Effect of acute stroke unit care integrated with care continuum versus conventional treatment: A randomized 1-year study of elderly patients: the Göteborg 70+ Stroke Study. A randomized controlled trial of a stroke rehabilitation ward. Home or hospital for stroke rehabilitation? results of a randomized controlled trial : I: health outcomes at 6 months. A non-intensive stroke unit reduces functional disability and the need for long-term hospitalization. Benefit of a stroke unit: a randomized controlled trial. Improving stroke rehabilitation. A controlled study. The effect of systematic care planning after acute stroke in general hospital medical wards. Stroke unit versus general medical wards, II: neurological deficits and activities of daily living: a quasi-randomized controlled trial. Randomised controlled trial to evaluate early discharge scheme for patients with stroke.
The aim of the study was to compare the effect of conventional treatment with the effect of acute stroke unit care integrated with geriatric stroke unit care continuum.
                A 1-year study was undertaken with 2:1 randomization to stroke unit care or conventional care, with assessment by an independent team. The study was composed of 249 elderly patients (aged >/=70 years) hospitalized for acute stroke, without previous cerebral lesion and without recognized need of care. Main outcome measures were patients at home after 1 year, ability in daily living activities, health-related quality of life score according to questionnaire, death or institutional care, and death or dependence.
                One hundred two patients (61%) in the stroke unit and 49 patients (59%) in the general ward group were alive and at home after 1 year (95% CI -10% to 16%). There were no significant differences in daily life activities or quality of life. In patients with concomitant cardiac disease, there was a reduction in death or institutional care after 3 months in the stroke unit group compared with the group receiving conventional care (28% versus 49%, respectively; 95% CI -40% to -3%). This effect did not remain after 1 year. Patients seeking care after 24 hours often had mild stroke and lived alone.
                There was no effect on the number of patients living at home after 1 year, but after 3 months of stroke unit care, a beneficial effect was found on mortality and the need for institutional care among those with concomitant heart disease. This study involved patients who were considerably older than those investigated in previous randomized studies of acute stroke unit care; thus, these findings will contribute to the specialized register of controlled trials in stroke. In S.E. Kent, during 1978 and 1979, 225 patients, representing 228 occurrences of hemiplegia, were referred to a new 20-bed stroke rehabilitation ward. These patients were randomly allocated to treatment in the special ward (group A 112 strokes) or to remain in conventional treatment locations (group C 116 strokes); the two groups were closely similar, except for the initial level of consciousness. Survivors were observed at four-month intervals to one year. There are indications of benefit for patients in group A by comparison with Group C in terms of treatment received (number treated by remedial therapists, the extent of treatment, and the arrangements for after-care), and in outcome (survival and the proportion returned to the community). The direction of the trend of advantage is consistent with another recent controlled trial, although not all modes of improvement are identical in the two trials. It is suggested that every health district should develop a comprehensive policy of stroke management. We wished to examine the effectiveness of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke.
                This was a randomized, controlled trial comparing early hospital discharge and home-based rehabilitation with usual inpatient rehabilitation and follow-up care. The trial was carried out in 2 affiliated teaching hospitals in Adelaide, South Australia. Participants were 86 patients with acute stroke (mean age, 75 years) who were admitted to hospital and required rehabilitation. Forty-two patients received early hospital discharge and home-based rehabilitation (median duration, 5 weeks), and 44 patients continued with conventional rehabilitation care after randomization. The primary end point was self-reported general health status (SF-36) at 6 months after randomization. A variety of secondary outcome measures were also assessed.
                Overall, clinical outcomes for patients did not differ significantly between the groups at 6 months after randomization, but the total duration of hospital stay in the experimental group was significantly reduced (15 versus 30 days; P<0.001). Caregivers among the home-based rehabilitation group had significantly lower mental health SF-36 scores (mean difference, 7 points).
                A policy of early hospital discharge and home-based rehabilitation for patients with stroke can reduce the use of hospital rehabilitation beds without compromising clinical patient outcomes. However, there is a potential risk of poorer mental health on the part of caregivers. The choice of this management strategy may therefore depend on convenience and costs but also on further evaluations of the impact of stroke on caregivers. In a prospective controlled trial we compared the clinical outcome for unselected acute stroke patients in a non-intensive stroke unit (n = 110) and in general medical wards (n = 183). The patients were comparable in age, marital state and functional impairment on admission. Case fatality rates over the first year after the stroke were similar in the two groups. By three months after the stroke, 15% of the survivors initially admitted to the stroke unit and 39% of those admitted to general medical wards remained hospitalized (p less than 0.001). The corresponding figures by one year after the cerebrovascular accident were 12% and 28%, respectively (p less than 0.05). A greater proportion of surviving stroke unit patients was independent in walking (0.10 greater than p greater than 0.05), personal hygiene (p less than 0.05) and dressing (p less than 0.001). Essential features of the stroke unit are team work headed by a stroke nurse, staff, patient and family education and very early onset of rehabilitation. We conclude that this strategy improves functional outcome and reduces the need for long-term hospital care. In a randomized controlled trial we compared the clinical outcome of acute stroke patients, 110 of whom were allocated to treatment in a stroke unit and 110 to treatment in general medical wards. No significant difference existed between these groups with regard to sex, age, marital status, medical history, or functional impairment on admission. Outcome was measured at 6 and 52 weeks after the stroke by the proportion of patients at home, the proportion of patients in an institution, the mortality, and the functional state. After 6 weeks 56.4% of the patients randomized to the stroke unit and 32.7% of the patients randomized to the general medical wards were at home (p = 0.0004), and after 52 weeks 62.7% and 44.6%, respectively, were at home (p = 0.002). After 6 weeks 36.3% of the patients from the stroke unit and 50.0% from the general medical wards were in an institution (p = 0.02); after 52 weeks 12.7% and 22.7%, respectively, were institutionalized (p = 0.016). After 6 weeks mortality was 7.3% for the stroke unit group and 17.3% for the general medical wards group (p = 0.027). After 52 weeks mortality was 24.6% for the stroke unit group and 32.7% for the general medical wards group (difference not significant). Functional state was significantly better for patients treated in the stroke unit after both 6 and 52 weeks. We conclude that care of patients with acute stroke in a stroke unit improves clinical outcome compared with treatment in general medical wards. Assessment of stroke rehabilitation is complicated by the heterogeneity of patients and settings and by difficulties in disentangling effects of organization from effects of types and amounts of treatment input.
