Comprehensive Stroke Unit Research Articles

Integrated multidisciplinary assessment of cerebral stroke outcome after treatment in a comprehensive stroke unit

Objective – to explore the possibility of integral assessment of the stroke outcome and to develop a method of integral assessment of the stroke outcome after in-patient treatment on the level of impairment and and the level of activities of daily living, which were assessed using rating scales and indices.Materials and methods. The study was conducted at the Stroke Center (SC), Oberig’ multidisciplinary hospital division, which operates according to the principles of Comprehensive Stroke Unit. Patients with a cerebral stroke who were admitted to the SC in 2010–2018 were enrolled. The data of the participants were prospectively entered into a special database and included discharge assessments using 8 valid rating scales and indices. Cluster analysis methods (in particular Kohonen neural networks) were used to design the integral assessment. Statistical analysis of the values ​​of the rating scales and indices in the selected clusters was performed using the Kruskal–Wallis criterion, post hoc comparisons were made using the Dunn multiple comparison criterion.Results. 852 patients (42.5 % women and 57.5 % men, median age – 66.7 year) were enrolled. 81 % of patients were diagnosed with ischemic stroke, and 19 % had hemorrhagic stroke. According to the chosen method, it is necessary and sufficient to split the data into 4 clusters. All participants in the study according to their assessments at discharge using the set of selected measures could be assigned to one of 4 isolated clusters: K1 (n = 366), K2 (n = 93), K3 (n = 104) or K4 (n = 289). National Institutes of Health Stroke Scale, modified Rankin scale, Barthel Index, Berg Balance Scale та Functional Ambulation Classification were the most significant determinants of the patient cluster. For the 5 measures there have been significant differences (p < 0.001) in the four clusters. The condition of the patients in K4 cluster was the best (p < 0.05), whereas the patients in the K1 cluster were worse (p < 0.05), and the condition of the patients in the clusters K2 and K3 was much worse (p < 0.05) compared with the cluster K4.Conclusions. Based on the integrated assessments of neurological impairments and activities of daily living all of stroke patients could be assigned to one of four identified clusters. Detecting predictors of poor outcome after in-patient management may help to find ways to improve their prognosis.

Prognostic indicators of the lack of a great functional improvement and sustained disability among in-patients with cerebral stroke who were managed in a Comprehensive Stroke Unit

High-quality care may help reduce the severity of stroke consequences, but the optimal model of in-patient cerebral stroke care is not yet defi ned. The aim of the study was to determine the predictors of failing to achieve favorable functional outcome assessed with the Barthel index (BI) after treatment in the Comprehensive Stroke Unit (CSU). Patients with cerebral stroke, who were in 2010 to 2018 admitted to the Stroke Center — a multidisciplinary hospital unit that operates according to the CSU principles — were enrolled to the study. Patients’ data were prospectively entered into a special database and included baseline and fi nal assessments with neurological scales. If the BI total at discharge exceeded 60 or increased at least by 50 compared with baseline, the favorable outcome was considered achieved, otherwise — failed. Among 677 included in-patients, age 20 to 95 years, 271 (40.4 %) females, 80.8 % had an ischemic, and 19.2 % hemorrhagic cerebral stroke. The median NIHSS score at was 10. The onset to CSU hospitalization delay ranged from less 24 hours (17.5 % of the patients) to more than 180 days (17.2 % of the patients), and 59.7 % of the participants were admitted during the fi rst 30 days from the index stroke. In multivariate analysis, 7 indicators were strongly and independently linked with the risk for unfavourable functional outcome. The area under the operating characteristics curve (AUC = 0.93) indicates excellent consistency of the prediction model and the strong association of the predictors with the risk for a signifi cant need in help in ADLs. Independent predictors of functional insolvency can help better estimate the prognosis and optimize decision making on treatment strategy. Patient’s age, recurrent stroke, severity of the initial impairments and long delay to CSU admission has the most signifi cant infl uence on the risk for disability after discharge from CSU.

