Organisation of acute stroke care

Transcription

1 Peter Langhorne Academic Section of Geriatric Medicine, Royal Infirmary, Glasgow, UK Information from randomised trials and systematic reviews is used to address issues in the organisation of early stroke care. Specifically, the following areas are discussed: (i) hospital-based care versus home-based care; (ii) organisation of care in hospital; and (iii) discharge and post-discharge care. The organisation and delivery of acute stroke care represents only one component of a truly comprehensive stroke service (Fig. 1). However, the last 10 years have seen a renewed interest in the management of acute stroke patients, accompanied by an increased awareness that patient STROKE PATTBfr 1,2 3/4 Stroke Clinic Assessment/Advice Stroke Ur* Assessment/Advice MuHdfcdplnary rehawtaflon 2 Prevention Correspondence to Dr Peter Langhorne, Academic Section of Geriatric Medicine, 3rd Floor Centre Block, Royal Infirmary, Glasgow G4 OSF, UK Stroke Onk: Advice and 2 Prevention Fig. 1 Comprehensive stroke service. Key: 1, very mild or fully resolved symptoms/disability; 2, mild symptoms/disability; 3, moderate symptoms/disability; 4, severe symptoms/disability. Bnmh Medical Bulletin 2000, 56 (No 2) C The British Council 2000

2 outcomes may be directly influenced by the way services are organised. This chapter will use information from randomised trials and systematic reviews to focus on important issues in the organisation of early stroke care, i.e. the structures and processes of care in the first few weeks after stroke. In addressing the organisation of acute stroke care, the following areas will be discussed: (i) hospital-based care versus home-based care; (ii) organisation of care in hospital; and (ui) discharge and post-discharge care. Home versus hospital In many countries 1, a great majority of stroke patients are admitted to hospital if only for a short period of time. In contrast, the UK has featured a debate around whether hospital-based or home-based care is the most appropriate for acute stroke patients 2 ' 3. Most clinicians are comfortable that patients with transient ischaemic attacks can be managed as out-patients, but there has been uncertainty about whether the routine care of stroke patients should be provided in a hospital or home-based setting. The current interest in acute stroke drug therapies has undoubtedly brought this uncertainty into focus. A recent systematic review 4 has identified three controlled clinical trials which have compared routine processes of care (often involving hospital admission) with a home-based team trying to provide care in the home setting. There was considerable heterogeneity between the different studies with no evidence from either individual studies or combined analyses to support a radical change in stroke care. In fact, there was a trend for greater resource use by those randomised to homebased care. The reviewers concluded that there is currently no evidence to support a radical shift of acute stroke care from hospital-based to home-based services. The picture may be different when considering early discharge services (see below). Hospital-based care The majority of stroke patients in the UK are admitted to hospital at least for a short period of time 1. Recent surveys indicate that stroke patients are often admitted to a variety of different settings and will usually be managed by a general physician or a consultant in geriatric medicine. The main debate around hospital-based care has been whether a patient should be managed in an organised (stroke unit) setting and if British Medical Bulletin 2000,56 (No 2) 437

3 Stroke this adds any benefit over conventional care in general wards. There is a long history of research examining this question with 20 controlled clinical trials identified in a recent systematic review 5. Before proceeding with this discussion we need to define some terms. Terminology Stroke unit The best working definition of a stroke unit is the provision of coordinated multidisciplinary care usually provided within a geographically discreet area such as a stroke ward 6. Typically, these units have a variety of disciplines involved (medical, nursing, physiotherapy, occupational therapy, speech therapy, social work), whose work is coordinated through regular (weekly) multidisciplinary meetings. Type of stroke unit The stroke units can differ in a variety of ways, for example: 1 Acute stroke unit - providing stroke unit care for the first few days after stroke 2 Rehabilitation stroke unit - accepting patients 1-2 weeks after stroke and providing rehabilitation care for several weeks if necessary 3 Comprehensive stroke unit - combining both acute care and rehabilitation for several weeks if necessary 4 Dedicated stroke unit - providing care exclusively for stroke patients 5 Mixed assessment/rehabilitation unit aiming to improve stroke care within a mixed disability setting Effectiveness of stroke units A total of 20 controlled clinical trials have compared organised in-patient (stroke unit) care with conventional care usually provided in general wards 5. Overall, there were significant reductions in the odds of death (odds ratio 0.83: 95% CI : P <0.05), and the combined adverse outcomes of death or requiring institutional care (odds ratio 0.76; 95% CI : P <0.0001) and death or dependency (odds ratio 0.75; 95% CI ; P <0.0001). The overall analysis indicated that, for every 100 stroke patients receiving organised (stroke unit) care, 3 additional patients would survive, 3 would avoid long-term institutional care, and an additional 6 would return home, of whom the majority would be physically independent. These apparent benefits were seen in both male and female patients, those aged above or below 75 years, and in those with mild or severe strokes. The benefits were observed in all types of stroke unit which were able to provide a period of care lasting several weeks if 438 British Medical Bulletin (No 2)

