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| Journal of the New Zealand Medical Association,
02-March-2007, Vol 120 No 1250
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Improving care to stroke patients: adding an acute
stroke unit helps
Carl Hanger, Valerie Fletcher, John Fink, Andrew Sidwell,
Anne Roche
Patients with stroke have better outcomes if they are
admitted to a stroke unit
(SU);1–3 they
have greater chance of being alive and independent and less likely to require
long term institutional care at one year.1
Guidelines for the management of stroke advocate for the establishment of stroke
units as well as organised stroke services throughout New
Zealand.4
Christchurch Hospital is the acute hospital for Christchurch
and surrounding North Canterbury and serves a catchment population of
approximately 450,000 people.5 It is a
university teaching hospital and has the regional neurosurgical unit.
Approximately 800 people are admitted each year with a diagnosis of an acute
stroke.
In Christchurch, a stroke rehabilitation unit (SRU) for
older patients was opened in 2001 with documented benefits both for patients and
the District Health Board
(DHB).6,7
The Christchurch SRU was always envisaged as being one part
of a larger integrated stroke service, with an acute stroke unit (ASU) and a
community based specialist rehabilitation team planned from the
outset.8
As the SRU is on a separate, geographically distant campus
from the acute hospital, a combined acute and rehabilitation unit was deemed not
feasible. Instead an ASU was established on the acute hospital site in October
2004 with an emphasis on making the transitions to other parts of stroke care as
seamless as possible.
Prior to the establishment of the ASU, patients admitted
with an acute stroke to Christchurch Hospital were treated on any one of six
different medical wards or one neurology ward. These patients were under the
care of general physicians (12 teams, with 2 teams admitting on any given day)
or neurologists in approximately 80:20 ratio. The decision as to whether the
admitting team was neurologist or general physician was based predominantly on
an age cut-off (<65 years) but also comorbidities and presence of
neurological complications. There were no formal protocols for the management of
stroke used consistently across all areas, with the exception of thrombolysis.
Thrombolysis for selected stroke patients started in April
2002.9 These patients were admitted to the
neurology high dependency area for post thrombolysis monitoring and care. A
Clinical Nurse Specialist in Stroke (CNSS) position was established in 2002.
Referrals to allied health professionals (AHPs) were made on individual basis by
each clinical team.
Patients requiring further inpatient rehabilitation were
transferred either to the SRU, or to the Brain Injury Rehabilitation Service
(BIRS) for patients younger than 65 years. Both of these rehabilitation services
are 5 kilometres away (in Cashmere and Burwood respectively) from the acute
hospital (Central Christchurch city), but on different campuses. Outpatient
rehabilitation services were also provided from these distant sites.
The ASU was established on 4 October 2004. This is a 15-bed
unit embedded in one of the general medical wards (30 beds total). The ASU aims
to take all stroke patients, irrespective of age, gender, and stroke
severity.10 The patients are admitted under a
general physician or neurologist as before, with the exception that only one (of
the two) general medical teams on take each day admitted strokes—this
reduced the number of general medical teams involved to six.
To develop and maintain consistency of care between the many
different treating teams, and to across different geographic sites within the
city, common protocols (e.g. hypertension, use of urinary catheters, early
mobilisation), educational strategies, and documentation were developed. These
were developed jointly by members of the multidisciplinary teams (MDT) in the
ASU, SRU, and BIRS.
Thrombolysis for selected patients continues, but is now
provided in the ASU. All stroke patients are admitted using a mutually agreed
proforma which acts as a prompt, but is not a formal clinical
pathway.11 The aim
is to minimise duplication of information collection, whilst ensuring important
information is not omitted.
Pre-stroke functioning is recorded only once in a joint
“Life before Stroke” section and each professional group of the MDT
supplements this with their own initial assessment proforma. Following these
initial assessments, all of the MDT record ongoing progress in the same part of
the notes. When a patient transfers to the SRU, this common documentation is
continued as a contiguous, single set of notes.
Staff numbers were increased for AHP (physiotherapy by 1
full-time equivalent [FTE] position, occupational therapy by 1 FTE, social
worker by 0.5 FTE, and speech language therapist by 0.6 FTE). Nursing or medical
staff were not increased. The CNSS position predated the ASU, but it was always
envisaged as an integral part of its establishment.
Each discipline is expected to see every patient within one
working (Monday–Friday) day, thus negating the need for written referrals.
