organised management teams for stroke

Organised Management Teams for StrokeWhat Are They and What Are Their Advantages?

David Spriggs1 and Suzanne Busch2

1 Waitakere Hospital, Auckland, New Zealand2 North Shore Hospital, Auckland, New Zealand

Abstract Stroke units have been shown to improve the outcome of individuals admittedto hospital with acute stroke when compared with standard care in hospitals. Thisimprovement is seen in mortality, discharge destination and disability levels. Thecost effectiveness and the precise intervention that improves the outcome in suchunits is not certain; however, a coordinated, multidisciplinary approach by pro-fessionals with an interest in stroke is clearly superior to other forms of acutestroke treatment.

LEADING ARTICLE CNS Drugs 1998 Dec; 10 (6): 399-4041172-7047/98/0012-0399/$03.00/0

© Adis International Limited. All rights reserved.

Stroke is a common condition and a leading causeof death and disability in the Western world. Medicalintervention in the short term management of thiscondition to date has been disappointing. Strokeunits were first established 20 to 30 years ago; sincethat time, their principles have been adopted in vari-ous forms and studied with respect to outcomes.

1. What Is a Stroke Unit or Team?

The acute stroke unit admits patients directlyand offers intensive management during the firstweek of hospital stay. It is made up of a team con-sisting of physician, nurse, physiotherapist, occupa-tional therapist, speech therapist and social worker.The focus is on the short term treatment of strokeand its complications, as well as early rehabilita-tion. Such units frequently have established guide-lines for the early detection and management ofcomplications of stroke, and regular staff trainingsessions.

The rehabilitation stroke unit usually admits pa-tients within the first 2 weeks of the acute stroke.It consists of the same multidisciplinary team ap-proach as the acute stroke unit team. Both of these

models include frequent multidisciplinary team meet-ings. They can be combined, and will differ depend-ing on geography and resources.

A third type of stroke unit is the mixed rehabil-itation ward where the above philosophies are alsofollowed. Such units cater for patients with bothstroke and other disabling illnesses.

Stroke units can be a geographically isolated ward,or beds allocated within a medical, neurological orgeriatric rehabilitation ward. Another model some-times found is that where patients can be distrib-uted throughout the hospital but looked after by amobile stroke team.

There are a number of studies comparing strokeunits of varying types with conventional care on ageneral medical, neurological or mixed rehabilita-tion ward. There has been significant controversyabout their respective benefits, and evaluation ofcare is difficult because of the heterogeneous na-ture of the intervention group as well as the con-trols in any randomised trials.

From the many outcomes that could be measured,the most simple and functional way to observe theeffect of treatment after stroke is the following: Is

the patient alive or dead? At home or not? Needingsupport or not?[1] In addition, duration of hospitalstay and cost are almost a required measure in to-day’s healthcare climate.

2. What Are the Advantages of Stroke Units?

2.1 Mortality

A recent meta-analysis[2] reviewed 19 prospec-tive, randomised trials of stoke units prior to 1995.These were either dedicated stroke units or mixedrehabilitation/stroke units. The trials studied a totalof 3249 patients and compared: (i) dedicated strokeunits with general medical wards or mixed rehabil-itation wards; and (ii) mixed rehabilitation wardswith general medical wards. Only one trial was con-cerned with acute management only. The duration offollow-up was between 6 and 12 months.

The first outcome measurement was mortality[odds ratio (OR) of death in stroke unit versus con-trol group 0.82; 95% confidence interval (CI) 0.69to 0.98; p < 0.05]. The same group also calculatedsome absolute outcome rates. The proportion of pa-tients dead at the end of the follow-up was 20.9%in the stroke unit group and 25.4% in the controlgroup. On that basis, the patient number needed totreat (NNT) to prevent one death was 22. Becausethe baseline fatality rate varied from 0 to 50%, theNNT ranged from 10 to infinity in the differentpopulations.

A trial published since the meta-anlysis[3] com-pared an acute stroke unit with a general medicalward and followed 802 patients for 18 months. Thedifference in mortality (r2 = 0.72 at 10 days, 95%CI 0.59 to 0.89; p < 0.0018) appeared early thenstabilised, with the absolute difference remainingthe same at the end of 18 months.

A Norwegian group[4] followed their patients for5 years from their acute and rehabilitation unit anddocumented that the survival benefit persisted.

2.2 Place of Residence

In the meta-analysis outlined in section 2.1[2]

using the combined end-point of institutionalisa-

tion and death, there was a significant benefit fromthe stroke units (OR 0.71, 95% CI 0.65 to 0.87; p< 0.0001).

The proportion of patients unable to live at homeat the end of follow-up was 40.1% in the stroke unitgroups and 47.2% in the controls; NNT was 14, butwith baseline variability ranging from 8 to 30.

