The ideal of stroke care is the stroke unit, in which a multidisciplinary staff of doctors, nurses, and therapists collaborate on treatment and recovery. In Alberta, that type of care is offered to 52% of patients, mainly in urban settings. The proportion of patients who receive this type of care is lower in many other provinces. Hospitals in smaller centers frequently do not have the same resources as urban centers do.
“There are challenges in these smaller centers, mainly because of a lack of subspecialists, dedicated beds, or early exposure to therapists,” said Thomas Jeerakathil, MD, stroke neurologist and cochair of the Stroke Action Plan project. “What we are trying to do is replicate the experience of stroke unit care for rural and smaller urban areas.”
The model described in the study starts with Stroke Unit Equivalent Care (SUEC). “You train staff to have additional expertise in stroke, have standardized orders and pathways, which are protocols that are followed, and increase rehabilitation staffing,” said Dr. Jeerakathil.
In smaller hospitals, patients with stroke should all be admitted consistently to the same ward. In this way, staff in that ward will develop greater proficiency in responding to these patients over time.
Another major element of the Alberta model is early supported discharge (ESD). Between 14% and 19% of stroke patients receive intensive rehabilitation after discharge. Dr. Jeerakathil suggested that ESD could expand intensive home-based rehabilitation to an additional 30% of stroke patients.
With ESD, patients with stroke who do not need inpatient nursing and who are not frail are discharged from the hospital sooner when plans are in place for caregiver support. These plans might include frequent visits from a physiotherapist or occupational therapist at home to meet the patient’s rehabilitation needs. ESD is used in Canadian cities such as Edmonton and Calgary, as well as in larger centers in other provinces such as Ontario.
The third service-delivery method integrated into the model is community rehabilitation. Sometimes patients living with the residual effects of a stroke may fare well for a time, but then decline. Community rehabilitation is intended to assist such people with follow-up for medical attention and monitoring and potentially rehabilitation.
The SUEC model has been implemented at 14 rural centers, five of which also use ESD and community rehabilitation. “We are seeing the results, in terms of decreasing length of stay, the increasing number of patients with access to rehabilitation, and increased patient satisfaction,” said Agnes Joyce, study author and manager of the Cardiovascular Health and Stroke Strategic Clinical Network.
Patient Management System Reduces Hospital Bed Usage
A patient management system at the acute stroke unit of the General Hospital in Kelowna, Canada, reduced the number of stroke patient bed days by more than 25%, according to researchers. Data suggest that the new system is saving the 380-bed hospital more than 1,000 bed days per year without the need for new investment in devices, treatments, or personnel.
The program is called Proprietary Physician, or Pro-MD, and ensures that one of the hospital’s five neurologists is always designated as the person primarily responsible for best bed usage and patient flow in the acute stroke unit. Each physician’s assignment as Pro-MD lasts for a period of several weeks to one month.
A crucial component of the program is that, in addition to the normal care that neurologists and other caregivers provide to their patients, the Pro-MD makes twice-weekly rounds of all patients with the full care team. This team includes the ward head nurse, physiotherapist, occupational therapist, social worker, transition nurse, pharmacist, rehabilitation ward head nurse, and the patient’s family.
“This [system] brings everyone who needs to have input into decisions about a patient’s care together to agree on the action needed,” said John B. Falconer, MD, Director of the Transient Ischemic Attack and Stroke Clinic at the hospital and author of the study. “This is very advantageous, compared to formerly having to compare written notes from one another and wait for input from others.”
The meetings take between 30 and 45 minutes to discuss an average of six patients, and participants, including the family, agree on the course of care. This agreement is crucial, particularly when discussing the timing and terms of a patient’s discharge from the hospital.
The program is simple and has proven effective, said Dr. Falconer. “It could perhaps be used in other areas of the hospital, but it’s particularly relevant to stroke care because of the many players involved and the crucial role the patient and family play in rehabilitation.” In addition, the system ensures that “patients are better and more efficiently treated, the hospital saves resources, and the morale of the whole unit is much better,” he concluded.