2. Stroke Rehabilitation Unit Care

6th Edition - 2019 UPDATED

2.1 Stroke Rehabilitation Unit Care

All people who require inpatient rehabilitation following stroke should be treated on a specialized stroke rehabilitation unit [Evidence Level A], characterized by the following elements:
1. Rehabilitation care is formally coordinated and organized [Evidence Level A].
2. The rehabilitation unit is geographically defined [Evidence Level A].
3. The rehabilitation unit is staffed by an interdisciplinary rehabilitation team with expertise/core training in stroke rehabilitation consisting of physicians (i.e., physiatrist, neurologist, or other physicians with training in stroke rehabilitation), nurses, physiotherapists, occupational therapists, speech-language pathologists, social workers, and clinical dietitians [Evidence Level A].
4. Additional members of the interdisciplinary team may include pharmacists, transition planners, (neuro) psychologists, palliative care specialists, recreation and vocational therapists, kinesiologists, therapy assistants, spiritual care providers, peer supporters and stroke recovery group liaisons [Evidence Level C].
5. People who have experienced a stroke, their families and caregivers should have early and active involvement in the rehabilitation process [Evidence Level B].
6. The interdisciplinary rehabilitation team follows evidence-based best practices as defined by current consensus-based clinical practice guidelines [Evidence Level B].
7. Transition and discharge planning is initiated on admission to the unit [Evidence Level B]. Refer to CSBPR Transitions and Community Participation module, Section 3 for additional information on care planning.
8. Education for the person who experienced a stroke, the family and caregivers is provided both formally and informally, with consideration given to individual and group settings as appropriate [Evidence Level A]. Refer to the CSBPR Transitions and Community Participation module, Section 2 for additional information on education following stroke.
9. All team members should be trained and capable of interacting with people with communication limitations such as aphasia, by using supported conversation techniques [Evidence Level C].
People who have experienced a moderate or severe stroke, who are ready for rehabilitation and have goals amenable to rehabilitation, should be given an opportunity to participate in inpatient stroke rehabilitation [Evidence Level A].
Where admission to a stroke rehabilitation unit is not possible, inpatient rehabilitation provided on a general rehabilitation unit is the next best alternative (i.e., where interdisciplinary care is provided to patients disabled by a range of disorders including stroke), where a physiatrist, occupational therapist, physiotherapist and speech-language pathologist are available on the unit or by consultation [Evidence Level B].
1. Patients treated on general rehabilitation units should receive the same levels of care and interventions as patients treated on stroke rehabilitation units, as described in section 2.1 (I and ii).

2.2 Stroke Rehabilitation Team

Note: Applicable for all stroke rehabilitation settings (acute care hospital, outpatient clinic, community-based services and programs)

2.2 Stroke rehabilitation should be delivered by an interdisciplinary team of health professionals, experienced in providing post-stroke care, regardless of where services are provided, to ensure consistency and reduce the risk of complications [Evidence Level B].

The interdisciplinary rehabilitation team should assess patients within 48 hours of admission and together with the patient and family develop and document a comprehensive individualized rehabilitation plan which reflects the severity of the stroke and the needs and goals of the patient, the best available research evidence, and clinical judgment [Evidence Level C].
Stroke unit teams should conduct at least one formal interdisciplinary meeting per week to identify ongoing or new rehabilitation problems, set goals, monitor progress, and plan discharge for patients on the unit [Evidence Level B]. Individualized rehabilitation plans should be regularly updated based on review of patient status [Evidence Level C].
Clinicians should consider use of standardized, valid assessment tools to evaluate the patient’s stroke-related impairments, functional activity limitations, and role participation restrictions. Tools should be adapted for use in patients with communication limitations due to aphasia [Evidence Level C]. Refer to Table 1: Stroke Rehabilitation Screening and Assessment Tools.
Personal factors (such as coping) and environmental factors could also be considered. [Evidence Level C].

