Acute Stroke Units: Achieving the best hospital care for Irish stroke sufferers By: Dr Peter Kelly MD MS MRCPI
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In the last ten years, it has become recognized that patients with acute stroke may achieve improved recovery if they are treated in an Acute Stroke Unit following their admission to hospital.

This has led to the introduction of Stroke Units in many countries in Europe and other parts of the developed world, similar to the widwspread introduction of acute Coronary Care Units in the 1970s.

Unlike similar developments in some other fields of medical care, the effect of Stroke Unit care has been carefully studied in clinical trials. Recently the UK-based Cochrane collaborative group analysed the result of 22 separate studies of Stroke Unit care. Compared to care on a General Medical Ward, these studies indicated that Stroke Unit care reduced the chance of death or serious disability following stroke by 22%, and reduced the liklihood of death following stroke by 16%. The liklihood of these figures being due to a chance finding was less than 1 in 1,000, indicating that proof of the benefits of Stroke Units had been established with a high degree of scientific accuracy.

The size of these benefits are about the same as can reasonably be expected from the introduction of a new medical intervention (e.g. a drug) for stroke patients. However, unlike some drugs, which can only benefit a small number of selected patients with stroke, the benefits of Stroke Unit care may be gained by most patients admitted to hospital with acute Stroke. Therefore, the large-scale impact of Stroke Unit care on mortality, disability, and reduction of hospital costs is likely to be substantial.

TYPES OF STROKE UNITS:

Two main types of Stroke Units have been developed in Europe and North America. Acute Stroke Units focus on treatment of patients in the immediate hours and days following their stroke, with the aim of identifying the cause of stroke, starting appropriate medical treatments, and beginning early rehabilitation. By their nature Acute Stroke Units are based in acute medical hospitals.

Stroke Rehabilitation Units focus on providing intensive inpatient rehabilitation for weeks or months, after the acute medical treatments and assessments have been completed. The patient is kept in a hospital setting so that they can have high-intensity rehabilitation after the acute medical concerns have been stabilized. In many European countries and the USA, these Rehabilitation Units are based in specialised rehabilitation hospitals. "Fast-track" admission systems are often set up between acute hospitals and off-site Stroke Rehabilitation Units. These allow a patient to bypass the Casualty Department and be reassessed in the acute hospital without delay if the need arises. Unfortunately, hospital and community rehabilitation services remain under-developed in Ireland, so that many Irish patients with stroke remain in acute general hospitals for prolonged periods.

GOALS OF STROKE UNIT CARE:

The principle behind Stroke Unit care is straightforward. The goal is to treat patients in the early hours and days following their stroke in a specialised area within the hospital, where they are assessed and treated by staff with special expertise in stroke management. Patients are cared for by a multidisciplinary team who work closely together, and are skilled in all aspects of care of patients with stroke. The team is usually led by a Consultant Stroke Physician, and includes trainee Hospital Doctors, trained Nurses, Physiotherapists, Occupational Therapists, Speech and Language Therapists, a Nutritionist and a Medical Social Worker.

Specialist medical care in this crucial early period is important to establish the cause of the stroke, and take measures to prevent an early recurrence. A brain scan (CT or MRI) is performed to gather information about the type of stroke (Table1) and exclude other conditions such as brain infections and tumours. This provides essential information to direct further treatment. Often, evaluations of the heart are performed such as blood testing, cardiac ultrasound and cardiac rhythm monitoting. (Table 2)

Many patients are started on antithrombotic medications (blood thinners) such as asprin, warfarin, or sometimes intravenous heparin. Some patients benefit from early surgical treatments such as aneurysm clipping (for subarachnoid haemorrhage) or carotid endarterectomy (for stroke due to narrowing of the carotid artery). Medical treatment is usually begun to limit the size of the stroke, and to anticipate and prevent common complications, such as oedema (brain swelling), haemorrhage conversion (bleeding into the stroke), pneumonia, urinary sepsis (bladder infections) and life-threatening blood clots in the legs and lungs (venous thrombosis).

Each component of the team has an important contribution to improving the overall outcome of the patient. Skilled nursing care is essential for neurological observation of acutely-ill patients with severe stroke, preventing skin complications such as pressure ulceration, preventing incontinence, managing behavioural problems, and counselling the patient and family members. Early rehabilitation (physiotherapy and occupational therapy) prevents medical complications of immobility and promotes recovery of strength and function. Prompt evaluation by a Speech and Language therapist frequently prevents pneumonia due to spillage of food into the airways in patients whose cough reflex has been weakened following their stroke. Language rehabilitation is also essential for patients whose stroke has resulted in language impairment (aphasia). For patients with severe stroke which has affected their ability to swallow food and liquids, early evaluation by a Nutritionist is important to prevent malnutrition, which can predispose to serious infections and prevent effective rehabilitation.

THE MATER UNIVERSITY HOSPITAL ACUTE STROKE UNIT

At the Mater Hospital in Dublin, an Acute Stroke Unit was established in 2002. The Unit currently comprises a protected 6-bedded ward, with anticipated expansion to two wards in July 2004. The Unit has its own rehabilitation gym and equipment, separate from the main rehabilitation departments in the hospital. Computer monitors for viewing brainCT and MRI scans are available so that the medical team do not have to travel to the Xray department to review scans.

The Unit is led jointly by Consultant Neurologists and Consultants in Medicine for the Elderly at the Mater. Dedicated nursing staff, a Clinical Nurse Specialist, Physiotherapists and Occupational Therapist, Speech and Language Therapist, Nutritionist and Medical Social Worker comprise the multidisciplinary team. An Acute Stroke team assesses patients in the Accident and Emergency Department, CT brain scan is performed, and patients are directly admitted to the Stroke Unit from A+E or following a brief stay in the Acute Medical Unit. After acute medical treatment and evaluation is complete, younger patients (under 65 years) are discharged from the Unit to home, or to continued rehabilitation under the care of the Neurology service, while older patients (over 65) will have continued rehabilitation under the care of the Medicine for the Elderly service. Coordinated care is achieved by a weekly team meeting, and weekly joint medical Stroke Unit rounds by the Neurology and Medicine for the Elderly teams. Following discharge, continuous care is provided by follow-up at the hospital Stroke Prevention Clinic, in close cooperation with the General Practitioner and community services. To increase the capacity of the Unit to admit patients who are medically-unstable following their stroke, an off-site Stroke Rehabilitation Unit is being developed. A pilot programme is operated with the Stroke Volunteer Group, who visit patients in the Unit to assist with the transition back to the community following discharge.

STROKE UNITS IN IRELAND

The Stroke Council of the Irish Heart Foundation has recommended that all Irish hospitals who admit patients with acute stroke develop Stroke Units, led by a trained Stroke Physician (Consultant Neurologist or Geriatrician). While the format of these Units may vary according to local hospital needs, they all share the key requirements of a dedicated area within the hospital, trained nursing and rehabilitation staff, and access to brain imaging (usually CT scan) and other support services.

Unfortunately, very few acute hospitals in Ireland have developed Stroke Units to date. For hospitals in large population centres, the combined approach (Neurology/Medicine for the Elderly) which have operated sucessfully at the Mater offers an efficient model to provide a high quality of care for stroke patients comparable to international best practice in an Irish setting. For regional or local hospitals, smaller Units may be feasible. Regardless of the exact format, the widespread introduction of Stroke Units should be a priority to provide the highest standards of hospital care for all patients with stroke in Ireland in the future.