The risk of incomplete functional recovery and sustained disability in patients treated in an integrated stroke unit

Objective – to identify factors that are associated with incomplete functional recovery or sustained disability in patients managed at a Comprehensive Stroke Unit (CSU).Materials and methods. We included 764 patients (41.7 % of women) aged from 20 to 95 years (median – 66 years, interquartile interval 57–75 years), who were in period from 2010 to 2018 admitted to our Stroke Center (SC) operating as a CSU. Upon admission all participants were examined by a Neurologist. Work-up and treatment were in line with recommendations of clinical guidelines. Ischemic stroke was diagnosed in 80.5 % of the patients, hemorrhagic stroke – in 19.5 %. Univariate and multivariate analyses were performed. The functional state was assessed using a modified Rankin scale (MRS). We The considered that the desired outcome was achieved if, at the time of discharge from the hospital, the initial MRS score decreased by ≥ 2 or reached ≤ 2.Results. The baseline NIHSS score ranged from 0 to 39 (median – 10, interquartile interval 6–17). 17.5 % of patients were admitted to our SC in the 1st day, 19.0 % – between 2 and 7 days, 7.5 % – between 8 and 14 days, 14.7 % – between 15 and 30 days, 10.3 % – between 31 and 60 days, 13.0 % – between 61 and 180 days, and 18.0 % – later than 180 days after the stroke onset. According to the univariate analysis, the risk of not achieving the desired outcome was associated with many factors: stroke type and subtype, the patient’s age, time delay before SC admission, the initial severity of stroke, cognitive impairment, limitations of mobility and ADLs, the presence and severity of certain types of neurological deficit, in addition to certain vascular risk factors (atrial fibrillation, smo-king) and signs of inflammation (increased erythrocyte sedimentation rate and C-reactive protein) on admission. Multivariate analysis revealed 4 independent predictors that are strongly associated with the lack of the desired functional outcome: patient age (odds ratio (OR) – 1.03, on average, for each additional year), initial stroke severity (after adjustment to the rest of factors, OR – 1.05, on average, for each additional point of the baseline NIHSS score), global disability on admission (OR – 2.3, on average for each point of the initial MRS score) and the time from stroke onset to the SC admission (compared with a shorter delay, OR – 3.3–4.2, if the patient was hospitalized between 15 and 180 days from the onset, OR – 9.2 if admitted later than 6 months after the onset). The area under the curve of operational characteristics – 0.92 (95 % CI 0.89–0.94) proved the excellent quality of the prediction model and the strong link of this set of factors to the risk of incomplete functional recovery at the time of discharge.Conclusions. According to the results of univariate analysis, the risk of incomplete functional recovery and sustained disability after treatment is associated with a wide range of factors, such as stroke type and subtype, severity of neurological and cognitive deficit, activities limitations, certain risk factors and laboratory abnormalities. Multivariate analysis identified 4 independent predictors of sustained disability, which may help us better predict the length of stay and the outcome of treatment.

Risk factors for incomplete functional recovery in post-stroke patients undergoing treatment in a comprehensive stroke unit

