Stroke Units

Evidence Reviewed as of before: 09-03-2010
Author(s): Adam Kagan, B.Sc.
Patient/Family Information Table of contents

Introduction

Organized stroke care (also known as ‘stroke units’) is characterized by an interdisciplinary group of health professionals working cohesively and closely, to provide a comprehensive rehabilitation program for each patient. Although these programs may vary in terms of the types of therapies offered as well as their intensity and duration, they should, in order to be deemed a stroke unit, have routine, multi-disciplined input from therapists with experience in stroke rehabilitation.

Moreover, stroke units and teams are attuned to prevention, recognition, and treatment of co-morbidities and medical complications, early goal-directed treatment, systematic assessment of patients, and modification of treatment to maximize benefits. Most programs focus on education and psycho-social issues of both the patient and family/caregiver.

Patient/Family Information

Author: Adam Kagan, BSc

What are Stroke Units?

There are three main categories of Stroke Unit:

  • The first consists of a team of stroke specialists who provide specialized care to people where they are located within the hospital. These units are sometimes referred to as “mobile teams specialized in stroke”.
  • Another type of unit is located in a specific area of the hospital or rehabilitation centre where people with stroke are admitted and treated by a specialized team. Usually these units do not admit people with other health problems.
  • Finally, in some hospitals, “acute” and “rehabilitation” units are grouped in one place, assessments and treatments are provided by the same team.

These units include health professionals who specialize in the treatment of people with stroke; nurses, physicians, physical therapists, occupational therapists, social workers, speech language pathologists, nutritionists or clinical dieticians and possibly physiatrists, psychologists and neuropsychologists. These Stroke Units work both in the acute and stroke rehabilitation phases.

Here are the descriptions of the phases:

  1. Acute phase: During the first few days (or weeks if it is a more severe stroke) after a stroke, the treatment focuses on the prevention of other illnesses and complications. Health professionals will assess you to determine the impact of stroke on your speech, how you work, your ability to eat solid foods, the strength of your arms and legs, and so on. During this time of assessment, your rehabilitation will be spread over short periods of time and will be consolidated as soon as you begin to recover your strength and regain your tolerance.

    Some patients return home directly after the acute phase. For others, treatments continue during a rehabilitation phase.

  2. Rehabilitation Phase: You may be referred to a Rehabilitation Hospital where you will still be treated by specialized clinicians who will use various types of interventions to work on the skills and activities affected by the stroke.

NOTE: A link to a description of several of these interventions can be found on https://www.strokengine.ca/

The acute care hospital may have a different room or floor that offers rehabilitation services and you can be transferred there.

In conclusion, as mentioned above, in some hospitals, acute care and rehabilitation units are grouped together in one place, assessments and treatments are provided by the same team.

How can Stroke Units help me?

All members of a stroke rehabilitation team are specially trained to treat people who have had a stroke. Treatments should be specifically tailored to your needs. It is important that the team also considers goals that are important to you – for example, if you have stairs at home you might want to practise walking up the stairs more than someone who lives in an apartment with an elevator. It is also important that your family be involved in your rehabilitation. Various members of the stroke unit team are trained to work with families. There is strong evidence that family support and education help the recovery process after a stroke. One of the most important aspects of a stroke unit is that the team adjusts to you and adapts to your changing state. So, when you get better, they focus on encouraging you to regain the skills that have been affected by the stroke. For example, shortly after a stroke you may need the help of two people and a cane to walk. As your balance and strength improve, team members will let you know when it is safe to walk with only one person.

Do Stroke Units make a difference after a stroke?

Note: The research results presented in StrokEngine come from past and present studies, but as we write these lines, new studies are being conducted and new evidence is being released. Thus, if the answers to certain questions continue to show a lack of agreement or even remain unanswered, it only means that the studies have not mentioned this question specifically.

