Stroke Unit Patients Research Articles

Abstract TP218: Mobile Stroke Unit Improves Time to Treatment in Suburban Community

Introduction: Recent evidence suggests that Mobile Stroke Units have demonstrated improved time to treatment in urban settings. These vehicles are equipped to respond to out of hospital strokes and begin treatment with the use of IV alteplase. The evidence is limited to urban settings and the full impact of mobile stroke units on stroke treatment times and outcomes should be studied in urban, suburban and rural communities. This abstract aims to describe the impact of a mobile stroke unit in a suburban community. Hypothesis: A mobile stroke unit in a suburban setting can improve time to treatment for stroke patients for ischemic stroke patients. Methods: The mobile stroke unit responds to a 6 town area within the hospital’s EMS (Emergency Medical Services) system, data from mobile stroke unit patients was compared to data from stroke patients brought to the Emergency department by conventional EMS from January-June 2017. The mobile stroke unit is dispatched for patients deemed as potential strokes by the centralized 911 dispatch. The patient is then evaluated by a specially trained crew consisting of a critical care paramedic and a critical care nurse. Neurology evaluation occurs via telemedicine. The mobile stroke unit is equipped with IV alteplase. Data is collected EMS EMR and imported to stroke database. Inclusion criteria includes: 18 years or older, receive treatment in mobile stroke unit or emergency department, treated with IV alteplase. Results: Ischemic stroke patients cared for by the Mobile Stroke Unit received IV alteplase (n=4) 25 minutes faster from time of dispatch than patients arriving to the Emergency Department (n=7). 100% of mobile stroke unit patients treated with IV alteplase had a 90 day modified rankin score of 2 or less (n=2) compared to 66% in the Emergency Department group (n=3). Symptomatic intracranial hemorrhage rate was 0% in both groups. Conclusions: Patients treated in the mobile stroke unit demonstrate a decrease in time to treatment and a preliminary improvement in outcomes. Data is not significant at this time due to small sample size, however, the data is encouraging and should continue to be studied. In conclusion, the use of a mobile stroke unit in a suburban setting provides a time to treatment benefit.

Three Stages of Evolution in the Treatment of Acute Ischemic Stroke: Stroke Unit Care, Intravenous Thrombolysis and Endovascular Therapy

Ischemic stroke is the most frequent cause of disability in adults in the world and its treatment remains a challenge. The care management of stroke patients in organized stroke units has improved and various revascularization approaches have emerged during the past decades. Stroke patients cared in organized stroke units are more likely to survive, to return home and to be functional independency. It is recommended that all patients with stroke, regardless of age, should be cared in a stroke unit.

Early Experience on Intravenous Tissue Plasminogen Activator Delivery in Mobile Stroke Unit Patients with Stroke Mimics (P1.269)

Early Experience on Intravenous Tissue Plasminogen Activator Delivery in Mobile Stroke Unit Patients with Stroke Mimics (P1.269)

Abstract WP72: Early Experience on Intravenous Tissue Plasminogen Activator Delivery in Mobile Stroke Unit Patients with Stroke Mimics

Background: A mobile stroke unit (MSU) allows for early delivery for intravenous tissue plasminogen activator (IV-tPA). A proportion of IV-tPA treated patients may turn out to be stroke mimics. We evaluated the rate and complications seen in stroke mimics treated with tPA from our early experience on MSU. Methods: Retrospective review of patients treated with IV-tPA on the MSU from 2014 to 2016. Charts were reviewed for confirmed strokes by imaging (MRI or CT) and hemorrhagic transformation. Stroke mimics were defined as those without imaging evidence of infarction and a final diagnosis which was not suspected to be stroke. Results: Among 62 patients treated with IV-tPA, 14 (28.6%) had a final diagnosis consistent with a stroke mimics. The majority of these occurred in the first year of the MSU program. Most common mimics included conversion disorder (n=5) and seizures (n=5). While the last known well to IV-tPA times were similar, the MSU door-to-needle time was significantly longer in stroke mimics (38 vs 31 minutes, p = 0.03). No intracerebral hemorrhages or other IV-tPA related complications were identified in the stroke mimics group. Conclusions: In our early experience with MSU, treatment of stroke mimics occurred without IV-tPA related complications. This does not appear to be due to rushed decision making.