Objective — to identify factors that are associated with incomplete functional recovery (disability) after stroke in patients who were admitted to the comprehensive stroke unit (CSU). Methods and subjects. The study included stroke in‑patients, who were admitted to our Stroke Center in 2010 to 2018, operated on the principles of the CSU. All patients were examined by a Neurologist upon admission, and their workup and treatment were in line with the recommendations of the clinical guidelines. Patient data were prospectively included in the database and retrospectively analyzed using one‑factor and multivariate analysis. Functional recovery was evaluated using the modified Rankin scale (mRS). Results. The study enrolled 764 patients (42 % of women) aged 20 to 95 years (mean age 66 years, interquartile interval [IQI] 57 — 75 years). 80 % of the patients had an ischemic stroke, and 20 % had a hemorrhagic stroke. The total baseline NIHSS score ranged from 0 to 39 points (median — 10 points, IQI 6 — 17 points). 18 % of patients were admitted to the CSU during the first 24 hours, another 19 % — on Day 2nd to 7‑th days, 7 % on Day 8‑th to 14, 15 % on Day 15‑th to 30‑th, 10 % from Day 31st to 60‑th, 13 % from Day 61st to 180‑th, and 18 % — later 180 days from stroke onset. According to the results of a single‑factor analysis, the risk of incomplete functional recovery (scores for mSR ³ 2 at discharge) is associated with numerous factors: hemorrhagic stroke (odds ratio [OR] 1.7), atherosclerotic (OR 3.6) and cardioembolic (OR 3.1) subtypes of ischemic stroke, age of the patient (OR 1.02 per each additional year), delay from the stroke onset to admission to the CSU, initial stroke severity (OR 1.3 per each additional NIHSS point), initial level of daily activities (OR 0.96 per each Bartel Index point) and disability (OR 3.5 per each additional mRS point), as well as elevated ESR, CRP and glycosylated hemoglobin levels. In the multivariant analysis, three independent predictors were identified: initial stroke severity (baseline total NIHSS score), the degree of disability at admission (mRS score), and the time from the stroke onset to the CSU admission. The area under the operational curve is AUC = 0.92 (95 % CI 0.89 — 0.94), which proves excellent quality of the prediction model and the strong link between this set of three factors and the risk of incomplete functional recovery at discharge. Conclusions. Single‑factor analysis showed that the disability after the CSU treatment is associated with many initial factors, such as patient age, admission delay, stroke type and subtype, severity and certain types of neurological deficit, disability, and laboratory tests results. In multivariate analysis, three main factors were found to be significant independent predictors of incomplete functional recovery: initial stroke severity, disability level at admission and the time from the onset of the hospitalization. The latter factor emphasizes the importance of reducing CSU admission delay.

Predictors of prolonged hospital stay in a Comprehensive Stroke Unit.

Objective to analyze the in-hospital complications of prolonged hospital stay in patients with ischemic stroke or transient ischemic attack, admitted to the stroke unit of a tertiary hospital.Method this is an evaluative correlational study. All first-ever ischemic stroke or transient ischemic attack patients admitted were retrospectively analyzed. During hospital stay, the predictors of long-term hospitalization considered were: 1) clinical complications (pneumonia, urinary tract infection, pressure damage and deep vein thrombosis), and 2) neurological complications (malignant ischemic stroke and symptomatic hemorrhagic transformation).Results 353 patients were discharged in the study period. Mean age was 64.1±13.7 years old and 186 (52.6%) were men. The mean time of hospital stay was 13.7±14.3 days. Pneumonia (25.3±28.8 days, p<0.001), urinary tract infection (32.9±45.2 days, p<0.001) and malignant stroke (29.1±21.4 days, p<0.001) increased significantly the length of hospital stay compared to patients without any complications (11.2±7.1 days).Conclusion this study showed that three complications delayed hospital discharge in patients admitted in a stroke unit, two preventable ones: pneumonia and urinary tract infection. More intense measures to avoid them should be included in the performance indicators to reduce the length of hospital stay in stroke units.