                A prospective controlled study was undertaken in 245 stroke patients stratified into three groups according to prognosis and managed on a stroke rehabilitation unit (n = 124) or general medical wards (n = 121). Patients were randomly allocated to either setting 2 weeks after stroke and were comparable for baseline characteristics.
                Patients on general medical wards received more physiotherapy on average (16.2 +/- 7.2 versus 14.3 +/- 3.2 hours; P < .05) but similar amounts of occupational therapy (9.3 +/- 2.8 versus 9.5 +/- 3.2 hours) compared with stroke unit patients. More time was spent on individual rehabilitation on the stroke unit compared with general wards (P < .001). Functional abilities at discharge, destination of discharge, and length of hospital stay in patients with good prognosis were comparable in both settings. Patients with poor prognosis managed on general wards showed higher mortality (P < .05) and longer hospital stay (123.2 +/- 48.2 versus 52.3 +/- 19.8 days; P < .001), but functional abilities at discharge in survivors were comparable with those of stroke unit patients. Patients with intermediate prognosis had significantly better outcome on the stroke unit, with more patients being discharged home (75% versus 52%; P < .001), shorter average length of hospital stay (48.7 +/- 17.2 versus 104.6 +/- 28.6 days; P < .001), and better functional abilities at discharge (P < .05).
                Stroke units improve outcome and reduce hospital stay without increasing therapy time. Their effectiveness may be enhanced by patient selection. In a multidisciplinary study comprising 280 patients with acute cerebrovascular disease, the functional capacity was followed from the acute stage onwards with a test battery mainly measuring activities of daily living and motor capacity. Systematized care procedures with written care plans in accordance with the nursing process model, together with a booklet of guidelines in stroke care, were introduced during an experimental period in the care of 173 of the stroke victims. The remaining 107 patients received conventional care. The functional improvements were equal from a statistical standpoint in these two groups. However, in the group, which received special activities, there was a significant decrease in bed days, and a slightly larger number were able to return to their own homes. Compared with another stroke population from the same hospital, measured with the same functional instrument 7 years ago, the patients in this study seemed better off from a functional standpoint. For the individual severely-disabled patient, the care planning procedures seemed to be valuable and an effective way of promoting communication between different units. The difficulties in introducing new routines for documentation are discussed. The efficacy of stroke units has been extensively examined. It is unknown, however, whether the superiority of the stroke unit will remain after the increased focus on stroke treatment in general medicine. This study of patients admitted to the hospital early and with a short length of stay determines the effect and identifies certain important components of a stroke unit.
                Five hundred fifty patients aged 60 years or older with acute stroke were allocated by a quasi-randomized design to a stroke unit or a general medical ward based on date of birth in the month. Patients admitted within 24 hours of onset were enrolled. Outcomes after 7 months were death, proportion needing long-term care, and change in neurological and functional state assessed by the Scandinavian Stroke Scale and Barthel Index.
                Seven months after admission there was a trend in favor of the stroke unit in all outcome measures, but no significant differences in clinical outcomes were found except for change in the Scandinavian Stroke Scale score. Recurrent stroke during hospitalization occurred more often in the general medical ward (P = .03). The stroke unit was significantly more aggressive in mobilization out of bed (P<.01) and use of parenteral fluid (P<.0001), aspirin (P<.0001), antipyretics (P<.0001), and antibiotics (P<.0001).
                Our study confirms the benefit of the stroke unit, but the effects on the most reliable clinical outcomes were modest and insignificant. Treatment in this stroke unit hastened recovery. More aggressive rehabilitation and use of parenteral fluid, aspirin, antipyretics, and antibiotics appeared in the stroke unit. To assess the clinical effectiveness of an early discharge policy for patients with stroke by using a community based rehabilitation team.
                Randomised controlled trial to compare conventional care with an early discharge policy.
                Two teaching hospitals in inner London.
                331 medically stable patients with stroke (mean age 71) who lived alone and were able to transfer independently or who lived with a resident carer and were able to transfer with help.
                167 patients received specialist community rehabilitation for up to 3 months after randomisation. 164 patients continued with conventional hospital and community care.
                Barthel score at 12 months. Secondary outcomes measured impairment with motoricity index, minimental state examination, and Frenchay aphasia screening test; disability with the Rivermead activity of daily living scales, hospital anxiety and depression scale, and 5 m walk; handicap with the Nottingham health profile; carer stress with caregiver strain index and patient and carer satisfaction. The main process measure was length of stay after randomisation.
                One year after randomisation no significant differences in clinical outcomes were found apart from increased satisfaction with hospital care in the community therapy group. Length of stay after randomisation in the community therapy group was significantly reduced (12 v 18 days; P < 0.0001). Patients with impairments were more likely to receive treatment in the community therapy group.
                Early discharge with specialist community rehabilitation after stroke is feasible, as clinically effective as conventional care, and acceptable to patients. Considerable reductions in use of hospital beds are achievable.
Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The benefits were most apparent in units based in a discrete ward. No systematic increase was observed in the length of inpatient stay.