The Italian real-life post-stroke spasticity survey: unmet needs in the management of spasticity with botulinum toxin type A.

The present national survey seeking to identify unmet needs in the management of spasticity with botulinum toxin type A focused on the use of OnabotulinumoxinA, since this is the brand with the widest range of licensed indications in Italy. Physicians from twenty-four Italian neurorehabilitation units compiled a questionnaire about "real-life" post-stroke spasticity management. OnabotulinumtoxinA was reported to be used in the following average doses: upper limb 316.7 ± 79.1 units; lower limb 327.8 ± 152.3; upper and lower limb 543.7 ± 123.7 units. Of the physicians surveyed, 37.5% felt that increasing the frequency of OnabotulinumtoxinA injection would improve its efficacy; 70.8% use electrical stimulation/electromyography guidance (one fourth of injections with no instrumental guidance). Instrumental evaluation was used by 41.7% of the physicians. The participants expressed the view that early identification of post-stroke spasticity would be facilitated by the availability of a post-stroke checklist, and that this should be used by physiotherapists (91.7%), physiatrists (58.3%), family doctors (50%), stroke unit physicians (25%), patients and caregivers (79.2%). According to our findings, the management of poststroke spasticity has several unmet needs that, were they addressed, might improve these patients' clinical outcomes and quality of life. These needs concern patient follow-up, where a clearly defined pathway is lacking; furthermore, there is a need to use maximum doses per treatment and to ensure early intervention on post-stroke spasticity.

Research of the factors that determine the rehabilitation potential and satisfaction of the medical care of patients with acute stroke in China and Russia

This study examined the factors that determine the recovery of the patient after an acute cerebrovascular accident, and satisfaction with medical care and rehabilitation in the Russian Federation and Republic of China. We interviewed 522 patients in Stroke units in Russian and China. We analyzed personal patient factors, quality of life (EQ-5D), social and economic factors, the characteristics of the treatment and rehabilitation of the patient and staff attitude to the rehabilitation process. Logistic regression with ROC-analysis was used. Results. Quality of life in patients with a stroke depends on the country where the patient is receiving treatment and rehabilitation (higher in Russia than in China). The more time a patient spends in the hospital leads to the low quality of life. Having diabetes reduces the quality of life. In Russia, a good recovery and rehabilitation high potential contributes to the presence of the total family income of patient 40-60 000 rub per month, and the highest value on the Rankin scale, but a high value on NIHSS and RI on admission reduces a good recovery after a stroke. A lot of money for rehabilitation and treatment of patients with stroke lead to good patient recovery. Conclusion. Rehabilitation of stroke patients will be more effective if patient has a significantly limited ability to live, but has not high severity of the stroke and immobility problem then other factors such environment and psychological factors plays key role.

Embolic stroke of undetermined source: a retrospective analysis from an Italian Stroke Unit

The new clinical construct of embolic stroke of undetermined source (ESUS) suggests that many cryptogenic strokes are related to minor-risk covert embolic cardiac sources or to embolus from non-occlusive plaques in the aortic arch or in the cerebral arteries. The authors analyzed the prevalence of ESUS in a real-life condition in Italy and compared the recurrence rates in cryptogenic strokes, cardioembolic strokes, and ESUS. The authors retrospectively reassessed according to ESUS criteria 391 consecutive admissions in a stroke unit where extensive diagnostic search was routinely performed. Recurrences in each stroke type within a 3-year follow-up period (mean time: 25.44 months - standard deviation: 9.42) were also compared. The prevalence of ESUS in the aforementioned cohort was 10.5%. All ESUS patients received antiplatelet agents. Warfarin was prescribed in 56.9% of cardioembolic strokes. The recurrence rate in ESUS patients was 4.4% per year, slightly higher than in cardioembolic strokes (3.5%) and significantly higher than in cryptogenic non-ESUS (1.2%) (P<0.0001). This is the first description of a cohort of ESUS patients in an Italian stroke unit. Patients with ESUS have a significantly higher risk of recurrence than in those with non-ESUS cryptogenic strokes, and slightly higher than in those with cardioembolic strokes. Results support the hypothesis of a more extensive diagnostic evaluation in cryptogenic strokes and the feasibility of such approach.

