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  • Print publication year: 2020
  • Online publication date: December 2020

Chapter 4 - Organized Stroke Care

from Part II - Systems of Care


Most patients with suspected stroke should be transported without delay to a hospital, which has access to the required diagnostic tests and appropriate hyperacute treatments 24 h/day and 7 days/week. Once admitted, patients should be managed in a stroke unit rather than a general medical ward. There appears to be no systematic increase in length of hospital stay associated with organized (stroke unit) care. The recent development of hyperacute stroke units is not based on evaluation within RCTs but appears to improve processes of care in the acute phase. Processes of care on a stroke unit should mirror those found to be effective in RCTs. Stroke care should be specialized, organized, and multidisciplinary (i.e. provided by medical, nursing, physiotherapy, occupational therapy, speech therapy, and social work staff who are interested and trained in stroke care). The other beneficial components of organized stroke care are likely to be many, but it remains uncertain which are the most effective. Early discharge from the stroke unit with support from a domiciliary rehabilitation team (coordinated by the stroke unit) promises to reduce hospital length of stay and improve rehabilitation in the home and patient outcome.

Allen, D, Gillen, E, Rixson, L. (2009). The effectiveness of integrated care pathways for adults and children in health care settings: a systematic review. JBI Reports, 7(3), 80129.
ATTEND Collaborative Group. Family-led rehabilitation after stroke in India (ATTEND): a randomised controlled trial. Lancet. 2017; 390: 588–599.
AVERT Trial Collaboration Group. (2015). Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet, 386, 4655. pii: S0140-6736(15)60690–0.
Aziz, NA, Leonardi-Bee, J, Phillips, MF, Gladman, J, Legg, LA, Walker, M. (2008). Therapy-based rehabilitation services for patients living at home more than one year after stroke. Cochrane Database Syst Rev, 2, CD005952. doi:10.1002/14651858.CD005952.pub2.
Ciccone, A, Celani, MG, Chiaramonte, R, Rossi, C, Righetti, E. (2013). Continuous versus intermittent physiological monitoring for acute stroke. Cochrane Database Syst Rev, 5, CD008444. doi:10.1002/14651858.CD008444.pub2.
Donnan, GA, Davis, SM. (2003). Neurologist, internist, or strokologist? Stroke, 34(11), 2765.
Evans, A, Perez, I, Harraf, F, Melbourn, A, Steadman, J, Donaldson, N, et al. (2001). Can differences in management processes explain different outcomes between stroke unit and stroke-team care? Lancet, 358(9293), 1586–92.
Govan, L, Langhorne, P, Weir, C, for the Stroke Unit Trialists’ Collaboration. (2007). Does the prevention of complications explain the survival benefit of organised inpatient (stroke unit) care? Further analysis of a systematic review. Stroke, 38, 2536–40.
Indredavik, B, Bakke, F, Slordahl, SA, Rokseth, R, Haaheim, L. (1999). Treatment in a combined acute and rehabilitation stroke unit. Stroke, 30, 917–23.
Ingeman, A, Pedersen, L, Hundborg, HH, Petersen, P, Zielke, S, Mainz, J, et al. (2008).Quality of care and mortality among patients with stroke: a nationwide follow-up study. Med Care, 46(1), 63–9.
Kalra, L, Evans, E, Perez, I, Knapp, M, Donaldson, N, Swift, C. (2000). Alternative strategies for stroke care: a prospective randomised controlled trial. Lancet, 356, 894–9.
Kwan, J, Sandercock, P. (2004). In-hospital care pathways for stroke. Cochrane Database Syst Rev, 4, CD002924.