Whilst acute stroke treatments are an important component of the ASU work, the
ethos is also to provide consistent, skilled nursing and allied health
professional care and to begin the rehabilitation and education processes
early12—in
line with the 5 key components of stroke units
(SU).13
This emphasis on SU care has greater potential community
benefit than a pure medical model.14 An
interdisciplinary approach for each patient is fostered with regular team
meetings. To facilitate nursing involvement in rehabilitation, therapy is
performed on the ward where possible.
All staff were given the opportunity to update their stroke
skills. In particular, nurses were trained to screen for dysphagia and are
involved in a programme of continuing professional development coordinated by
the CNSS. Close linkages with the SRU and BIRS were emphasised, and the stroke
specific documentation is common to all three units.
Following the introduction of the ASU, we wished to assess
whether it gave additional benefit over and above the gains accrued by the
SRU.6,7 Benefit may be assessed in two main
ways. One is to look at overall patient outcomes such as function, domicile, and
survival, whereas the other is to look at consistency of key clinical care
processes.15
As consistency of care (particularly in the acute phase) was
thought to be poor, we have chosen to focus on the latter approach in this
study. Using an internationally recognised stroke audit
tool16, this paper
addresses the question—“Does the addition of an ASU give
improvements in stroke care over and above the benefits already accrued by a
SRU?”
MethodsThe Royal College of Physicians of London stroke audit
tool (RCPLSA) was used to assess the process stroke
care.16 This was designed for retrospective
case note review and has been shown to have high inter-rater
reliability.17 It has two main sections: (1)
casemix indicators and (2) 48 clinical process audit questions covering 12 broad
areas of care.
As the last section covered five aspects of care after
hospital discharge, which are not recorded in the hospital clinical record, we
did not collect data on these five areas. The response to each standard is
recorded as either Y (meets standard), N (does not meet standard), or not
appropriate. Criteria for the latter category are tightly defined. Overall
compliance (%) for each standard is defined as Y*100/(Y+N), thus excluding those
not appropriate.
Prior to ASU implementation, function was only assessed
in the two rehabilitation hospitals (using the Functional Independence Measure
[FIM]). Since 4 October 2004, functional abilities are also routinely measured
at CH using the FIM. As the two questions on function in the casemix section of
the audit require a Barthel Index (BI), and not the FIM, these two questions
were also omitted.
Discharge coding data (ICD-10 codes I61-I64, I67.2, and
I67.5-9) were used to identify both the “before” and
“after” cohorts. All patients admitted to Christchurch Hospital (CH)
between 1 December 2003 and 29 February 2004, formed the “before”
group. The “after” group consisted of a selection of patients
(two-thirds selection, by omitting every third patient) admitted to CH between 1
February 2005 and 31 March 2005. Both groups included some patients transferred
to Princess Margaret Hospital (PMH). As the audit aimed to assess stroke care
throughout all three hospitals, admission to ASU was not a prerequisite in the
“after” cohort.
Categorical and continuous casemix variables were
compared using Chi-squared (χ2) analysis
and Student’s t-test respectively.
The study was approved by the Upper South A Regional
Ethics Committee (URA/05/02/004).
ResultsDuring the 12-month period from 4 October 2004—3 March
2005, 648 patients with an acute stroke were admitted to the ASU, with a mean
(median) length of stay (LOS) of 8 (6) days. 305/648 (47.0%) were transferred to
PMH or BIRS for further inpatient rehabilitation. During the same period, 735
patients were discharged from CH with a diagnosis of acute stroke. Thus
approximately 88% of all strokes were admitted to ASU.
Casemix variables for the two cohorts that were audited
using RCPLSA are shown in Table 1. Patients in the post-ASU cohort were
significantly more likely to spend the majority of their hospital stay in a SU
and less likely to have multiple ward transfers.
This group had a higher
proportion of women, and had more disabling strokes as indicated by a lower
level of consciousness on admission, and a worse continence status at 1 week.
There were no differences in discharge destinations between the cohorts.
The results from the audit of process of care variables are
shown in Table 2. Significant improvements in process
of care were shown for the post-ASU cohort (compared to pre-ASU) in 27 of the 43
areas recorded.
Table 1. Casemix of the two audited
groups
DiscussionThis audit has shown that important PoC for stroke patients
improved following the introduction of an ASU. These benefits were additional to
those already gained by having a SRU.6,7 These
results also indicate that changes made at the “front end” of stroke
care can improve a wide range of processes throughout the whole inpatient stay.