The Norwegian group’s data at 12 months com-paring 206 patients from general medical wards withtheir acute and rehabilitation unit showed a rate ofinstitutional care of 49% in those managed on amedical ward versus 33% in those from the strokeunit (p = 0.012).[5] These data were part of the abovemeta-analysis, but this difference was no longer sig-nificant when follow-up was extended to 5 years.[4]

2.3 Independence

Independence has been more difficult to defineas studies have used different assessments with vary-ing indices. Independence was defined as not requir-ing physical assistance for transfers, mobility, dress-ing, feeding or toileting. The criteria were roughlyequivalent to a Rankin score of 0 to 2 or a Barthelindex of >18/20. When this outcome was combinedwith death, the overall OR from the meta-anlysis[2]

was 0.71 (95% CI 0.61 to 0.84, p < 0.0001) [seefig. 1]. There was some heterogeneity in these re-sults and the issue of bias with an unknown degreeof blinding for the final assessment needs to betaken into account when interpreting these data. Intotal, 60% of stroke unit patients and 66.4% of con-trol patients failed to regain independence. The NNTwas 16, with baseline variability ranging between 10and 25.[1]

2.4 Cost

Data on duration of stay vary greatly, reflecting:(i) heterogeneity of the various groups; (ii) what isactually counted (i.e. acute hospital stay versus to-tal hospital stay); and (iii) local resources (i.e. theavailability of long term care with slow rehabilita-tion streams).

The review[2] cited in section 2.1 reported a widevariety of mean duration of stay. Ten trials reporteda shorter duration of stay with stroke units, and 8 a

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longer duration of stay. Overall, there was a rela-tive reduction in duration of stay in the stroke unitgroup of 8%. If this end-point is calculated fromabsolute values, the reduction was nonsignificant(95% CI –1.8 to 1.1 days).

3. How Are They Different?

Stroke units have been referred to as a ‘blackbox’ as, although recent trials consistently showbenefits in various outcomes,[6-21] it is difficult toestablish any discrete interventions that account forthe benefits.

All stroke unit trials which have shown benefitincluded a rehabilitation component. The most con-sistent feature has been the early involvement ofthe multidisciplinary team with early mobilisation,usually within 24 hours from the onset of symp-toms. One trial comparing intensive but short staytreatment found that this did not compare favoura-bly with that given in a mixed rehabilitation ward.[21]

Statistically significant differences in the char-acteristics of the stroke unit when compared withconventional care have included: (i) carers routine-ly being involved in rehabilitation; (ii) regular staff

Figure 1 is not available for electronic viewing

Fig. 1. Odds of death or dependency at the end of scheduled follow-up after stroke unit compared with conventional care. Odds ratioand 95% confidence intervals (CI) of individual trials are presented as a black box and horizontal line. The pooled odd ratios and95% confidence interval for a group of trials is represented by an open diamond; the black diamond shows the pooled results for alltrials (reproduced from Stroke Unit Trialists Collaboration,[2] with permission). SD = standard deviation.

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training; (iii) nursing interest in rehabilitation; (iv)physicians interested in stroke; (v) increased pro-portion of patients receiving physiotherapy and oc-cupational therapy overall; and (vi) medical inves-tigation and treatment protocols.[2]

Complication rates that were reduced in somestroke units included aspiration pneumonia and pul-monary embolism.[5] In some units, patients weremore likely to have secondary prevention investi-gations and treatment. Deaths due to neurologicalcauses did not change, and are considered unavoid-able and usually are the result of cerebral oedemathat is not responsive to corticosteroids or osmoticagents.

Patients admitted to acute stroke units are morelikely to have an early computerised tomography(CT) scan and earlier administration of aspirin(acetylsalicylic acid).[3] Although aspirin has beenshown to have a beneficial effect on mortality, thisalone is not enough to account for the differencesbetween stroke unit patients and control patients.[1,22]

Use of thrombolysis in the management of strokeremains unclear, with the risks being substantial.[23]

However, such intervention, if useful, should be ad-ministered by a team with experience in such man-agement. This could realistically be achieved on anacute stroke unit.

4. Who Benefits Most?

Initially, many studies excluded patients affec-ted by very mild and very severe strokes. However,recent studies[6,9,11,14] and the meta-analysis[2] foundthat patients experiencing all stroke types receive ben-efit from stroke units. The more severe stroke pa-tients appear to have the most gain. One trial[11]

specifically looked at severe strokes, and random-ised 71 patients to a general medical ward or a re-habilitation stroke unit after medical stabilisation.Mortality rates were 21% in the stroke unit com-pared with 46% on the general medical ward (p <0.05). 47% of patients were discharged home com-pared with 19% (p < 0.01), and the median durationof stay was 43 versus 59 days (p < 0.02), respec-tively.

