 year follow up:After median 1 year follow up:

GeneralMed. Ward

AcuteStroke Unit

Odds Ratio infavour ofStroke Unit

Death 413/1623(25.4%)

340/1626(20.9%)

0.83P<0.05

Death orDependency

755/1600(47.2%)

640/1597(40.1%)

0.69P<0.0001

HomeIndependent

463/1388(33%)

546/138239%)

1.41P<0.01

Odds Ratio of Death or Requiring long term InstitutionOdds Ratio of Death or Requiring long term Institution

0.3 0.5 1 2 4

<75 years old

>75 years old

Mild Stroke

Moderate Severity

Severe Stroke

Geriatric Medicine

General Medicine

Neurology

Rehabilitation

Cochrane Review

Main findings of 23 trialsMain findings of 23 trials compared with alternative services, stroke compared with alternative services, stroke

unit showed reductions in odds of death unit showed reductions in odds of death recorded at final (median 1 year) follow-up recorded at final (median 1 year) follow-up (OR 0.86; 95% CI 0.71-0.94)(OR 0.86; 95% CI 0.71-0.94)

reduced odds of death or institutionalised reduced odds of death or institutionalised carecare

(OR=0.8; CI 0.71-0.9)(OR=0.8; CI 0.71-0.9) reduced death or dependencyreduced death or dependency

(OR= 0.78; CI 0.68-0.89)(OR= 0.78; CI 0.68-0.89)

Of 23 TrialsOf 23 Trialsnumber needed to treat (NNTT)number needed to treat (NNTT)

Approx. absolute figures for numbers of stroke unit Approx. absolute figures for numbers of stroke unit and alternative care patients in various outcome and alternative care patients in various outcome

categories were as follows:categories were as follows:

Dead (21% vs 25%)Dead (21% vs 25%) Institutional care (19% vs 21%)Institutional care (19% vs 21%) Home but dependent (16% vs 15%)Home but dependent (16% vs 15%) Home and independent (44% vs 39%)Home and independent (44% vs 39%)

(Part a)(Part a)

Based on information aboveBased on information aboveOn average, On average, NNTT to prevent one death is 33 (CI 20-100)NNTT to prevent one death is 33 (CI 20-100)NNTT to prevent one patient unable to stay NNTT to prevent one patient unable to stay home is 20 (12-50)home is 20 (12-50)NNTT to prevent one patient failing to regain NNTT to prevent one patient failing to regain independence is 20 (12-50)independence is 20 (12-50)

(Part b)(Part b)

SummarySummary

Patients admitted to SU (versus general Patients admitted to SU (versus general wards) have lower recurrent stroke, greater wards) have lower recurrent stroke, greater early mobilisation, greater use of aspirin, early mobilisation, greater use of aspirin, antipyretics and antibiotics and lower rsik antipyretics and antibiotics and lower rsik of mortality or institutionalisationof mortality or institutionalisation

World-wide and local experienceWorld-wide and local experience

Stroke Unit care has been shown to reduce case fatality in Stroke Unit care has been shown to reduce case fatality in UK by 25%UK by 25%

Benefit shown in recent Chinese stroke studiesBenefit shown in recent Chinese stroke studies Benefit of stroke unit care still evident at 10 years post-Benefit of stroke unit care still evident at 10 years post-

stroke in Norwegian study where patients were admitted to stroke in Norwegian study where patients were admitted to combined acute stroke and rehabilitation unitcombined acute stroke and rehabilitation unit

However, less than 10% of stroke patients are admitted to However, less than 10% of stroke patients are admitted to dedicated stroke units in regional Italy and in Austriadedicated stroke units in regional Italy and in Austria

As of start of 2004, only 23% of Australian hospitals were As of start of 2004, only 23% of Australian hospitals were offering dedicated stroke unit careoffering dedicated stroke unit care

Stroke units - how do they work?Stroke units - how do they work?

Stroke unit benefits are seen within first 10 days – in Stroke unit benefits are seen within first 10 days – in one study of 802 patients, the case fatality rate in 1one study of 802 patients, the case fatality rate in 1stst 10 days was 8.2% amongst patients in stroke unit and 10 days was 8.2% amongst patients in stroke unit and 15.1% in general ward (p=0.02) [Stroke 1998; 29:58-15.1% in general ward (p=0.02) [Stroke 1998; 29:58-62].62].

Stroke Unit Trialists Collaboration showed that Stroke Unit Trialists Collaboration showed that reduction in case fatality of patients managed in stroke reduction in case fatality of patients managed in stroke unit setting developed between 1 and 4 weeks after unit setting developed between 1 and 4 weeks after index stroke. Reduction in odds of death was evident index stroke. Reduction in odds of death was evident across all causes of death and most marked for those across all causes of death and most marked for those deaths considered to be secondary to immobility deaths considered to be secondary to immobility [Stroke 1997; 11: 2139044].[Stroke 1997; 11: 2139044].

Processes of CareProcesses of Care

There is a greater adherence rate to selected There is a greater adherence rate to selected processes of care in a stroke unit (75%) processes of care in a stroke unit (75%) versus mobile service (65%) versus versus mobile service (65%) versus conventional care (52%) (p<0.001).conventional care (52%) (p<0.001).