The gains were not limited to just one professional group’s work but were
across all disciplines.
By using shared protocols and documentation, together with
close linkages between the units, this ASU complements the existing SRU and goes
some way towards the goal of an overall coordinated stroke
service.4,18
Previous studies from both New Zealand and overseas have
shown significant deficits in stroke
care.19–22,
37 with inadequate assessment or treatment in acute phase, and poor
attention to secondary prevention strategies on discharge. More recent studies
have shown improvements in care
processes,23
clinician attitudes,24 and (in the last 5
years) development of SUs in some District Health Boards
(DHBs).6,23,25,26
This paper shows that with the development of an overall
inpatient stroke service (with most patients under the care of a stroke
specialist team), these PoC can be further improved.
Whilst the initial assessments have greatly improved (with
exception of visual attention), further improvements are still required. There
was a documented plan to manage hypertension in the longer term in only 75%,
despite recent studies and guidelines advocating more aggressive blood pressure
management 4,27. Others have noted similar
deficits in hypertension plans, although overaggressive management in some older
frail patients may cause postural hypotension
later.23
Whilst screening for swallowing difficulties improved
between the cohorts, only ¾ of the after sample were screened within 24
hours of admission. Some of those who were not screened were not admitted to
ASU. Thus we need to have alternative options to assess swallowing when patients
are cared for in non-SU settings. Some processes for important, yet
non-life-threatening consequences of stroke (continence, cognition, mood, and
carer needs) have improved, but there remains considerable room for further
improvement. Attention in these areas may improve quality of life for stroke
patients.
The gains above have been achieved without extending length
of stay (LOS) in hospital. The mean LOS in this study is similar, or lower, than
comparable studies.15,22,23,28–30 This is
in keeping with international SU literature, where better quality outcomes are
achieved with similar LOS.1 The return home
rate is also comparable or better.23,25,31
Our reported 30-day mortality (24–25%) appears high
compared to New Zealand studies, but these have reported in-hospital mortality
only.15,22,23,25 Our 30-day figures are
comparable to those reported in the Auckland Stroke
Study.32
There is not uniform agreement whether an improvement in
documented PoC translates into better patient outcomes. McNaughton et al
22 found that there
is a relationship between PoC and outcomes, but that this relationship is weak
and complex. We agree with their comments on complexity. However their
conclusions on the strength of relationship were derived from audits using the
older RCPL stroke audit tool.20This was heavily
biased towards the medical management of stroke.
The newer version (used in this
study)16 is much broader and looks at many
multidisciplinary processes over 12 key clinical domains. Each process was
chosen because it was sensitive to variations in quality of care; was thought to
be relevant to clinical outcomes; and (where possible) were based on the UK
guidelines for
stroke.33
Kwan11
found that improvements in quality of documentation and PoC were associated with
fewer complications. In two recent studies, greater adherence to quality PoCs
were associated with improved patient outcomes (reduced complications or
mortality, and trend to improved independence at
home).34,35 Similarly better performance on
process measures was strongly associated with better survival amongst community
dwelling older adults.36
Some secondary prevention PoC (such as antiplatelet therapy
and blood pressure management) have long-term beneficial
outcomes,27 but these are hidden when measuring
short term functional or domicile outcomes. Thus we believe that the improved
PoC demonstrated here will have a very positive longer term impact on the
quality and consistency of care given to our stroke patients.
The development of an ASU at Christchurch Hospital occurred
within a larger context, with a plan to develop an overall stroke
service.4 A pilot community-based stroke
rehabilitation team commenced in March 2006, and is the third (and equally
important) component of such a service.
ASUs should not occur in isolation and need close links with
rehabilitation, community, vascular surgical, and general medical services. This
will ensure the patient gets the appropriate care at the right time and
transitions through the various stages of their illness with minimal
disruption.1,18
What has made the difference? Was it just better
documentation? This may be a partial answer as each discipline has initial
assessment proforma, which may have prompted better recording. Consistency of
care given by staff (with an interest and expertise in stroke) in a SU is
another critical component.
During the planning and implementation of the ASU,
considerable emphasis was placed on developing all of the key elements of a
successful
SU.13,37
These elements include acute assessment procedures; early management policies
(not just medical treatment); rehabilitation (including coordination of
multidisciplinary team (MDT) care, regular carer involvement, and MDT meetings);
and building staff expertise with regular education and training.