The second subgroup of patients who also ap-pear to benefit more are those with haemorrhagicstrokes. A trial looking at short term stroke manage-ment and mortality at up to 18 months showed thatpatients with haemorrhagic strokes appeared to re-ceive more benefit from stroke unit care than pa-tients with cerebral infarctions (r2 = 0.77 for haem-orrhage and 0.90 for infarcts).[3]

5. Interpretation of the Literature andUnanswered Questions

There have been 2 meta-analyses published inthe past 5 years, both concluding that stroke unitssave lives and improve independence.[2,24] Theyalso concluded that observed benefits were not re-stricted to any subgroup of patients or model of strokeunit care,[2] although patients with haemorrhagicstrokes may benefit more than those with cerebralinfarctions.[3] It is recognised, however, that meta-analysis is not a panacea and may lead to mislead-ing results due to publication bias towards statisti-cally significant trials while ignoring meaningfulheterogeneity between trials.[25] The latter is par-ticularly relevant to trials of stroke units. It is pos-sible that the management of the control groupmight have been adversely affected by the devel-opment and funding of stroke units within the samehospital or group of hospitals. However, there islittle evidence either to support or to refute thissuggestion.

No single element of the stroke unit model isidentifiable as being responsible for the apparentbenefits of the unit as a whole. It does, however,seem easy to accept that a combined multidiscipli-nary approach with the best medical and nursingcare and ongoing education of staff and familieswill result in a better outcome for patients.

Why then has this approach not been adoptedwidely despite being recommended by the Pan-European Consensus Meeting on Stroke Manage-ment in 1995? Perhaps the answer lies in the def-inition of a stroke unit, and whether the sameprinciples can be followed on a general ward aslong as the resources are available. In the meta-analysis,[2] mixed rehabilitation wards also had

402 Spriggs & Busch


better outcomes than general medical wards. How-ever, there was a nonsignificant trend in favour ofdedicated stroke units compared with mixed reha-bilitation wards[2] (fig. 2).

Some questions remain unanswered, includinghow to make the outcomes in conventional wardsbetter when resources are limited. The institutionof stroke protocols/guidelines with recommendedclinical pathways has been tried, but when this wasused for 390 patients compared with historical con-trols the only difference was in duration of stay.[26]

In an environment of limited resources it is unclear

as to the relative cost effectiveness of acute strokeunits versus rehabilitation units.

6. Conclusions

There is little doubt that a combined, structured,multidisciplinary approach to stroke managementis beneficial. However, whether or not the strokeunit needs to be in a geographically defined areawill be determined by local constraints and re-sources. With the development of short term drugtherapy for stroke, a dedicated stroke unit may be-come a requirement in the future. Nonetheless, at

Figure 2 is not available for electronic viewing

Fig. 2. Analysis of patient and service characteristics on the effectiveness of stroke unit care versus conventional care. Results arepresented as odds ratio (95% confidence interval) of combined adverse outcome of death or requiring long term institutional care.Departmental setting refers to the medical department in which organised stroke care unit was established (reproduced from StrokeUnit Trialists Collaboration,[2] with permission).

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present it is clear that early, directional, multidisci-plinary care from professionals who are interestedin stroke, its complications and the various socialand psychological dynamics involved, providespatients with the optimal conditions to maximisetheir recovery.

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15. Peacock PB, Riley CHP, Lampton TD, et al. Trends in epidemi-ology. In: Stewart GT, editor. The Birmingham stroke, epide-miology and rehabilitation study. Springfield (IL): Thomas,1972: 231-345

16. Kaste M, Palomaki H, Sarna S. Where and how should elderlystroke patients be treated? A randomised trial. Stroke 1995;26: 249-53

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18. Feldman DJ, Lee PR, Unterecker J, et al. A comparison of func-tionally orientated medical care and formal rehabilitation inthe management of patients with hemiplegia due to cerebro-vascular disease. J Chron Dis 1962; 15: 297-310

19. Aitken PD, Rodgers H, French JM, et al. General medical orgeriatric unit care for acute stroke? A controlled trial. AgeAgeing 1993; 22 Suppl. 2: 4-5

20. Hamrin E. Early activation after stroke: does it make a differ-ence? Scand J Rehabil Med 1982; 14: 101-9

21. Ilmavirta M, Frey H, Erila T, et al. Stroke outcome and outcomeof brain infarction. A prospective randomised study compar-ing the outcome of patients with acute brain infarction treatedin a stroke unit and in an ordinary neurological ward [aca-demic dissertation]. Tampere: University of Tampere Facultyof Medicine, 1994 (Series A, vol. 410)

22. CAST (Chinese Acute Stroke Trial) Collaborative. CAST:randomised placebo-controlled trial of early aspirin use in20,000 patients with acute ischaemic stroke. Lancet 1997:349: 1641-9

23. Wardlaw JM, Warlow CP, Counsell C. Systematic review ofevidence on thrombolytic therapy for acute ischaemic stroke.Lancet 1997: 350: 607-14

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Correspondence and reprints: Dr David Spriggs, WaitakereHospital, 55-75 Lincoln Rd, Henderson, Auckland, NewZealand.E-mail: [email protected]

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