Rationale +-

There is strong and compelling evidence in favour of admitting patients with moderate and severe stroke to a geographically defined stroke rehabilitation unit staffed by an interdisciplinary team. Death and disability are reduced when post-acute stroke patients receive coordinated, interdisciplinary evaluation and intervention on a stroke rehabilitation unit. For every 100 patients receiving organized inpatient interdisciplinary rehabilitation, an extra five return home in an independent state (Stroke Unit Trialists’ Collaboration, 1997).

System Implications +-

To ensure patients receive best practice stroke rehabilitation care, health systems funders and organizations must plan for:

Timely access to specialized inpatient stroke rehabilitation services.
An adequate number of geographically defined stroke rehabilitation units with a critical mass of trained staff with expertise in stroke rehabilitation interdisciplinary team care during the rehabilitation period following stroke.
Resources to enable patient access to appropriate type and intensity of rehabilitation professionals throughout their stay (including weekends when required).
Protocols and strategies to prevent complications and the recurrence of stroke developed and communicated to all staff.
System and process changes to allow therapists to ensure effective therapist to patient ratios in rehabilitation settings, with the goal of therapists spending approximately 80% of their time providing direct care to patients.

Performance Measures +-

Number of stroke patients treated in a geographically defined stroke rehabilitation unit at any time during their inpatient rehabilitation phase following an acute stroke event (core).
Final discharge disposition for stroke patients following inpatient rehabilitation: percentage discharged to their original place of residence; percentage discharged to a long-term care facility or nursing home; percentage requiring readmission to an acute care hospital for stroke-related causes; percentage of patients discharged back to the community who were residing in a community setting prior to their stroke (core).
Number of stroke patients assessed by a physiotherapist, occupational therapist, speech–language pathologist, dietitian, and social workers during inpatient rehabilitation.
Proportion of total time during inpatient rehabilitation following an acute stroke event that is spent on a stroke rehabilitation unit.
Frequency, duration and intensity of therapies received from rehabilitation professionals while in an inpatient rehabilitation setting following stroke.
Change in functional status measured with a standardized measurement tool, from time of admission to an inpatient rehabilitation unit for stroke patients to the time of discharge.

Measurement Notes:

Performance measure 1: The denominator should be the total number of stroke patients admitted to inpatient rehabilitation.
Performance measure 2: Data should be correlated with stroke severity scores during analysis.
To determine the duration and intensity of services by rehabilitation professionals, a chart review is required or the availability of consistent use of reliable workload measurement tools that are implemented locally or regionally.

Implementation Resources and Knowledge Transfer Tools +-

Health Care Provider Information

Information for People with Stroke, their Families and Caregivers

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). The different forms of rehabilitation services varied and included acute, intensive and semi-intensive models, comprehensive models, which combined acute and rehabilitation services, comprehensive stroke units that integrated Traditional Chinese Medicine, stroke rehabilitation units (with post-acute transfer to a separate unit or facility), mobile stroke units and mixed rehabilitation units, where patients with other neurological conditions are admitted. The majority of trials in this updated review compared stroke wards with general medical wards. Overall, 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.

In subgroup analysis of 3 trials that compared stroke rehabilitation units versus an alternative service, the odds of death at end of follow-up were reduced significantly (OR=0.51, 95% CI 0.29-0.90, p=0.019), while the odds of death or institutionalization dependency, death or dependency and hospital LOS, were not reduced. In another systematic review, Foley et al. (2007) examined the effectiveness of 3 different models of stroke rehabilitation including acute stroke unit care, comprehensive models and stroke rehabilitation units. Using data from the 5 studies that compared stroke rehabilitation unit care with either general medical ward or community-based care, post-acute rehabilitation stroke units were associated with reduced odds of death (OR=0.60, 95% CI 0.44 to 0.81, p<0.05) and death or dependency (OR=0.63, 95% CI 0.48 to 0.83, p<0.05), but without a significant reduction in hospital LOS.

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. In most cases, studies compared acute stroke units with conventional 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).

2. Stroke Rehabilitation Unit Care

2.1 Stroke Rehabilitation Unit Care

2.2 Stroke Rehabilitation Team

Stroke Resources