Responsiveness of five measures of arm function in acute stroke rehabilitation

Objective: To determine the responsiveness of five arm function measures in people receiving acute inpatient stroke rehabilitation. Design: Inception cohort study. Setting: Comprehensive stroke unit providing early rehabilitation. Subjects: A total of 64 consecutively admitted stroke survivors with moderately severe disability (Modified Rankin Scale score median (interquartile range (IQR)): 4.0 (1.0)). Main measures: Responsiveness was analyzed by calculating effect size, standardized response mean and median-based effect size. Floor/ceiling effects were calculated as the percentage of participants scoring the lowest/highest possible scores. Results: Average length of stay and number of therapy days were 34 (SD = 27.9) and 12 (SD = 13.1), respectively. Box and Block Test and Functional Independence Measure–Self-Care showed the highest responsiveness with values in the moderate–large range (effect size = 1.09, standardized response mean = 1.07 and median-based effect size = 0.76; effect size = 0.94, standardized response mean = 1.04 and median-based effect size = 1.0). Responsiveness of Action Research Arm Test and Upper Limb–Motor Assessment Scale were moderate (effect size = 0.58, standardized response mean = 0.69 and median-based effect size = 0.59; effect size = 0.62, standardized response mean = 0.75 and median-based effect size = 0.67). For Manual Muscle Test, responsiveness was in the small–moderate range (effect size = 0.42, standardized response mean = 0.59 and median-based effect size = 0.5). Box and Block Test showed the largest floor effect on admission (28%), and Action Research Arm Test and Manual Muscle Test showed the largest ceiling effect on discharge (31%). Conclusion: These five measures varied in their ability to detect change with responsiveness ranging from the small to large range. Box and Block Test and Functional Independence Measure–Self-Care showed a greater ability to detect change; both demonstrated moderate–large responsiveness.

Acupuncture with smoothing liver and regulating qi for post-stroke slow transit constipation and its gastrointestinal hormone level

To compare the efficacy between acupuncture with smoothing liver and regulating qi and lactulose for post-stroke slow transit constipation(STC) and to explore the mechanism. Sixty patients were randomized into an acupuncture group and a medication group,30 cases in each one. Based on the comprehensive stroke unit care,acupuncture with smoothing liver and regulating qi was used at Danzhong(CV 17),Qihai(CV 6),Tianshu(ST 25),Neiguan(PC 6),Gongsun(SP 4) and Taichong(LR 3) in the acupuncture group,once a day. Lactulose oral liquid was taken at a draught in the morning in the medication group,20 to 30 mL a time,once a day. The study period was 11 weeks,including 1-week baseline evaluation,6-week treatment and 4-week follow-up. We recorded the time of the first independent defecation,constipation symptom score,and gastrointestinal hormone level,including somatostatin(SS),motilin(MTL),P substance(SP) and vasoactive intestinal peptide(VIP). Also,the side effects were recorded at any time. The time of the first independent defecation was (30.18±16.14) h in the acupuncture group,which was significantly different from (43.22±28.42) h in the medication group(P<0.05). The constipation scores after 6-week treatment and at follow-up were lower than those before treatment in the two groups (all P<0.05),with better results in the acupuncture group(both P<0.05). MTL and SP increased,as well as SS and VIP decreased after treatment in the two groups(all P<0.05). The changes were better in the acupuncture group(all P<0.05). The side effect was not observed in the two groups. Acupuncture with smoothing liver and regulating qi achieves better effect than lactulose for post-stroke STC in terms of efficacy onset,extent,and long term. The mechanism may relate to increasing excitatory regulatory peptide and reducing inhibitory regulatory peptide.

Editorial introductions

Editorial introductions

Functional Status and Disability in Patients After Acute Stroke: A Longitudinal Study

Stroke is a major public health problem. To use the Barthel Index to evaluate basic activities of daily living in stroke survivors and detect any predictors of functional outcome at 6 months after stroke. In an observational longitudinal study, data were gathered on consecutive patients admitted to the comprehensive stroke unit at Hospital San Pedro de Alcantara, Cáceres, Spain. Sociodemographic and clinical data were obtained prospectively at hospital admission and during follow-up 6 months later. Information on type of stroke, score on the Barthel Index, findings from the neurological evaluation, and other relevant data were collected. Of 236 patients admitted, 175 participated in the study. Mean age was 69.60 (SD, 12.52) years, 64.6% were men, and mortality was 12.8%. Six months after experiencing a stroke, 84.8% of patients had returned to their own homes, 8.0% were institutionalized, and the others were residing at a family member's home. Scores on the Barthel Index 6 months after stroke correlated with baseline scores on the National Institute of Health Stroke Scale (r = -0.424; P < .001) and with depressive mood 6 months after stroke (r = -0.318; P < .001). Age was negatively associated with Barthel Index scores at the time of hospital discharge and 6 months after stroke. Functional status 6 months after stroke was influenced by age, sex, stroke severity, type of stroke, baseline status, mood, and social risk. Comorbid conditions, socioeconomic level, and area of residence did not affect patients' functional status.