Abstract WP386: Swallowing Assessment of Nurses and Speech-Therapists

Background: A relevant number of stroke patients have swallowing disabilities; assessment of swallowing ability is an important procedure on a stroke unit to reduce complications. There is still doubt whether or not a trained nurse has a similar efficacy in the assessment of swallowing difficulties as does a specialized speech therapist (ST). Methods: Our ST has trained any stroke unit nurse (SN) in assessment of swallowing function. A test using first thickened flavored water (custard consistency) and 5 ml water is done. For a pilot study, during 6 weeks all stroke unit patients with cerebral ischemia were included. Patients with TIA, non-stroke diagnoses or altered consciousness (score 2-3 for item 1a of the NIHSS) were excluded. Swallowing function was evaluated independently by the patient’s SN and latest on the next working day by the ST. A 5 step scale was used, measuring from no food, to 2 different texture-modified diets, to normal food. Cohen’s kappa statistic was calculated to evaluate congruence of the assessments. Univariate statistics were done to analyze difference between cohorts with equivalent and different grading. Results: Overall 90 patients were included (53% male, 93% ischemic stroke, mean age 71 years). In 72 (80%) of the SN and ST scored identical (10% no food allowed, 11% special food preparation, 79% no problem). In 11 (12%) SN were more careful than the ST, and in 7 (8%) the SN assessed less swallowing-problems than the ST. Cohens’s kappa was 0.6067. In four of those patients the ST found relevant swallowing problems, which could have led to feeding abstention (2 patients) or special food preparation (2 patients). Comparing those 18 patients with differences in the assessments and those 72 without, presence of dysarthria was the only different parameter and was more present in the patients with varying rating (Mann Whitney U, p=0.0019) Conclusion: In this unselected cohort of ischemic stroke patients, swallowing problems were detected in 32%, when using the ST’s assessment as gold standard. Inter-rater agreement with a trained SN was good. In a small percentage (8%) nurses had overseen swallowing problems and in 4% this was relevant. Presence of dysarthria was the only factor, which was different between equal and unequal graded patients.

Resource utilization and costs for treatment of stroke patients in an acute stroke unit in Greece

BackgroundStroke comprises the leading cause of death in Greece, and more than 40% of the overall lifetime cost for stroke care, represents the acute phase hospitalization. The aim of the present study was to assess the resource utilization and estimate the costs for treatment of stroke patients in an Acute Stroke Unit (ASU). MethodsPatients with first-ever stroke treated in the ASU of an academic hospital in Athens during 2003–2009 were included in the analysis. The National Institutes of Health Stroke Scale (NIHSS), and the modified Rankin Scale (mRS) were employed to assess the neurological impairment on admission and the handicap at discharge, respectively. The cost categories measured were: diagnostic investigations, medications, medical and nursing staff, and overhead costs. A generalized linear model was used to predict the mean cost per patient, based on the clinical characteristics of the patients on admission, and during their hospitalization. ResultsIn total, 784 patients were included in the analysis, with mean age of 72.2 (11.2) and mean length of hospital stay of 12.3 (9.5) days. The mean cost per patient was estimated at €2,864 (2,198), and the mean cost per day at €244 (54). The relevant cost for the mildly handicapped patients was €1,573 (625), while for the severely handicapped patients it was €4,136 (2,538). Delayed discharge was associated with a mean cost of €362 (634) per patient, while the cost for the acute phase management of the patients was €2,445 (2,471). The neurological impairment on admission (NIHSS score) and the delayed discharge, were strong predictors of the mean cost per patient. ConclusionsThe costs for treatment of stroke patients in an ASU comprise a significant burden in Greece. Further research should be performed to explore the long-term costs for the treatment of the disease at a nation-wide level.

