Key points

Stroke units are the cornerstone of quality stroke care.

The benefits of stroke unit care are supported by a very strong evidence base

In 2007 the National Stroke Strategy mandated that all stroke patients should have prompt access to stroke unit care.

Despite policy and guidelines, only 62% stroke patients were treated on specialist stroke units in 2010.

Patients spend long periods of inactivity on stroke units; multidisciplinary teams need to encourage rehabilitation activities outside therapy sessions.

Rehabilitation needs to be family- and carer-oriented to prepare patients for life after discharge.

1 Introduction

Twenty years ago, stroke rehabilitation was given low priority by health care professionals and planners: it was considered to be at the periphery of health service provision. A Consensus Conference on Stroke was held in London in 1988 with invited experts. It concluded that services for stroke patients were haphazard, with no clear policy on planning or implementation (1). There was a striking lack of convincing evidence for widely used rehabilitative treatments and a serious shortage of treatment—patients were unoccupied for long periods. This picture of disorganized and ineffective care was further strengthened by outcome studies showing significant variations in case fatality and levels of independence after treatment across different areas of the country (2). The studies indicated poor performance on these measures when the UK was compared with other Western European and international centres (3).

In contrast, the National Stroke Strategy in 2007 (4) mandated that all stroke patients have prompt access to an acute stroke unit and spend the majority of their time at hospital in a stroke unit with high-quality stroke specialist care. This was based on overwhelming evidence that stroke units reduce death and increase the number of independent and non-institutionalized individuals, with proven benefits for five and ten years. An estimation of this benefit is provided by the National Sentinel Audit report, which calculated that if timely access to stroke units were increased to 75% of stroke patients, this would prevent more than 500 deaths per year and result in more than 200 more independent individuals (5).

The remarkable transition of stroke management from being in the shadows to its prominent position in UK health care today is testimony to the impact that research has on improving clinical care and patient outcomes. It is true that another major development—the introduction of thrombolysis for acute stroke patients in clinical practice—has revolutionized the management of stroke patients, but the trial benefits of thrombolysis do not translate equally into clinical effectiveness in mainstream practice (6). The proportion of patients with ischaemic stroke varies between settings, and the 4.5-hour time window for thrombolysis severely limits the benefits of an otherwise powerful intervention. Many studies have shown that only 25–33% of patients present to hospitals within thrombolysis time windows onset (7) and only a small proportion, 5–20%, of incident ischaemic stroke actually end up being thrombolyzed. Although National Stroke Audit data show that the thrombolysis rates rose from 1–2% to 5% of the stroke population with the implementation of the National Stroke Strategy, the majority of stroke patients remain excluded from the benefits of thrombolysis. In contrast, stroke units can benefit the vast majority of stroke patients regardless of pathology or time of presentation (8).

2 The rationale for stroke unit care

As early as the 1990s, research showed that organized care provided on stroke units facilitates neurological recovery and expedites discharges (Figure 13.1) (9). More recently, positron emission tomography (PET) and magnetic resonance imaging (MRI) studies have confirmed the concept of brain plasticity, which implies that it is possible to modulate or facilitate reorganization of cerebral processes by external inputs (10). The paradigm for function has shifted from strict cerebral localization to that of interactive functioning multiple motor circuits activated by the constantly changing balance of inhibitory and excitatory impulses. Disruption of major pathways in stroke reduces the inhibition normally exerted by these pathways and allows activation of alternate pathways, which take over the function of the damaged circuits. Furthermore, neuroimaging studies have shown that increased intensity of therapy results in greater activation of areas associated with the function towards which therapy was directed (11). Hence, evidence suggests that the human brain is capable of significant recovery after stroke, provided that the appropriate treatments and stimuli are applied in adequate amounts and at the right time. It is likely that this is achieved better with organized stroke care, where the intensity and timing of interventions can be managed proactively.

**Fig. 13.1** The effect of stroke units on the speed and extent of functional recovery (Barthel Index) and weeks to discharge from inpatient settings (8).