Recognition of posterior circulation stroke.

Better identification and triage of acute posterior circulation (PC) stroke patients is needed as the PC ischemic stroke (IS) patients may be allowed longer thrombolysis window than anterior circulation (AC) IS patients and PC patients with hemorrhagic stroke (ICH) may require care in a neurosurgical unit possibly remote from stroke unit. Consecutive stroke patients treated at a tertiary center with thrombolysis (100% for IS) and/or comprehensive stroke unit care. Altogether, 1641 patients had AC (75%) and 553 PC strokes. The PC-IS patients were younger (65 vs 70), had less often prior hypertension (51 vs 61%), and were twice more often on warfarin. They presented 3.5 times more often with seizure, vomited five times more often, had headache twice as often, and required intubation 2 to 3 times more often despite equal NIHSS (9 vs 8) or GCS (15 both) scores with AC-IS patients. Among PC patients, IS (n = 190) associated with younger age, prior atrial fibrillation (AF) in 25% and dyslipidemia in ~40%. One-third of PC-ICH patients (n = 363) had headache and vomited at the onset. PC-ICH patients had BP median of 177/92 mmHg and blood glucose 7.4 mmol/l on ER arrival. Warfarin use was twice as common in PC-ICH. Despite being of typical age for multiple cardiovascular conditions the PC-ICH patients less often have a previous history of AF or dyslipidemia than IS patients do. The vomiting PC-ICH patient with hypertensive BP values often has headache and a red flag for hemorrhage is warfarin treatment.

Functional outcome after common poststroke complications occurring in the first 90 days.

The aim of this study was to explore the associations of common medical complications with functional outcome at 90 days post stroke. Patients with unselected acute stroke were included and observed for 16 predefined complications during the first week. Fifty percent (244 patients) were allocated to follow-up of 13 complications until 90 days and then assessed with the modified Rankin Scale 90. Common complications were defined as complications with frequencies of ≥5%. Ordinal logistic regression (worsened outcome), as well as binary logistic regression for severe dependency and death (modified Rankin Scale score>3) was performed. Seven of the 13 complications occurred at a frequency ≥5%. Recurrent stroke and chest infection were found to have an odds ratio for worsened outcome of 7.45 (95% confidence interval, 2.83-20.96; P<0.0001) and 3.28 (95% confidence interval, 1.16-9.29; P=0.025), respectively. Infections other than chest infections and urinary tract infections had an odds ratio for worsened outcome of 1.59 (95% confidence interval, 1.12-2.24; P=0.009) and falls an odds ratio of 1.43 (95% confidence interval, 1.06 to 1.93; P=0.021). Myocardial infarction, urinary tract infections, and pain were not associated with a worsened outcome in terms of modified Rankin Scale 90. Recurrent stroke and chest infections were strongly associated with a worsened outcome. Other infections and falls were associated with less worsening. For myocardial infarction, urinary tract infections, and pain no association with functional outcome was found. Active strategies for prevention and early treatment of the first 2 complications seem advisable; patient monitoring as part of comprehensive stroke unit care should ensure timely identification and treatment of all complications.

Determinants of Quality of Life in Stroke Survivors After 6 Months, from a Comprehensive Stroke Unit: A Longitudinal Study.