The researchers conducted studies to see if treatment in a stroke Unit, combining the acute and rehabilitative phases, helped people and that they demonstrated faster recovery. The researchers also looked specifically at the benefits gained from being treated within a rehabilitation unit or by the “mobile stroke unit” teams. These various studies looked at the effects of different types of stroke units and their impact on:

  1. Function – this refers to basic activities such as eating, dressing, getting out of bed, going to the bathroom, etc.
  2. Institutionalization – the need for institutionalization is felt when patients cannot recover enough to return home. In this case, the person may need long-term care and rehabilitation.
  3. The length of hospital stay – the number of days or weeks that a patient stays in hospital after being admitted for a stroke.
  4. Mortality rate – It is rare, but possible, that some people who have had a very severe stroke die following the cessation of vital functions.

What are the benefits of combining acute care units with rehabilitation units?

High quality studies have shown that when acute and rehabilitative care is combined in a stroke unit, patients demonstrate better functional improvements.

There is strong evidence that stroke units are useful in reducing the need for institutionalization, length of hospital stay, and mortality rates.

But when acute care is combined with rehabilitation units, they are not effective in reducing the rate of stroke-related hospital deaths.

It appears that recovery is best when acute care is given in an acute unit, and rehabilitation is offered in a department or Rehabilitation Center.

Stroke Units (with transfer from a unit or acute care unit)

Currently, high quality research provides strong evidence that when specialized rehabilitation teams are used during the rehabilitation phase, there is no additional functional gain over a regular rehabilitation unit.

The need for institutionalization is not reduced when patients are treated in an intensive rehabilitation unit compared to those treated by a regular rehabilitation team or a general medical team.

There are conflicting answers to the question of whether treatment by a specialized stroke rehabilitation team decreases mortality or reduces length of stay in hospital. High quality research supports the idea that mortality and length of stay are reduced, while other high quality studies indicate that they are not.

Post stroke a mobile team

Research shows that mobile stroke teams do not reduce the number of stroke-related deaths, the need for institutionalization, or the length of stay in hospital following a stroke. We can also compare the level of recovery of patients followed by a mobile team with that of those followed in a department of general medicine. Studies have found that improvements in the ability to manage personal care and perform activities of daily living are not better for patients treated by a mobile team.

What can I expect in Stroke Units?

Stroke Units are designed so that patients make the most gains during their stay in the hospital or at the Rehabilitation Center. Treatment of the after-effects of a stroke requires the active participation of the person concerned. In the post-stroke unit, patients are expected to attend treatment sessions on their own, or possibly with the help of a family member or friend, and perform the exercises or activities that their team of therapists explained to them.

The team approach is a key component of stroke units. As mentioned previously, you can benefit from occupational therapy, physical therapy, speech therapy, and other therapies depending on the help you need. Sometimes, these professionals will ask you questions or use assessments that you think you have already done. Keep in mind that everyone is trying to identify ways to help you recover from the harmful effects of stroke.

The team should always work to help you improve and should work toward the goals that are important to you.

Are there any risks related to Stroke Units?

Being treated in a Stroke Unit does not involve more risk to your health. In fact, the team is specifically trained to prevent and mitigate (if any) the consequences that might result from stroke.

Who works in a stroke rehabilitation unit?

  • Doctors (neurologists and / or general practitioners, physiatrists)
  • Physical therapists
  • Occupational therapists
  • Social workers
  • Speech language pathologists
  • Psychologists or neuropsychologists
  • Nutritionists or clinical dieticians
  • Specialized stroke nurses
  • Team coordinators
  • Pharmacists

For more details on all these professions, click on the titles or visit The National Institute of Health

Should I consider a stroke rehabilitation unit a good option for me or a family member?

Usually the decision regarding admission to a stroke unit is made as soon as a stroke is diagnosed. This decision is made on the basis of several factors defined by the hospital’s administration and its ability to provide post-stroke care.

Choosing where to go for your rehabilitation may be difficult to determine if the Rehabilitation Center closest to your home does not have a stroke rehabilitation unit. The decision should be made carefully and it is important to discuss the different alternatives and what is best for you with your team of health professionals.