Langhorne, P, Baylan, S; Early Supported Discharge Trialists. (2017). Services for reducing duration of hospital care for acute stroke patients. Cochrane Database Syst Rev, 7, CD000443. doi:10.1002/14651858.CD000443.pub4.
Langhorne, P, Bernhardt, J, Kwakkel, G. (2011). Stroke rehabilitation. Lancet, 377, 1693–702.
Langhorne, P, Collier, JM, Bate, PJ, Thuy, MNT, Bernhardt, J. (2018). Very early versus delayed mobilisation after stroke. Cochrane Database Syst Rev, 10, CD006187.
Langhorne, P, Dennis, MS. (1998). Stroke Units: An Evidence-Based Approach. London: BMJ Publishing.
Langhorne, P, Dennis, MS. (2004). Stroke units: the next 10 years. Lancet, 363, 834–5.
Langhorne, P, de Villiers, L, Pandian, JD. (2012). Applicability of stroke-unit care to low-income and middle-income countries. Lancet Neurol, 11, 341–8.
Langhorne, P, Dey, P, Woodman, M, Kalra, L, Wood-Dauphinee, S, Patel, N, et al. (2005). Is stroke unit care portable? A systematic review of the clinical trials. Age Ageing, 34, 324–30.
Langhorne, P, O’Donnell, MJ, Chin, SL, Zhang, H, Xavier, D, Avezum, A, et al.; INTERSTROKE Collaborators. (2018).Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE): an international observational study. Lancet, 391(10134), 2019–27.
Langhorne, P, Pollock, A, in conjunction with the Stroke Unit Trialists’ Collaboration. (2002). What are the components of effective stroke unit care? Age Ageing, 31(5), 365–71.
Legg, L, Langhorne, P; Outpatient Service Trialists. (2004). Rehabilitation therapy services for stroke patients living at home: systematic review of randomised trials. Lancet, 363(9406), 352–6.
Major, K, Walker, A. (1998). Economics of stroke unit care. In Langhorne, P, Dennis, M, eds., Stroke Units: An Evidence Based Approach. London: BMJ Books, pp. 5665.
Ramsay, AI, Morris, S, Hoffman, A, Hunter, RM, Boaden, R, McKevitt, C, et al. (2015). Effects of centralizing acute stroke services on stroke care provision in two large metropolitan areas in England. Stroke, 46(8), 2244–51. doi:10.1161/STROKEAHA.115.009723.
Saka, O, McGuire, A, Wolfe, C. (2009). Cost of stroke in the United Kingdom. Age Ageing, 38(1), 2732. doi:10.1093/ageing/afn281.
Saposnik, G, Hill, MD, O’Donnell, M, Fang, J, Hachinski, V, Kapral, MK. (2008). Variables associated with 7-day, 30-day, and 1-year fatality after ischemic stroke. Stroke, 39, 2318–24.
Seenan, P, Long, M, Langhorne, P. (2007). Stroke units in their natural habitat. Stroke, 38, 1886–92.
Shepperd, S, Doll, H, Angus, RM, Clarke, MJ, Iliffe, S, Kalra, L, et al. (2008). Hospital at home admission avoidance. Cochrane Database Syst Rev, 4, CD007491. doi:10.1002/14651858.CD007491.
Stroke Unit Trialists’ Collaboration. (2013). Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev, 9, CD000197. doi:10.1002/14651858.CD000197.pub3.
Terent, A, Asplund, K, Farahmand, B, Henriksson, KM, Norrving, B, Stegmayr, B, et al. (2009). Stroke unit care revisited: who benefits the most? A cohort study of 105 043 patients in Riks-Stroke, the Swedish Stroke Register. J Neurol Neurosurg Psychiatry, 80, 881–7.
Turner, M, Barber, M, Dodds, H, Dennis, M, Langhorne, P, Macleod, MJ; on behalf of the Scottish Stroke Care Audit. (2015). The impact of stroke unit care on outcome in a Scottish stroke population, taking into account case mix and selection bias. J Neurol Neurosurg Psychiatry, 86, 314–8. doi:10.1136/jnnp-2013-307478.
Veerbeek, JM, van Wegen, E, van Peppen, R, van der Wees, PJ, Hendriks, E, Rietberg, M, et al. (2014).What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PLoS One, 9(2), e87987. doi:10.1371/journal.pone.0087987. eCollection 2014.