Stroke Units Southern Neurology

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

Meta-analysis of Acute Stroke Unit Care vs Admission to General Medical Ward (“Western” populations) After median 1 year follow up:

Odds Ratio of Death or Requiring long term Institution <75 years old >75 years old Mild Stroke Moderate Severity Severe Stroke Geriatric Medicine General Medicine Neurology Rehabilitation

Cochrane Review Main findings of 23 trials compared with alternative services, stroke unit showed reductions in odds of death recorded at final (median 1 year) follow-up (OR 0.86; 95% CI ) compared with alternative services, stroke unit showed reductions in odds of death recorded at final (median 1 year) follow-up (OR 0.86; 95% CI )

reduced odds of death or institutionalised care reduced odds of death or institutionalised care (OR=0.8; CI ) reduced death or dependency reduced death or dependency (OR= 0.78; CI )

Of 23 Trials number needed to treat (NNTT) Approx. absolute figures for numbers of stroke unit and alternative care patients in various outcome 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)

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

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

World-wide and local experience Stroke Unit care has been shown to reduce case fatality in UK by 25% Stroke Unit care has been shown to reduce case fatality in UK by 25% Benefit shown in recent Chinese stroke studies Benefit shown in recent Chinese stroke studies Benefit of stroke unit care still evident at 10 years post- stroke in Norwegian study where patients were admitted to combined acute stroke and rehabilitation unit Benefit of stroke unit care still evident at 10 years post- stroke in Norwegian study where patients were admitted to combined acute stroke and rehabilitation unit However, less than 10% of stroke patients are admitted to dedicated stroke units in regional Italy and in Austria However, less than 10% of stroke patients are admitted to dedicated stroke units in regional Italy and in Austria As of start of 2004, only 23% of Australian hospitals were offering dedicated stroke unit care As of start of 2004, only 23% of Australian hospitals were offering dedicated stroke unit care

Stroke units - how do they work? Stroke unit benefits are seen within first 10 days – in one study of 802 patients, the case fatality rate in 1 st 10 days was 8.2% amongst patients in stroke unit and 15.1% in general ward (p=0.02) [Stroke 1998; 29:58- 62]. Stroke unit benefits are seen within first 10 days – in one study of 802 patients, the case fatality rate in 1 st 10 days was 8.2% amongst patients in stroke unit and 15.1% in general ward (p=0.02) [Stroke 1998; 29:58- 62]. Stroke Unit Trialists Collaboration showed that reduction in case fatality of patients managed in stroke unit setting developed between 1 and 4 weeks after index stroke. Reduction in odds of death was evident across all causes of death and most marked for those deaths considered to be secondary to immobility [Stroke 1997; 11: ]. Stroke Unit Trialists Collaboration showed that reduction in case fatality of patients managed in stroke unit setting developed between 1 and 4 weeks after index stroke. Reduction in odds of death was evident across all causes of death and most marked for those deaths considered to be secondary to immobility [Stroke 1997; 11: ].

Processes of Care There is a greater adherence rate to selected processes of care in a stroke unit (75%) versus mobile service (65%) versus conventional care (52%) (p<0.001). There is a greater adherence rate to selected processes of care in a stroke unit (75%) versus mobile service (65%) versus conventional care (52%) (p<0.001). The adjusted odds of patients being alive at discharge if adhering to all but one process of care is significant (aOR 3.63; 95% CI ; p=0.04) The adjusted odds of patients being alive at discharge if adhering to all but one process of care is significant (aOR 3.63; 95% CI ; p=0.04) [Stroke 2004; 35: ]

Statistically Significant Differences between a Stroke Unit and General Ward (Stroke 1998; 29: )