In the social model of stroke, health-related quality of life (HRQoL) is the result of interplay among stroke severity, social support, and health-promoting behaviors. Our objective was to identify determinants of HRQoL in stroke survivors. Ischemic stroke patients were evaluated at 6 months with the Short Form 12 Health Survey, including physical component survey (PCS) and mental health component survey (MCS) summary scores. Multivariate stepwise regression analyses determined independent predictors of scores. Models included age, gender, socioeconomic class, education, residential environment, social support, previous comorbidity (Charlson Index), previous stroke, side of stroke, National Institutes of Health Stroke Scale (NIHSS) score at admission, Barthel Index (BI) and modified Rankin Scale (mRS) scores at discharge, and length of stay. A total of 131 patients participated (mean age 70.1, SD = 12.5; 62.6% males). In all, 33.6% had a BI score <90 and an mRS score >2 (poor outcome). The mean (SD) PCS score was 39.46 (9.3) and mean (SD) MCS score was 34.86 (10.1). Lower PCS score was associated with female sex (β = 0.204, p = .009), poor social support (β = -0.225, p = .003), and poor Charlson Index (β = -0.162, p = .032) and BI scores (β = 0.384, p < .0001). Lower MCS score was associated with female sex (β = 0.162, p = .062) and poor NIHSS (β = -0.265, p = .019) and BI scores (β = 0.203, p < .071). Stroke severity, disability, gender, social support, and previous stroke have significant impacts on the physical and mental domains of generic HRQoL.

Responsiveness of the ten-metre walk test, Step Test and Motor Assessment Scale in inpatient care after stroke

BackgroundResponsiveness of a measurement tool is its ability to detect change over time. The aim of this study was to determine the responsiveness and floor/ceiling effects of the ten-metre walk test (10mWT), Step Test and Motor Assessment Scale (MAS) lower limb items.MethodsAn inception cohort study was conducted, including 190 stroke survivors admitted to a comprehensive stroke unit. The 10mWT, Step Test and MAS were administered within 48 hours of admission and repeated in the 48 hours before discharge. Responsiveness was analysed with Effect Size (ES), Standardised Response Mean (SRM) and a median-based Effect Size (mES). Floor/ceiling effects were calculated as the percentage of participants scoring the lowest/highest possible scores.ResultsResponsiveness of each outcome measure varied according to the statistic used. Values for the 10mWT were ES 1.44, SRM 0.93, mES 0.45; the step test ES 1.99, SRM 0.88, mES 0.36; MAS sit-to-stand (item 4) score ES 1.27, SRM 1.00, mES 0.50; and for MAS item 5 (walking) ES 1.43, SRM 1.10, mES 0.50. The MAS item 3 (sitting balance) was moderately responsive in all analyses (ES 0.72, SRM 0.71, mES 0.50). The MAS mobility score (summed items 3-5) consistently showed large responsiveness (ES 1.42, SRM 1.16, mES 0.92). The Step Test had the highest proportion of participants who didn’t change (46%) and item 4 of the MAS showed the largest ceiling effect on discharge (44%).ConclusionsMost measures were able to detect change in motor performance during inpatient stroke rehabilitation but the MAS mobility score was the only measure that demonstrated large responsiveness and no marked floor or ceiling effects.

Physical Activity Early after Stroke and Its Association to Functional Outcome 3 Months Later

Early rehabilitation that includes early mobilization and increased amount of motor activity is hypothesized to be one of the most important factors contributing to the beneficial effect of comprehensive stroke unit treatment, whereas too much bed rest is hypothesized to be harmful. The purpose of the present study was to assess the association between early activity/bed rest and functional outcome 3 months later. This was a prospective cohort study including patients with the diagnosis of stroke admitted to Trondheim University Hospital, Norway. Patients were eligible if they were less than 14days poststroke and did not receive palliative care. Motor activity/bed rest was recorded in the acute phase using a standard method of observation, and the outcome was assessed by the modified Rankin Scale (mRS) score 3months later. A proportional odds model was used to analyze the association between motor activity/bed rest and outcome. All analyses were adjusted for age, gender, stroke severity, time from stroke to observation, and prestroke function. A total of 106 patients (mean age 79.0years, 56.6% men) were included. The odds ratio for a higher mRS score (poor outcome) was 1.04 (95% confidence interval [CI] 1.02-1.07, P=.001) as time in bed increased and .97 (95% CI .93-1.02, P=.283) as time in motor activity increased. This study confirms that time in bed in the early phase is associated with poor functional outcome 3months later, indicating that too much bed rest should be avoided in the early phase after stroke.