The adjusted odds of patients being alive at The adjusted odds of patients being alive at discharge if adhering to all but one process discharge if adhering to all but one process of care is significant (aOR 3.63; 95% CI of care is significant (aOR 3.63; 95% CI 1.04-12.66; p=0.04)1.04-12.66; p=0.04)

[Stroke 2004; 35: 1035-40][Stroke 2004; 35: 1035-40]

Statistically Significant Differences between a Statistically Significant Differences between a Stroke Unit and General WardStroke Unit and General Ward

(Stroke 1998; 29: 586-590)(Stroke 1998; 29: 586-590)

Treatment Stroke Unit(n=279)

Gen Ward(n=271)

Mobilization outof bed <24 hrs

44% 27%

Aspirin <12 hrs 56% 19%

Paracetamol 57% 27%

Insulin 6% 3%

Patient characteristics ? Do they Patient characteristics ? Do they mattermatter

Stroke Unit Trialists’ Collaboration found that beneficial Stroke Unit Trialists’ Collaboration found that beneficial effects in relation to death and dependency are effects in relation to death and dependency are independent of patient’s age, sex, stroke severity and independent of patient’s age, sex, stroke severity and variations of stroke unit organisation. However, it is not variations of stroke unit organisation. However, it is not clear whether patient and system factors affect length of clear whether patient and system factors affect length of stay or FIM gain.stay or FIM gain.

A recent study comparing stroke unit versus stroke team A recent study comparing stroke unit versus stroke team care found that stroke unit care at 3 months and 1 year was care found that stroke unit care at 3 months and 1 year was better for large vessel strokes in terms of mortality or better for large vessel strokes in terms of mortality or institutionalisation but there was no benefit for lacunar institutionalisation but there was no benefit for lacunar strokes. Furthermore, lacunar strokes had longer LOS (18 strokes. Furthermore, lacunar strokes had longer LOS (18 versus 13.5 days) when cared for in a stroke unit [Stroke versus 13.5 days) when cared for in a stroke unit [Stroke 2002; 33:449-55].2002; 33:449-55].

Benefits of early mobilisation and Benefits of early mobilisation and social interactionsocial interaction

Stroke unit patients spend more time out of Stroke unit patients spend more time out of bed and out of their bay or room. There are bed and out of their bay or room. There are more observed attempts on the stroke unit more observed attempts on the stroke unit than on the general ward to interact with than on the general ward to interact with drowsy, cognitively or speech impaired drowsy, cognitively or speech impaired patients.patients.

Stroke unit patients spend more time with Stroke unit patients spend more time with visitorsvisitors

[Age Ageing 1999; 28:433-40][Age Ageing 1999; 28:433-40]

Benefits of cardiac-respiratory Benefits of cardiac-respiratory monitoringmonitoring

Monitoring in a SU is associated with a increased Monitoring in a SU is associated with a increased recognition of adverse changes which require acute recognition of adverse changes which require acute medical treatment and shorter duration of these medical treatment and shorter duration of these complications [Stroke 2003; 34: 2599-603].complications [Stroke 2003; 34: 2599-603].

At 1-year, mortality and combined mortality and At 1-year, mortality and combined mortality and dependency are not different if patients are admitted to a dependency are not different if patients are admitted to a semi-intensive SU (72 hr monitoring of cardiac, semi-intensive SU (72 hr monitoring of cardiac, respiratory, metabolic and neurological functions) versus respiratory, metabolic and neurological functions) versus conventional SU if all stroke severity types are included. conventional SU if all stroke severity types are included. However, OR of mortality for semi-intensive SU is 0.19 However, OR of mortality for semi-intensive SU is 0.19 (95% CI 0.07-0.54) in patients with severe stroke (CSS< (95% CI 0.07-0.54) in patients with severe stroke (CSS< or=4) [Cerebrovasc Dis 2005; 19:23-30].or=4) [Cerebrovasc Dis 2005; 19:23-30].

Cost-benefit analysis of SU versus Cost-benefit analysis of SU versus other modelsother models

A study of 457 patients randomised (152 to SU, 152 to A study of 457 patients randomised (152 to SU, 152 to stroke team and 153 to domiciliary stroke care). Mortality stroke team and 153 to domiciliary stroke care). Mortality or institutionalisation at 1 year was significantly lower in or institutionalisation at 1 year was significantly lower in the SU group [14%] when compared to stroke team [30%, the SU group [14%] when compared to stroke team [30%, p<0.001] or domiciliary care [24%, p=0.03. p<0.001] or domiciliary care [24%, p=0.03.

The total costs of stroke per patient over the 12 month The total costs of stroke per patient over the 12 month period were 11,450 pound for SU, 9527 pound for stroke period were 11,450 pound for SU, 9527 pound for stroke team and 6840 pound for domiciliary care. team and 6840 pound for domiciliary care.

The mean costs per day alive for the stroke unit were The mean costs per day alive for the stroke unit were significantly less than the stroke team but no different significantly less than the stroke team but no different from domiciliary care patientsfrom domiciliary care patients

[Health Technol Assess 2005; 9: 1-94][Health Technol Assess 2005; 9: 1-94]

Different ModelsDifferent Models AcuteAcute Comprehensive (? best)Comprehensive (? best) Mobile stroke team (not as good)Mobile stroke team (not as good) RehabRehab Mixed rehabMixed rehab General medical ward (not as good)General medical ward (not as good)