Patient characteristics ? Do they matter Stroke Unit Trialists’ Collaboration found that beneficial effects in relation to death and dependency are independent of patient’s age, sex, stroke severity and variations of stroke unit organisation. However, it is not clear whether patient and system factors affect length of stay or FIM gain. Stroke Unit Trialists’ Collaboration found that beneficial effects in relation to death and dependency are independent of patient’s age, sex, stroke severity and variations of stroke unit organisation. However, it is not clear whether patient and system factors affect length of stay or FIM gain. A recent study comparing stroke unit versus stroke team care found that stroke unit care at 3 months and 1 year was better for large vessel strokes in terms of mortality or institutionalisation but there was no benefit for lacunar strokes. Furthermore, lacunar strokes had longer LOS (18 versus 13.5 days) when cared for in a stroke unit [Stroke 2002; 33:449-55]. A recent study comparing stroke unit versus stroke team care found that stroke unit care at 3 months and 1 year was better for large vessel strokes in terms of mortality or institutionalisation but there was no benefit for lacunar strokes. Furthermore, lacunar strokes had longer LOS (18 versus 13.5 days) when cared for in a stroke unit [Stroke 2002; 33:449-55].

Benefits of early mobilisation and social interaction Stroke unit patients spend more time out of bed and out of their bay or room. There are more observed attempts on the stroke unit than on the general ward to interact with drowsy, cognitively or speech impaired patients. Stroke unit patients spend more time out of bed and out of their bay or room. There are more observed attempts on the stroke unit than on the general ward to interact with drowsy, cognitively or speech impaired patients. Stroke unit patients spend more time with visitors Stroke unit patients spend more time with visitors [Age Ageing 1999; 28:433-40]

Benefits of cardiac-respiratory monitoring Monitoring in a SU is associated with a increased recognition of adverse changes which require acute medical treatment and shorter duration of these complications [Stroke 2003; 34: ]. Monitoring in a SU is associated with a increased recognition of adverse changes which require acute medical treatment and shorter duration of these complications [Stroke 2003; 34: ]. At 1-year, mortality and combined mortality and dependency are not different if patients are admitted to a semi-intensive SU (72 hr monitoring of cardiac, respiratory, metabolic and neurological functions) versus conventional SU if all stroke severity types are included. However, OR of mortality for semi-intensive SU is 0.19 (95% CI ) in patients with severe stroke (CSS< or=4) [Cerebrovasc Dis 2005; 19:23-30]. At 1-year, mortality and combined mortality and dependency are not different if patients are admitted to a semi-intensive SU (72 hr monitoring of cardiac, respiratory, metabolic and neurological functions) versus conventional SU if all stroke severity types are included. However, OR of mortality for semi-intensive SU is 0.19 (95% CI ) in patients with severe stroke (CSS< or=4) [Cerebrovasc Dis 2005; 19:23-30].

Cost-benefit analysis of SU versus other models A study of 457 patients randomised (152 to SU, 152 to stroke team and 153 to domiciliary stroke care). Mortality or institutionalisation at 1 year was significantly lower in the SU group [14%] when compared to stroke team [30%, p<0.001] or domiciliary care [24%, p=0.03. A study of 457 patients randomised (152 to SU, 152 to stroke team and 153 to domiciliary stroke care). Mortality or institutionalisation at 1 year was significantly lower in the SU group [14%] when compared to stroke team [30%, p<0.001] or domiciliary care [24%, p=0.03. The total costs of stroke per patient over the 12 month period were 11,450 pound for SU, 9527 pound for stroke team and 6840 pound for domiciliary care. The total costs of stroke per patient over the 12 month period were 11,450 pound for SU, 9527 pound for stroke team and 6840 pound for domiciliary care. The mean costs per day alive for the stroke unit were significantly less than the stroke team but no different from domiciliary care patients The mean costs per day alive for the stroke unit were significantly less than the stroke team but no different from domiciliary care patients [Health Technol Assess 2005; 9: 1-94]

Different Models Acute Acute Comprehensive (? best) Comprehensive (? best) Mobile stroke team (not as good) Mobile stroke team (not as good) Rehab Rehab Mixed rehab Mixed rehab General medical ward (not as good) General medical ward (not as good)