LAST-Q : adaptation et normalisation franco-québécoises du Language Screening Test

The goal of the present study was to adapt and to establish normative data for the recently developed Language Screening Test (LAST; Flamand-Roze et al., 2011) in the French-Canadian population according to age and level of education. After an adaptation process, 100 French-Canadian speakers were evaluated with the LAST-Q. As expected, a perfect score of 15/15 was obtained for all high level education participants, and a score of 14/15 was obtained for all participants with a lowest level of education or aged 80 years or more. Thanks to this adaptation, LAST-Q can be used in acute patients in stroke unit in Quebec.

141 How Useful are Echocardiograms after Acute Stroke: Why, When, for Whom, What are the Results and How Does Echocardiography Influence Acute Stroke Unit Patients’ Treatment?

IntroductionMost modern Acute Stroke Services have a Local Guideline to indicate selection for Echocardiography. Nevertheless it is unknown who is selected and how the results influence Stroke patients’ management. In...

Guidelines for the treatment of acute ischaemic stroke

IntroductionUpdate of Acute Ischaemic Stroke Treatment Guidelines of the Spanish Neurological Society based on a critical review of the literature. Recommendations are made based on levels of evidence from published data and studies. DevelopmentOrganised systems of care should be implemented to ensure access to the optimal management of all acute stroke patients in stroke units. Standard of care should include treatment of blood pressure (should only be treated if values are over 185/105mmHg), treatment of hyperglycaemia over 155mg/dl, and treatment of body temperature with antipyretic drugs if it rises above 37.5°C. Neurological and systemic complications must be prevented and promptly treated. Decompressive hemicraniectomy should be considered in cases of malignant cerebral oedema. Intravenous thrombolysis with rtPA should be administered within 4.5hours from symptom onset, except when there are contraindications. Intra-arterial pharmacological thrombolysis can be considered within 6hours, and mechanical thrombectomy within 8hours from onset, for anterior circulation strokes, while a wider window of opportunity up to 12–24hours is feasible for posterior strokes. There is not enough evidence to recommend routine use of the so-called neuroprotective drugs. Anticoagulation should be administered to patients with cerebral vein thrombosis. Rehabilitation should be started as early as possible. ConclusionTreatment of acute ischaemic stroke includes management of patients in stroke units. Systemic thrombolysis should be considered within 4.5hours from symptom onset. Intra-arterial approaches with a wider window of opportunity can be an option in certain cases. Protective and restorative therapies are being investigated.

Development of Patient Classification System based on Nursing Intensity in Stroke Unit

Purpose: The purpose of this study was to develop a patient classification system based on nursing care intensity for patients with acute stroke-related symptoms and verify its validity and reliability. Methods: Data were collected between November, 2013 and February, 2014. The verification for content validity of the patient classification system was conducted by a group of seven professionals. Both interrater reliability and concurrent validity were verified at stroke units in tertiary hospitals. Results: The intensive nursing care for acute stroke patients consisted of 14 classified domains and 56 classified contents by adding ‘neurological assessment and observation’ and ‘respiratory care’: ‘hygiene’, ‘nutrition’, ‘elimination’, ‘mobility and exercise’, ‘education or counselling’, ‘emotional support’, ‘communication’, ‘treatment and examination’, ‘medication’, ‘assessment and observation’, ‘neurological assessment and observation’, ‘respiratory care’, ‘coordination between departments’, and ‘discharge or transfer care’. Each domain was classified into four levels such as Class I, Class II, Class III, and ClassⅣ. Conclusion: The results show that this patient classification system has satisfactory validity for content and concurrent and verified reliability and can be used to accurately estimate the demand for nursing care for patients in stroke units.