Impact of stroke unit in a public hospital on length of hospitalization and rate of early mortality of ischemic stroke patients

We ascertained whether a public health stroke unit reduces the length of hospitalization, the rate of inpatient fatality, and the mortality rate 30 days after the stroke. We compared a cohort of stroke patients managed on a general neurology/medical ward with a similar cohort of stroke patients managed in a stroke unit. The in-patient fatality rates and 30-day mortality rates were analyzed. 729 patients were managed in the general ward and 344 were treated at a comprehensive stroke unit. The in-patient fatality rates were 14.7% for the general ward group and 6.9% for the stroke unit group (p<0.001). The overall mortality rate 30 days after stroke was 20.9% for general ward patients and 14.2% for stroke unit patients (p=0.005). We observed reduced in-patient fatalities and 30-day mortality rates in patients managed in the stroke unit. There was no impact on the length of hospitalization.

European Stroke Organisation Recommendations to Establish a Stroke Unit and Stroke Center

In the recent Helsingborg declaration, acute organized stroke unit care was described as the backbone of the chain of care for all European stroke victims. Access to stroke units is, however, still limited. To improve the availability and the quality of affordable stroke care, the European Stroke Organisation (ESO) has appointed an ESO Stroke Unit Certification Committee to define the requirements and criteria for official certification as ESO Stroke Units and ESO Stroke Centres based on scientific evidence from randomized controlled trials, clinical practice guidelines, and expert consensus. Important features of modern stroke care include the presence of a dedicated stroke unit ward, a multiprofessional team approach, a comprehensive stroke unit organization, including emergency room organization, adherence to diagnostic and therapeutic time-windows, early swallowing diagnostics and therapy, intravenous thrombolytic therapy, periods of automated monitoring, access to decrompressive craniectomy and intraarterial thrombolysis, early mobilization and rehabilitation, supported discharge and basic aftercare with treatment of risk factors and poststroke prevention. The Committee defined the target population, the necessary infrastructure, technical equipment, diagnostic pathways, therapeutic interventions, nursing care, and multiprofessional rehabilitation. The definitions also cover the hospital environment characteristics and the stroke unit’s interactions with other departments. Quality indicators for benchmarking are presented. Although the ESO Stroke Unit’s requirements are largely evidence-based, expert consensus is also included where evidence was unavailable. These recommendations of the ESO task force should stimulate hospitals in Europe to apply for ESO certification. Fulfilling of the criteria will be checked by on-site visits.

How do comprehensive and acute stroke units differ? A critical review

Background: Stroke unit care is advocated for all acute stroke patients. Varying models of stroke unit care exist and there is a need to identify how these models differ and how these differences may affect patient outcomes. This review explores the difference between the comprehensive stroke unit model, which includes rehabilitation, and the acute stroke unit model, which does not. Content: A review of descriptive information regarding comprehensive and acute stroke units was performed to determine the differences in the underlying components of care. Conclusion: A greater emphasis on acute medical care appears to exist in the acute stroke unit, with higher levels of nurse staffing, earlier assessment and investigation, more intensive physiological monitoring and an increased use of thrombolysis and anti-platelet therapy. In contrast, the availability of a period of rehabilitation in the comprehensive stroke unit appears to create a greater emphasis on rehabilitation, even in the acute phase, with greater involvement of gerontologists, rehabilitation physicians and allied health professionals, increased multidisciplinary staff education and training, greater patient and carer participation in rehabilitation, and early mobilisation protocols.