Clinician Information

Note: This module differs from others on StrokeEngine in that conclusions are based mainly on the findings of a recent meta-analysis (Stroke Unit Trialists’ Collaboration, 2007), as opposed to the synthesis of individual studies by the StrokEngine team. Please note that newer studies not included in the meta-analysis will be added to the module shortly.

Rating of interventions:

In this module, an intervention is given the rating of:

  1. Effective if the meta-analysis revealed an effect of treatment that was significant
  2. Effective* if the meta-analysis revealed an effect of treatment that approached significance,
  3. May not be effective if an effect was found, however the effect was not significant nor did it approach significance,
  4. Not effective if none of the 3 conditions above are met

The following list describes the different types of organized stroke care analyzed in this review, ranging from most organized to least organized:

Types of organized stroke care:

  1. Stroke ward: a multidisciplinary team including specialist nursing staff based in a discrete ward caring exclusively for patients with stroke. This category includes the following sub-divisions:

    1. Acute stroke units, which accept patients acutely but discharge early (usually within 7 days).
    2. Rehabilitation stroke units, which accept patients after a delay, usually of seven days or more, and focus on rehabilitation; and,
    3. Comprehensive stroke units, which accept patients acutely but also, provide rehabilitation for at least several weeks if necessary. Both the rehabilitation unit and comprehensive unit models offered prolonged periods of rehabilitation.
  2. Mixed rehabilitation ward: a multidisciplinary team including specialist nursing staff in a ward providing a generic rehabilitation service but not exclusively caring for patients with stroke.
  3. Mobile stroke team: a multidisciplinary team (excluding specialist nursing staff) providing care in a variety of setting.
  4. General medical wards are defined as care in an acute medical or neurology ward without routine multidisciplinary input.

Outcomes

Overall organized stroke care

Death by the end of scheduled follow up
Effective
1

NOTE: This section compares overall organized stroke with general medical wards. For a breakdown of each type of stroke unit compared to general medical wards please see the next sections.

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of overall organized stroke care (which includes rehabilitation stroke units, comprehensive stroke units, mixed rehabilitation wards, and mobile stroke teams) for reducing death by the end of scheduled follow up in patients with stroke as compared to general medical wards. The analysis revealed a significant effect (OR= 0.86, 95% CI= 0.76, 0.98).

Conclusion: There is evidence from 1 meta-analysis that organized stroke care is effective in reducing death by the end of scheduled follow up as compared to general medical wards in patients with stroke.

Death or dependency by the end of scheduled follow up
Effective
1

NOTE: This section compares overall organized stroke with general medical wards. For a breakdown of each type of stroke unit compared to general medical wards please see the next sections.

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of overall organized stroke care (which includes rehabilitation stroke units, comprehensive stroke units, mixed rehabilitation wards, and mobile stroke teams) for reducing death or dependency by the end of scheduled follow up in patients with stroke as compared to general medical wards. The analysis revealed a significant effect (OR= 0.82, 95% CI= 0.73, 0.92).

Conclusion: There is evidence from 1 meta-analysis that organized stroke care is effective in reducing death or dependency by the end of scheduled follow up as compared to general medical wards in patients with stroke.

Death or institutional care by the end of scheduled follow up
Effective
1

NOTE: This section compares overall organized stroke with general medical wards. For a breakdown of each type of stroke unit compared to general medical wards please see the next sections.

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of overall organized stroke care (which includes rehabilitation stroke units, comprehensive stroke units, mixed rehabilitation wards, and mobile stroke teams) for reducing length of stay (days) in a hospital or institution in patients with stroke as compared to general medical wards. The analysis revealed an effect that approached significance (SMD= -0.11, 95% CI= -0.23, 0.01).

Conclusion: There is evidence from 1 meta-analysis that organized stroke care is effective* in reducing length of stay (days) in a hospital or institution as compared to general medical wards in patients with stroke.

Note: The effect of treatment approached significance.

Length of stay (days) in a hospital or institution
Effective*
2

NOTE: This section compares overall organized stroke with general medical wards. For a breakdown of each type of stroke unit compared to general medical wards please see the next sections.