Patients with stroke were previously managed on many
different wards, with varying degrees of expertise and interest. Our inclusive
admission policy has increased the numbers of patients who were cared for in a
SU environment (RCPLSA data 69%, but approximately 88% from discharge coding
data).
During the implementation phase there was some pressure to
develop a clinical care pathway for patients with acute stroke. This was
resisted, as evidence for a strict pathway is
equivocal.11,30,38,39
The team also resisted the concept of a mobile team of stroke experts—as
this has been shown to be an inferior model to a geographically distinct
SU.3
Instead, our team focused on a geographically distinct SU
concept together with development of a stroke proforma, shared documentation
(and protocols) across disciplines and units, and ensuring that all the key
elements of a SU were developed.12,13,35 Such
an approach allows the staff to use their expertise and experience to make
judgements, without the tight confines of a care pathway.
Using a historical control group in a before and after study
has limitations. Many different processes may have changed, rather than just the
intervention being tested. In this case, the intervention is not just the
setting up of an ASU, but also the change in documentation and ethos of all
stroke care. The magnitude of the changes found, suggests that the ASU and
associated changes in PoC have made a significant impact over and above other
background changes.
Whilst the audits were done
at a similar time of year for both cohorts, the pre-ASU audit did include the
Christmas holiday break, which could potentially have reduced therapist
availability for this cohort. However any negative effect from this is likely to
be mitigated by the larger number included in this cohort (N=119). The
assumption that what is documented reflects the PoC delivered has already been
discussed earlier.
It is disappointing that we have not been able to show
improved patient outcomes in this study. Like the profitability of any new
business, we expect these improved PoCs to translate into better outcomes over
time. However, the finding of similar clinical outcomes despite the post-ASU
cohort having more severe strokes (and hence more challenging to rehabilitate
and successfully discharge) is encouraging.
The reason for this change in casemix is not clear. Whilst
the sampling was non random, sample sizes were considerably larger than those
used for each trust in the UK National Sentinel
Audit.33 A trend to increased ambulatory care
for patients with TIA or minor stroke may be another factor with primary care
access to DHB funded CT scanning for stroke now available in Canterbury. It is
feasible that subtle drowsiness is better recognised in the ASU and hence lower
levels of consciousness are now being recorded. This might account for an
apparent worsening in casemix, but a similar explanation would not account for
the worsened continence status.
Setting up the ASU was challenging. One problem was the
perceived heaviness or dependency of acute stroke patients and hence the ASU was
not seen as a desirable place for nurses to
work.25 A counter
to this was giving nurses greater roles and a chance to specialise, as well as
the strong sense of teamwork that developed. Other clinical staff held the view
of “Why do we need a SU? We all look after stroke patients and do it
well”.
The pre-ASU audit shows that PoCs were not done well and
needed to be improved. Furthermore the literature is clear that SU care is
superior to general ward care,1,2,4 and
patients prefer SUs.40
Changes in service delivery in a large organisation are slow
and difficult to achieve. This ASU is no exception to that, taking at least 5
years from conception to fruition.8 Fiscal
restrictions were real, but the set-up costs are small compared to the much
larger costs of poor stroke outcomes such as institutional
care.41.
In summary, adding an ASU to complement an existing SRU gave
major improvements in PoC across many different facets of stroke care. We
believe this is one step closer to the ideals of an overall coordinated stroke
service, as recommended in stroke guidelines, and better care for patients with
stroke.
Conflict of interest statement: All
authors were involved in the set up of, and/or continue to work in, the Acute
Stroke Unit.
Author information: H Carl
Hanger1; Valerie
Fletcher1,2; John
Fink3;
Andrew Sidwell1,2; Anne
Roche1,2
Acknowledgements:
The authors thank all the dedicated staff who have been involved in the
establishment and running of the ASU. In particular, we acknowledge the huge
efforts of Alison Gallant (Clinical Charge Nurse), Christine Pithie, and Mary
Griffith (Clinical Nurse Specialists). Elder Care Canterbury have also
played a key role in assisting the reorganisation of stroke care within the
Canterbury District Health Board. The authors also acknowledge the useful
comments of the anonymous reviewers.
Correspondence: Dr H Carl Hanger, Older
Persons Health, The Princess Margaret Hospital, PO Box 800, Christchurch. Fax:
(03) 3377823; email: carl.hanger@cdhb.govt.nz
References:
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