TIA-Treatment: Stroke Units versus General Wards Mono-Center Study

Background and Purpose: Transient ischemic attack (TIA) is associated with a high short-term risk of stroke. The aim of this study is to compare the diagnostic evaluation, therapeutic procedures, and secondary prevention strategies in TIA patients who were directly admitted to a stroke unit (SU) and received semi-intensive care in comparison to those who were treated in general wards (GW) in a mono-center study. Methods: During a 6-year period (2008-2013), 1114 TIA patients who were admitted to the Department of Neurology at the University of Schleswig-Holstein, campus Lubeck, were evaluated in a mono-center study. Results: A total of 604 (57%) TIA patients were admitted to the SU, whereas 453(37%) patients were admitted to the GW. Patients with a TIA who were undergoing treatment in an SU were significantly younger (69.1 vs. 71.0 years; P=0.023) and had higher rates of paresis (30.1 vs. 21.8%; p<0.003), hypertension (79.7 vs. 74.3%; P=0.042) and hypercholesterolemia (57.2 vs. 46.7%; P=0.001) than those who were undergoing treatment in the GW. Patients in SUs received significantly higher rates of carotid revascularization for symptomatic carotid stenosis (5.8% vs. 0.4%; P<0.001), dysphagia screening (47.6 vs. 27.3%; P<0.001), speech therapy (33.0 vs. 14.8%; P<0.001), and physiotherapy (51.0 vs. 37.2%; P<0.001) in comparison to those admitted to GWs. The TIA etiology; cardioembolism was significantly more common (18.0 vs. 12.7%; P=0.037) in patients treated in stroke unit, whereas the undetermined etiology of TIA was significantly less diagnosed in patients who were admitted to SI-SU than those treated in CC (50. vs. 58%; P=0.037). Carotid revascularization for symptomatic stenosis was more performed in patients who underwent stroke unit care than those who were treated in general wards (5.8 vs. 0.4%, P<0.001). Conclusion: TIA-Treatment in the SU appears to be correlated with more diagnostic and therapeutic procedures in comparison to care in general wards.

Tracheostomy in Stroke Patients

Patients with severe ischemic and hemorrhagic stroke may require tracheostomy in the course of their disease. This may apply to stroke unit patients whose deficits include a severe dysphagia posing such risk of aspiration as it cannot be sufficiently counteracted by tube feeding and swallowing therapy alone. More often, however, tracheostomy is performed in stroke patients so severely afflicted that they require intensive care unit treatment and mechanical ventilation. In these, long-term ventilation and prolonged insufficient airway protection are the main indications for tracheostomy. Accepted advantages are less pharyngeal and laryngeal lesions than with prolonged orotracheal intubation, better oral hygiene and nursing care, and higher patient comfort. Optimal timing of tracheostomy is unclear, in general, as in stroke intensive care unit patients. Potential benefits of early tracheostomy concerning ventilation duration and length of stay, respirator weaning, airway safety, rate of pneumonia, and other complications, outcome and mortality have been suggested in studies on non-neurologic subgroups of critical care patients. Stroke patients have hardly been investigated with regard to these aspects, and mainly retrospectively. A single randomized pilot trial on early tracheostomy in 60 ventilated patients with severe hemorrhagic and ischemic stroke demonstrated feasibility, safety, and less need of sedation. Regarding the technique, bedside percutaneous dilational tracheostomy should be preferred over surgical tracheostomy because of several reported advantages. As the procedural risk is low and early tracheostomy does not seem to worsen the clinical course of the ventilated stroke patient, it is reasonable to assess the need of further ventilation at the end of the first week of intensive care and proceed to tracheostomy if extubation is not feasible. Reliable prediction of prolonged ventilation need and outcome benefits of early tracheostomy, however, await further clarification. Decannulation of stroke patients after discontinued ventilation has to follow reliable confirmation of swallowing ability, as by endoscopy.