4 necessary (comprehensive stroke units or rehabilitation stroke units). Effective units were housed in a variety of departments including general medicine, geriatric medicine, neurology, and rehabilitation medicine, but all had developed similar processes of care (see below). There was no systematic increase in the length of hospital stay associated with stroke unit care. This is important because in most Western countries the major healthcare costs of acute stroke are from nursing care and hospital overheads 1 and so relate closely to the length of stay. Costs in the longer term are largely attributable to the care of dependent individuals in hospitals or nursing homes 1 and so are likely to be determined by the number of patients with long-term disability. Therefore, it appears that stroke unit care will be more cost effective than conventional care providing long-term disability is reduced without increasing the cost of an episode of in-patient care or the mean length of stay in a hospital or institution. A recent economic analysis 7 indicates that stroke unit care is likely to save resources or provide improved outcomes for a modest increase in the cost. Developing stroke unit care The results of the stroke umt trials indicate that there are ways of improving the quality and outcome of routine stroke patient care in hospital. What lessons can be drawn from the stroke unit trials? Stroke ward or mobile team? Most of the stroke unit trials have evaluated a geographically discreet stroke ward with only one small trial specifically evaluating a mobile stroke team. At present, it seems reasonable to focus care within a stroke ward 6. Firstly, most of the costs of a unit are attributable in the stroke team staff. Secondly, geographically defined units allow nurses to develop skills and act as facilitators for patients' independence and potentially as providers of continued therapy over the full day. Thirdly, stroke units also provide a focus for the development of research, fundraising, and volunteer support groups. Finally, they can also facilitate the use of clinical guidelines and protocols. In practice, geographically defined units often overspill during busy periods and the staff have to operate as a mobile team to outlying patients. Acute or rehabilitation unit? Most of the clinical trial evidence comes from units which have provided a period of care lasting several weeks if necessary. These have included both comprehensive units, which combine acute and rehabilitation care, and rehabilitation units. The former are particularly common in Scandinavia. British Medical Bulletin 2000,56 (No 2) 439

5 Stroke Admitting all patients with stroke directly to a unit does allow the introduction of a standardised approach with assessment and treatment protocols, and may result in the early involvement of therapy staff 6. It can also facilitate research and probably allows skills to be focused. In practice, it is probably important that the process of 'stroke unit' care begins as early as possible and is delivered in a continuous way. Where should the unit be established? Whoever is responsible for stroke care should have the necessary knowledge, training, and enthusiasm to take on the task. In the UK, most stroke patients are managed by general physicians and geriatricians, but stroke patient care can often benefit from specialist input of neurologists. Ideally, the development of stroke units and stroke services in general should draw upon the skill of different individuals to provide the best quality patient care. Stroke unit size and staffing Most of the stroke units in the systematic review were of moderate size (6-15 beds), although some rehabilitation units were larger. The total number of beds should reflect the local stroke incidence and hospital activity. A major challenge is the ability to cope with large fluctuations in stroke patient numbers 6. Stroke units require medical, nursing, physiotherapy, occupational therapy, speech and language therapy and social work input as a basic minimum. A number of other professionals will also have a role in the management of some stroke patients 6. It is difficult to give specific advice on the appropriate staffing levels, but approximate numbers are outlined elsewhere 6. Patient selection criteria There appears to be a good case for offering stroke unit care to a wide range of patients extending at least from those who have mild disability (e.g. initially requiring assistance with walking) through to those with severe strokes (e.g. no sitting balance). The systematic review 5 provides little information to guide the care of patients with very minor stroke or transient ischaemic attacks and those in coma. Where prioritisation is required, it is important to seek local agreement on appropriate triage. Duration of stay Some stroke units set a maximum length of stay, although the only real rationale for this is to allow the management of resources and prevent blocking of beds. An appropriately sized unit with flexible operating procedures ought to be able to provide care until discharge home or placement in alternative care. A splitting of acute stroke care and 440 British Medical Bulletin 2000;56 (No 2)