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of overall organized stroke care (which includes rehabilitation stroke units, comprehensive stroke units, mixed rehabilitation wards, and mobile stroke teams) for reducing length of stay (days) in a hospital or institution in patients with stroke as compared to general medical wards. The analysis revealed an effect that approached significance (SMD= -0.11, 95% CI= -0.23, 0.01).

Conclusion: There is evidence from 1 meta-analysis that organized stroke care is effective* in reducing length of stay (days) in a hospital or institution as compared to general medical wards in patients with stroke.

Note: The effect of treatment approached significance.

Rehabilitation stroke ward vs. general medical ward

Death by the end of scheduled follow up
Effective*
2

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of rehabilitation stroke units for reducing death by the end of scheduled follow up in patients with stroke as compared to general medical wards. The analysis revealed an effect that approached significance (OR= 0.69, 95% CI= 0.46, 1.05).

Conclusion: There is evidence from 1 meta-analysis that rehabilitation stroke units are effective* in reducing death by the end of scheduled follow up as compared to general medical wards in patients with stroke.

Note: The effect of treatment approached significance.

Death or dependency by the end of scheduled follow up
May not be effective
3

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigating the effectiveness of organized stroke care revealed a reduction in death or dependency by the end of scheduled follow up in favour of rehabilitation stroke units as compared to general medical wards, however the effect was not statistically significant (OR= 0.83, 95% CI= 0.57, 1.23).

Conclusion: There is evidence from 1 meta-analysis that rehabilitation stroke units may not be effective for reducing death or dependency by the end of scheduled follow up as compared to general medical wards in patients with stroke.

Note: While the analysis did reveal lowered odds for death or dependency by the end of scheduled follow up, the results were not statistically significant.

Death or institutional care by the end of scheduled follow up
Effective*
2

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigating the effectiveness of rehabilitation stroke units in patients with stroke revealed a reduction in death by the end of scheduled follow up that approached significance compared to general medical wards (OR= 0.76, 95% CI= 0.52, 1.09).

Conclusion: There is evidence from 1 meta-analysis that rehabilitation stroke units are effective* in reducing death or institutional care by the end of scheduled follow up as compared to general medical wards in patients with stroke.

Note: The effect of treatment approached significance.

Length of stay (days) in a hospital or institution
Not effective
4

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigating the effectiveness of organized stroke care revealed that rehabilitation stroke units do not reduce length of stay compared to general medical wards (SMD= 0.37, 95% CI= 0.07, 0.67).

Conclusion: There is evidence from a meta-analysis that rehabilitation stroke units are not effective in reducing length of stay as compared to general medical wards in patients with stroke.

Comprehensive stroke ward vs. general medical ward

Death by the end of scheduled follow up
Effective
1

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of comprehensive stroke units for reducing death by the end of scheduled follow up, and compared to general medical wards, and revealed a significant effect (OR= 0.85, 95% CI= 0.72, 0.99).

Conclusion: There is evidence from 1 meta-analysis that comprehensive stroke units are effective in reducing death by the end of scheduled follow up as compared to general medical wards in patients with stroke.

Death or dependency by the end of scheduled follow up
Effective
1

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigating the effectiveness of comprehensive stroke units revealed a significant reduction (OR= 0.83, 95% CI= 0.71, 0.97) in death or dependency by the end of scheduled follow up as compared to general medical wards.

Conclusion: There is evidence from 1 meta-analysis that comprehensive stroke units are effective in reducing death or dependency by the end of scheduled follow up as compared to general medical wards in patients with stroke.

Death or institutional care by the end of scheduled follow up
Effective
1

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of comprehensive stroke units and revealed a reduction (OR= 0.80, 95% 0.70, 0.92) in death or institutional care by the end of scheduled follow up as compared to general medical wards.

Conclusion: There is evidence from 1 meta-analysis that comprehensive stroke units are effective in reducing death or institutional care by the end of scheduled follow up as compared to general medical wards in patients with stroke.