Quality in Acute Stroke Care (QASC): Process Evaluation of an Intervention to Improve the Management of Fever, Hyperglycemia, and Swallowing Dysfunction following Acute Stroke

Our randomized controlled trial of a multifaceted evidence-based intervention for improving the inpatient management of fever, hyperglycemia, and swallowing dysfunction in the first three-days following stroke improved outcomes at 90 days by 15%. We designed a quantitative process evaluation to further explain and illuminate this finding. Blinded retrospective medical record audits were undertaken for patients from 19 stroke units prior to and following the implementation of three multidisciplinary evidence-based protocols (supported by team-building workshops, and site-based education and support) for the management of fever (temperature ≥37·5°C), hyperglycemia (glucose >11 mmol/l), and swallowing dysfunction in intervention stroke units. Data from 1804 patients (718 preintervention; 1086 postintervention) showed that significantly more patients admitted to hospitals allocated to the intervention group received care according to the fever (n = 186 of 603, 31% vs. n = 74 of 483, 15%, P < 0·001), hyperglycemia (n = 22 of 603, 3·7% vs. n = 3 of 483, 0·6%, P = 0·01), and swallowing dysfunction protocols (n = 241 of 603, 40% vs. n = 19 of 483, 4·0%, P ≤ 0·001). Significantly more patients in these intervention stroke units received four-hourly temperature monitoring (n = 222 of 603, 37% vs. n = 90 of 483, 19%, P < 0·001) and six-hourly glucose monitoring (194 of 603, 32% vs. 46 of 483, 9·5%, P < 0·001) within 72 hours of admission to a stroke unit, and a swallowing screen (242 of 522, 46% vs. 24 of 350, 6·8%, P ≤ 0·0001) within the first 24 hours of admission to hospital. There was no difference between the groups in the treatment of patients with fever with paracetamol (22 of 105, 21% vs. 38 of 131, 29%, P = 0·78) or their hyperglycemia with insulin (40 of 100, 40% vs. 17 of 57, 30%, P = 0·49). Our intervention resulted in better protocol adherence in intervention stroke units, which explains our main trial findings of improved patient 90-day outcomes. Although monitoring practices significantly improved, there was no difference between the groups in the treatment of fever and hyperglycemia following acute stroke. A significant link between improved treatment practices and improved outcomes would have explained further the success of our intervention, and we are still unable to explain definitively the large improvements in death and dependency found in the main trial results. One potential explanation is that improved monitoring may have led to better overall surveillance of deteriorating patients and faster initiation of treatments not measured as part of the main trial.

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.

Laminar infarcts in clinical routine: a prospective analysis in standard stroke unit patients

The present study aimed to investigate prospectively the frequency of laminar infarcts (LI) within a standard stroke unit population. Laminar infarcts follow neuroanatomical borders rather than the vascular architecture. The LI are rarely noticed in clinical routine because they are typically not detected by computed tomography. As there is a lack of systemic studies about this specific infarct pattern, little is known about their frequency, clinical characteristics or pathophysiological mechanisms. Consecutive acute ischemic stroke unit patients were prospectively enrolled during a 12 month period. The LI were defined as ischemic lesions following the gyral anatomy of the cerebral cortex. The clinical assessment included a standardized questionnaire, clinical syndromes and standard diagnostic results. There were 491 consecutive ischemic stroke patients enrolled (243 female, mean age 75 ± 12 years). The MRI revealed no laminar lesion crossing vascular territories and 28 patients with LI non-crossing vascular territories (7 %). According to the TOAST classification, 61 % of LI were classified as stroke of undetermined etiology (TOAST V) including 46 % with completed evaluation (TOAST Vb). In contrast to these findings, only 20 % of the whole study cohort with non-laminar infarcts were classified as TOAST V. The results indicate that LI are rare. In clinical routine, patients with LI require particular attention. Within the TOAST classification, this specific infarct pattern seems to be underrepresented.

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.

Nursing interventions are needed to help staff promote hopefulness in stroke patients.

Patients in stroke units would benefit from interventions to encourage 'realistic hopefulness', suggest British researchers.