Stroke Units Improving the Outcome of Patients with a Cerebrovascular Event
Stroke Units Improving the Outcome of Patients with a Cerebrovascular Event
The development of stroke units has significantly changed the outcome of stroke patients – one-year mortality has decreased by 23%. The hospital stay has been reduced by six days on average and five out of 100 patients become more independent at home, while four more survive and one less needs to be transferred to a nursing home.1
The goals of a stroke unit are to improve stroke outcome and diagnostic accuracy, facilitate the introduction of new treatments, be an optimal setting for acute trials, reduce the length of hospitalisation and allow early discharge.2
A stroke unit must be part of an integrated healthcare programme with the possibility of urgent transport and arrival time of the patients to a hospital that has a 24-hour emergency department (ED) and a stroke team.
Public awareness of alarming stroke signs have to be promoted by general practitioners (GPs), by leaflets, by press conferences and by advertisements on television. Strokes need to be recognised as an emergency.3
This article will only deal with some practical recommendations for improving patient care in the stroke unit. For medical stroke management the recommendations of the European Stroke Initiative (EUSI) should be followed.4
Emergency Needs for Stroke Patients5
A multidisciplinary stroke team must be led by an experienced neurologist – the quick triage consultation of stroke patients in the ED reduces inefficiencies and delays. This increases the proportion of patients eligible for acute stroke treatment, such as thrombolysis.
Computed tomography (CT) of the brain and laboratory services must be available 24 hours a day. It must be possible to perform Doppler ultrasound, magnetic resonance imaging (MRI) and conventional angiography within three hours. Neurosurgical facilities must be present. A majority of stroke patients can be admitted to the stroke unit after the initial screening. Only 10% have to be admitted to an intensive care unit (ICU) for lifethreatening strokes.
Organisation of a Stroke Unit6
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 computed assisted monitoring for cardiac arrhythmia detection, arterial blood pressure assessment and oxygen saturation measurements.
Connecting the central computer screen to the station of the cardiac monitoring unit is an additional safety measure. In case of alarm, this allows the cardiologist on duty to immediately control the electrocardiogram (ECG) parameters and give urgent therapeutic instructions.
The stroke team should consist of a full-time neurologist (also in charge of patients leaving the unit) on average after 24 to 72 hours of monitoring. A consultant stroke rehabilitation physician should also evaluate each patient admitted to the unit in 24 hours.
Per four stroke beds two nurses are required 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. The social assistant must start planning the discharge modalities soon after admission – discharge at home with or without additional support or transfer to a revalidation centre or a nursing home. During a weekly multidisciplinary staff meeting, the files of all patients should be discussed. Training sessions and a discussion of new treatment and care modalities are appropriate at regular time intervals.
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.
- Stroke Unit Trialists’ Collaboration, “A systematic review of specialist multidisciplinary team (stroke unit) care for stroke inpatients”, in: Warlow C, van Gijn J, Sandercock P (eds.), Stroke Module of the Cochrane Database of Systematic Reviews, The Cochrane Collaboration, Oxford (1996);issue 2.
- Indredavik B, Fjaertoft H, Ekeberg G, Loge A D, Morch B, “Benefit of an extended stroke unit service with early discharge. A randomised controlled trial”, Stroke (2000);31: pp. 2,989–2,994.
- Adams H P, Jr, Brott T G, Crowell R M et al., “Guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association”, Stroke (1994);25: pp. 1,901–1,914.
- Hacke W, Kaste M, Bogousslavsky J et al., “European Stroke Initiative Executive Committee and the EUSI Writing Committee, European Stroke Initiative Recommendations for Stroke Management – update 2003”, Cerebrovasc Dis (2003);16: pp. 311–317.
- Gratina P, Greenberg L, Pasteur W, Grotta J C, “Current emergency department management of stroke in Houston, Texas”, Stroke (1995);26: pp. 409–414.
- Desfontaines P, Vanhooren G, Peeters A, Laloux P, “Proposal of guidelines for Stroke Units”, Acta Neurol Belg (2002);102: pp. 49–52.
- Goldstein L B, Bertels C, Davis J N, “Interrater reliability of the NIH Stroke Scale”, Arch Neurol (1989);46: pp 660–662.
- Orgogozo J M, Capildeo R, “Principes et methodes d’évaluation clinique des traitements à la phase aigue des infarctus cérébraux”, Mal Med (1984);1: pp. 240–255.
- de Haan R, Horn J, Limburg M et al., “A comparison of five stroke scales with measures of disability, handicap and quality of life”, Stroke (1993);24: pp. 1,178–1,181.
- Johnstone A J, Lohlun J C, Miller J D et al., “A comparison of the Glasgow Coma Scale and the Swedish Reaction Level Scale”, Brain Injury (1993);7: pp. 501–506.