A = Barthel Index of patients managed on the stroke rehabilitation unit (●, ■)B = Barthel Index of patients managed on general medical wards (❍,□ )A vs B, p = 0.001

Stroke affects several domains of human performance and results in multiple impairments, many of which interact to determine the level of disability. No single discipline has all the skills, resources, and expertise required to manage all impairments associated with stroke. Furthermore, different impairments recover at different speeds, requiring a staged approach to therapy interventions. Rehabilitation goals are also shaped by personal needs of stroke patients, the environment they will return to, and the personal support available after discharge. Hence, the complex interdisciplinary process of stroke rehabilitation requires a multidisciplinary approach and collaborative policy of coordinated delivery of treatments. Such treatments need to be based on comprehensive assessments and delivered by staff trained in stroke management, in consultation with patients and their caregivers. This level of coordination of care is another argument in support of specialist stroke units (12).

3 The evidence for stroke unit care

In the 1980s and 1990s, a number of randomized controlled trials suggested that organized care offers advantages to patients with stroke. However, many of these studies were too small to demonstrate a robust statistical benefit. Studies were also undertaken in different settings, using different methods of organized care, and using stroke patients at varying duration from stroke onset. Interventions ranged from acute dedicated units to teams providing coordinated care in community settings; the patients ranged from those within a few hours of stroke onset to those included only when they were neurologically and medically stable. In order to obtain meaningful evidence relevant to clinical practice, the Stroke Unit Trialists’ Collaboration (SUTC) pooled data from all studies that met strict inclusion and quality-control criteria from different centres. The meta-analysis of pooled data from 29 trials, which include 6,536 patients, shows odds reductions in mortality of 0.86 (95% CI: 0.71–0.94), death or dependence of 0.78 (95% CI: 0.68–0.89), and death or institution of 0.80 (95% CI: 0.71–0.90) at one year are associated with organized care, independent of age and gender (13). More important, and in contrast with thrombolysis for acute stroke, these benefits are seen for all stroke patients regardless of stroke aetiology or the duration between stroke onset and intervention. Furthermore, the translation of trial efficacy outcomes into clinical effectiveness in mainstream practice has been demonstrated in longitudinal studies (14).

4 Processes that contribute to a good outcome

Organized stroke unit care is considered a ‘black box’ intervention: there is no one single process of care or intervention that has been shown to be responsible for better outcomes. A major problem in the generalizability of different interventions or processes of care is that most stroke units have evolved in response to local patient needs, priorities, and service arrangements, which may not be replicated in other settings (15). Hence, the same process may have a different impact on outcomes on different units, depending upon case mix, the type of unit, and the environment in which the unit functions. Survival is strongly associated, however, with processes of care that are carried out significantly more frequently on stroke units. These include comprehensive and early stroke-specific assessments, particularly assessments for swallowing and aspiration risk, early detection and management of infections, maintenance of hydration and nutrition, early mobilization, clear goals for function, and communication with patients and their families (16). In addition to doctors and nurses, speech and language therapists, physiotherapists, occupational therapists, and dieticians have specific contributions to make in delivering these particular aspects of care. The probable explanation for higher survival and lower institutionalization rates on stroke units are attributable to improved medical management, prevention of complications, and coordination of multidisciplinary care.

5 Issues in providing stroke unit care

Although evidence strongly supports stroke units for reducing mortality, dependence, and institutionalization in stroke patients, the benefits expected from stroke units are not fully realized in day-to-day clinical practice. The National Stroke Audit in 2000 showed that only 18% of patients were managed on a stroke unit for the majority of their stay. By 2010 this rose to 62%, but it still implies that more than one in three patients are denied stroke unit care. In England the number of hospitals with a stroke unit increased from 40% to 98% between 2000 and 2010, but—despite all the investments made into stroke care—there are still disparities in stroke outcome between centres in the UK. Very often, poor outcomes are attributed to the lack of investment, but comparisons show that the UK spends more than most of its European neighbours on stroke care, especially on specialist stroke services (17). Possible explanations include differences between what has been recommended and what actually has been implemented in the organization of stroke services, compliance of the staff with multidisciplinary guidelines, variations in how multidisciplinary teams function, and the tailoring of rehabilitation to the priorities of stroke patients and their caregivers.