Length of stay (days) in a hospital or institution
Effective
1

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of organized stroke care and revealed that comprehensive stroke units reduce length of stay compared to general medical wards (SMD= -0.19, 95% CI= -0.31, -0.06).

Conclusion: There is evidence from a meta-analysis that comprehensive stroke units are effective in reducing length of stay as compared to general medical wards in patients with stroke.

Mixed rehabilitation ward vs. general medical ward

Death by the end of scheduled follow up
Not effective
4

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of organized stroke care and revealed a reduction (OR= 0.91, 95% CI= 0.58, 1.42) in death by the end of scheduled follow up for mixed rehabilitation wards as compared to general medical wards. However, the effect was not statistically significant.

Conclusion: There is evidence from 1 meta-analysis that mixed rehabilitation wards are not effective in reducing death by the end of scheduled follow up as compared to general medical wards in patients with stroke.

Death or dependency by the end of scheduled follow up
Effective
1

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of organized stroke care and revealed a reduction (OR= 0.65, 95% CI= 0.47, 0.90) in death or dependency by the end of scheduled follow up for mixed rehabilitation wards as compared to general medical wards.

Conclusion: There is evidence from a meta-analysis that mixed rehabilitation wards are effective in reducing death or dependency by the end of scheduled follow up as compared to general medical wards in patients with stroke.

Death or institutional care by the end of scheduled follow up
Effective
1

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of organized stroke care and revealed a reduction (OR= 0.71, 95% CI= 0.51, 0.99) in death or institutional care by the end of scheduled follow up for mixed rehabilitation wards as compared to general medical wards.

Conclusion: There is evidence from 1 meta-analysis that mixed rehabilitation wards are effective in reducing death or institutional care by the end of scheduled follow up as compared to general medical wards in patients with stroke.

Length of stay (days) in a hospital or institution
Not effective
4

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of mixed rehabilitation wards and revealed no effect on length of stay (days) in a hospital or institution as compared to general medical wards (SMD= 0.08, 95% CI= -0.21, 0.37).

Conclusion: There is evidence from a meta-analysis that mixed rehabilitation wards are not effective in reducing length of stay (days) in a hospital or institution as compared to general medical wards in patients with stroke.

Mobile stroke team vs. general medical ward

Death by the end of scheduled follow up
Not effective
4

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of organized stroke care and revealed that mobile stroke teams do not reduce death by the end of scheduled follow up as compared to general medical wards (OR= 1.03, 95% 0.74, 1.42).

Conclusion: There is evidence from a meta-analysis that mobile stroke teams are not effective for reducing death by the end of scheduled follow up as compared to general medical wards in patients with stroke.

Death or dependency by the end of scheduled follow up
Not effective
4

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of organized stroke care and revealed that mobile stroke teams do not reduce death or dependency by the end of scheduled follow up as compared to general medical wards (OR= 0.96, 95% 0.69, 1.34).

Conclusion: There is evidence from a meta-analysis that mobile stroke teams are not effective in reducing death or dependency by the end of scheduled follow up compared to general medical wards in patients with stroke.

Death or institutional care by the end of scheduled follow up
Not effective
4

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of organized stroke care and revealed that mobile stroke teams do not reduce death or institutional care by the end of scheduled follow up as compared to general medical wards (OR= 1.16, 95% 0.84, 1.60).

Conclusion: There is evidence from a meta-analysis that mobile stroke teams are not effective in reducing death or institutional care by the end of scheduled follow up as compared to general medical wards in patients with stroke.

Length of stay (days) in a hospital or institution
Not effective
4

A meta-analysis (Stroke Unit Trialists` Collaboration, 2007) investigated the effectiveness of organized stroke care and revealed that mobile stroke teams do not reduce length of stay (days) in a hospital or institution as compared to general medical wards (SMD= -0.04, 95% -0.67, 0.59).

Conclusion: There is evidence from a meta-analysis that mobile stroke teams are not effective in reducing length of stay (days) in a hospital or institution as compared to general medical wards in patients with stroke.

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