6 rehabilitation is common, but it is important to ensure that there is a seamless transition of care as if provided by one single unit. Practices and procedures Having focused on aspects of stroke unit structure and policy, what are the important processes of care identified in the systematic review which should be adopted 6? Communication All stroke units had a formal multidisciplinary team meeting at least once per week, lasting between 1-3 h, which was chaired by a senior staff member. These meetings provided a forum for multidisciplinary assessment, identification of problems and for the setting of short and long-term recovery goals. Many units also held less formal meetings on other occasions to ensure effective multidisciplinary working and involvement of carers 6. A distinctive feature of stroke unit care was the early active involvement of carers in the rehabilitation process, including the provision of appropriate information about stroke disease and its management. Care pathways The following care pathways are typical of most stroke units 6. 1 Assessment: each patient would have a full medical assessment, including examination to establish the neurological impairment, routine blood chemistry and haematology and cranial CT scan. Other investigations such as MRI scanning, carotid Doppler ultrasound, and echocardiography were usually reserved for selected patients. Nursing and therapy assessments included the general care needs of the patient, identification of swallowing problems, and an assessment of the risk of developing pressure sores plus an evaluation of impairment and disability. 2 Management: stroke units which provided care in the acute phase have typically included the use of intravenous fluids to prevent and treat dehydration, early use of antibiotics for suspected infections, and measures to prevent DVT and other complications of immobility. These measures include compression stockings, early mobilisation, careful positioning and turning. Nursing management includes careful attention to posture and positioning, appropriate lifting and handling, and regular observation of key variables, e.g. swallowing problems, nutritional status, continence and skin integrity. Therapy input usually begins early, with nurses having a key role in the link between therapy staff and patients, incorporating recommended practices into the everyday handling of the patient. Standardised protocols were often used to detect swallowing problems and prevent aspiranon. The routine use of intravenous fluids and nasogastric supplements were often considered in those with impaired swallowing. British Medical Bulletin 2000,56 (No 2) 441

7 Stroke The subsequent management of the rehabilitation process involved the regular reassessment of impairments and disabilities, multidiscrplinary goal setting (involving patients and carers), and the monitoring of the patient's progress against these goals 6. Discharge planning and post-discharge support In the UK, the conventional approach to stroke patient care is to have a period in hospital with discharge planning at the time when the patient has made sufficient functional recovery to have a reasonable prospect of returning home alone or with the support of a carer. A recent development has been the promotion of an earlier discharge from hospital with increased support and rehabilitation input in the home setting. This has been termed 'early supported discharge' and has been tested in a number of randomised controlled trials. A recent systematic review of the four trials currently available 8 has indicated that these systems of care can shorten the length of hospital stay (by approximately 9 days) and there is a trend towards improved functional outcomes in the longer term. The two trials which have undergone economic analysis 9 " 11 have indicated that there is a margmal balance in favour of early discharge services. A number of trials are currently underway and more information is likely to become available in the future. Conclusions The current evidence on the organisation of acute stroke care suggests the following: There is no evidence to support a radical shift from hospital-based care to home-based care for the acute stage of stroke Within hospital stroke care should be provided in an organised (stroke unit) setting Processes of care within the stroke unit should reflect those of the randomised trials There may be a future role for early supported discharge services with post-discharge rehabilitation and support. References 1 Warlow CP, Bamford J, Dennis MS et al. Stroke: A Practical Guide to Management Oxford: Blackwell Science, Young J. Is stroke better managed in the community? Community care allows patients to reach their full potential BMJ 1994, 309: British Medical Bulletin 2000;56 (No 2)

8 3 Lincoln NB. Only hospitals can provide the required skills. BMJ 1994, 309: Langhorne P, Dennis MS, Kalra L, Shepperd S, Wade DT, Wolfe CDA. Services for helping acute stroke patients avoid hospital admission Oxford: Cochrane Library, Stroke Unit Trialists' Collaboration Organised m-panent (stroke unit) care for stroke Oxford- Cochrane Library, Langhorne P, Dennis M Stroke Units: An Evidence Based Approach. London. BMJ Books, Major K, Walker A. Economics of stroke unit care. In: Langhorne P, Dennis M (eds) Stroke Units: An Evidence Based Approach. London: BMJ Books, 1998, Early Supported Discharge Tnahsts'. Services for reducing duration of hospital care for acute stroke patients. Oxford: Cochrane Library, Rudd AG, Wolfe CDA, Filling K, Beech R. Randomised controlled trial to evaluate early discharge scheme for patients with stroke. BMJ 1997; 315: 1039^4 10 Rodgers H, Soutter J, Kaiser W et al. Early supported hospital discharge following acute stroke pilot study results. Chn Rehabd 1997; 11: McNamee P, Rodgers RH, Craig N, Pearson P, Bond J. Cost analysis of early supported hospital discharge for stroke. Age Ageing 1998; 27: British Medical Bulletin 2000,56 (No 2) 443