Early Physical Activity and Discharge Destination after Stroke: A Comparison of Acute and Comprehensive Stroke Unit Care

Background. Common models of acute stroke care include the acute stroke unit, focusing on acute management, and the comprehensive stroke unit, incorporating acute care and rehabilitation. We hypothesise that the rehabilitation focus in the comprehensive stroke unit promotes early physical activity and discharge directly home. Methods. We conducted a two-centre prospective observational study of patients admitted to a comprehensive or acute stroke unit within 14 days poststroke. We recruited 73 patients from each site, matched on age, stroke severity, premorbid function, and walking ability. Patient activity was measured using behavioural mapping. Therapy activity was recorded by therapist report. Time to first mobilisation, discharge destination, and length of stay were extracted from the medical record. Results. The comprehensive stroke unit group included more males, fewer partial anterior circulation infarcts, more lacunar infarcts, and more patients ambulant without aids prior to their stroke. Patients in the comprehensive stroke unit spent 14.4% more (95% CI: 8.9%–19.8%; P < 0.001) of the day in moderate or high activity, 18.5% less time physically inactive (95% CI: 5.0%–32.0%; P = 0.008), and were more likely to be discharged directly home (OR 3.7; 95% CI 1.4–9.5; P = 0.007). Conclusions. Comprehensive stroke unit care may foster early physical activity, with likely discharge directly home.

Preferences, barriers and facilitators for establishing comprehensive stroke units: a multidisciplinary survey

To determine the preferences of multidisciplinary stroke clinicians for models of inpatient stroke unit care and perceived barriers to establishing a comprehensive stroke unit (CSU) model (acute and rehabilitation care in the same ward). Written questionnaires distributed and completed at multidisciplinary stroke unit case conferences in NSW, Australia. Twenty hospitals with 22 stroke units were surveyed, 13 acute stroke units, 7 rehabilitation stroke units, 2 CSUs. Two hundred and twenty-eight respondents: 99 (43.4%) allied health, 72 (31.6%) nurses and 57 (25.0%) doctors. One hundred and fifty-one respondents (67.0%) thought CSU to be the best model. Seventy-three % of doctors and 79% of allied health preferred CSU v. 57% of nurses (P=0.041). Of doctors, rehabilitation specialists were most likely to favour comprehensive model (84.2%) and neurologists least (57.0%). The main perceived advantages of CSU were reduced cost and improved functional outcomes; perceived disadvantages were increased workload and unwell patients unable to participate in rehabilitation. Main perceived barriers to establishing CSU were lack of space, money, staffing and time. Although most current stroke unit care in NSW is based on the traditional model of acute and rehabilitation components in separate wards or hospitals, the majority of multidisciplinary stroke team clinicians believe CSU is the optimum model. What is known about the topic? Stroke unit care is known to improve survival and dependency but the optimum model of care is unproven, despite some small studies suggesting that the CSU model may result in better outcomes. What does this paper add? This paper is the first to survey stroke clinicians from various disciplines and types of unit, to determine their preferences for stroke unit model. What are the implications for practitioners? A majority of clinicians expressed a preference for the CSU model, suggesting that most would be comfortable caring for patients in both acute and rehabilitation phases of stroke care if further such units are established.

Physical Activity Patterns of Acute Stroke Patients Managed in a Rehabilitation Focused Stroke Unit

Background. Comprehensive stroke unit care, incorporating acute care and rehabilitation, may promote early physical activity after stroke. However, previous information regarding physical activity specific to the acute phase of stroke and the comprehensive stroke unit setting is limited to one stroke unit. This study describes the physical activity undertaken by patients within 14 days after stroke admitted to a comprehensive stroke unit. Methods. This study was a prospective observational study. Behavioural mapping was used to determine the proportion of the day spent in different activities. Therapist reports were used to determine the amount of formal therapy received on the day of observation. The timing of commencement of activity out of bed was obtained from the medical records. Results. On average, patients spent 45% (SD 25) of the day in some form of physical activity and received 58 (SD 34) minutes per day of physiotherapy and occupational therapy combined. Mean time to first mobilisation out of bed was 46 (SD 32) hours post-stroke. Conclusions. This study suggests that commencement of physical activity occurs earlier and physical activity is at a higher level early after stroke in this comprehensive stroke unit, when compared to studies of other acute stroke models of care.