Stroke Units

1. Stroke Units May 2013 Inservice

2. This inservice is an opinion piece authored by Isobel, and based on her “read” of the evidence. Please note: all health professionals should refer to, and critically appraise the relevant, available evidence for themselves Objectives • This inservice will: • Explore the history of Stroke Units • Define five different Stroke Unit models • Investigate the impact of Stroke Unit care in today’s health service • Raise one issue of concern Stroke Unit care is the single, most effective intervention that is currently available to most people diagnosed with a stroke that’s less than 4 weeks post-event.

3. The History of Stroke Units When were Stroke Units first introduced and why?

4. History of Stroke Units • Back in 1998, Langhorne and Dennis reported their original findings as a British Medical Journal booklet titled: "Stroke Units: An evidence based approach". • These authors coined the phrase "Stroke Units". • Since then, the group of authors publishing ongoing results refer to themselves as the Stroke Unit Trialists Collaboration (SUTC) • Their evidence has demonstrated that people cared for in Stroke Units are 20% more likely to survive, go home and be independent!! • Therefore, Stroke Units are the single, most effective intervention currently available to most people diagnosed with recent stroke A truly amazing intervention! But, as most of you will realise, Stroke Units were introduced prior to the advent of post-stroke thrombolysis, and in turn, the introduction of Acute Stroke Units.

5. What’s so special about Stroke Units? Good question! • What did Langhorne & Dennis (1998) define as a Stroke Unit? • What they found was that “organised” care post-stroke was responsible for the 20% -better benefit. • They found “organised care” (Stroke Unit care) had 5 significant components: • Geographically-designated stroke beds • A multi-professional (MP) team approach • An MP team that was enthused and educated in stroke • An MP that met formally at least once a week • Early involvement of the family

6. Different Stroke Models of Care (Units) Different hospitals have different Stroke Units. What are they and how do they differ?

7. Multiplicity of Stroke Units As you’ll see, it’s only the Comprehensive Stroke Unit that offers “all of the above” • From my experience and my ‘read’ of the evidence, there are currently 5 different stroke models of care. All of these models have a multi-professional team and geographically-designated beds. • In no particular order, they are:

8. Stroke Unit Models in more detail. The Stroke Unit, which was the original model of care, obviously, was demonstrated to be sooooo…. effective that they were introduced in as many hospitals as possible. The evidence was simply too difficult to ignore! This is one of the great success stories of applying an evidence-based approach. But, evidence is a shifting landscape as this unfolding story demonstrates. Evidence demonstrating the efficacy of post-stroke thrombolysis meant that the SU model was not sufficient. Hence the multiplicity of models as Stroke teams responded to the emerging evidence. • The Hyper-acute Stroke Unit (HASU). This is the most recently introduced model. It provides 24 hour, intensive care, to people who are only a few hours post-stroke. • The Acute Stroke Unit (ASU), provides 24 hour monitoring in the first few hours, and semi-intensive monitoring in the first few days. After that, patients must be transferred to…??..hmm.. • A Comprehensive Stroke Unit (CSU) is what I’d want to be admitted to if I’d been diagnosed with stroke. It’s a one-stop shop where patients can stay for their entire admission. • A Stroke Rehabilitation Unit is usually a set of stroke-designated beds that are part of a larger Rehabilitation Unit.

9. Impact of Stroke Units today Does it matter which Stroke Unit model is being used?

10. Impact of Stroke Units • Despite the unfolding Stroke Unit story, the Stroke Unit Trialists’ Collaboration (SUTC) evidence still stands. To date, no other intervention has been shown to have a 20%-better benefit. • As opposed to post-stroke thrombolysis, Stroke Unit care is simply a reorganisation of what is usually already there! Nurses, doctors, therapists and some neurobeds. • Designate some beds, introduce stroke education, employ the enthused, formalise the team meetings and involve the carers and hey presto - you have a Stroke Unit! • Thousands of Stroke Units have been established across the world in response to this watershed evidence. It has quite literally, revolutionised how we ‘do’ stroke

11. Want to know more about Stroke Units? Go to…… • The Cochrane Library: http://summaries.cochrane.org/CD000197/organised-inpatient-stroke-unit-care-for-stroke • Google and search for Stroke Units and Langhorne and you’ll find articles like these two: • Stroke Unit Trialists’ Collaboration (1997) How do Stroke Units improve patient outcomes? Stroke, 28, 2139-2144 • Langhorne, Pollack et al (2002) What are the components of effective Stroke Unit care? Age and Aging, 31(5), 365-371 • YouTube and search for Langhorne and Stroke Units and you’ll find a series of interesting presentations

12. Stroke Units: Concerning Issue Something to think about!

13. But, as I said right at the start, this is just my humble opinion. Please don’t get me wrong, I’m certainly not against Acute Stroke Units; just concerned that they may be denying some patients the additional benefits of Stroke Unit Care….hmmm….time will tell… A Concerns that I have • Because the Stroke Unit evidence is so compelling, I have one major concern. • As I alluded to before, are some patients being classified as receiving “Stroke Unit” care, when that care may have only been provided to them for a couple of days? Let me explain………. • More hospitals have an Acute Stroke Unit (ASU), but, if a patient receives 2 days of ASU care and is then transferred onto the neurology ward, and, in a few days time, transferred on to a rehabilitation facility, can we claim they have received Stroke Unit care? • I’m not sure and this is my concern………..