ppt mira bab 58

8/19/2019 ppt mira bab 58

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Acute stroke units and teams

Presenter : dr. Mira Arianti

Pembimbing : Dr. dr. Aldy S. Rambe, SpS (K)

Modul Neurovasular

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Introduction

• The type of care patients receive varies

from country to country also depending on

local habits, political issues and resources

available.

• The sensitivity of the brain to brief

episodes of profound ischemia or

prolonged periods of modest ischemiarequires an aggressive approach to acute

stroke care.

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The common goals of the management of

patients affected from possible symptoms of

transient ischemic attacks or stroke are

prompt and accurate diagnosis of the stroke and

the underlying etiology

specific medical and surgical treatment

assessment of patients’ stroke-related medicalproblems in the acute phase and providing

adequate care

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terminal care for patients that are unlikely to

survive

comprehensive rehabilitation

continuing long-term care for severely disabled

patients

hospital discharge and placement


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adequate secondary prevention of further

vascular events including surgery orinterventional radiology, !here appropriate

educational and research program

established guidelines

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#efinitions

• $t is crucial to first outline the different

e%isting types of stroke care !hich range

from services providing acute stroke care

during the first days after stroke to the

service only providing rehabilitation.

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Acute stroke unit and acute stroke intensive

care unit

This category includes the 'acute intensive

stroke unit( or 'acute stroke intensive care unit,(

!hich accepts patients acutely but discharges

early) that is, usually !ithin * days.

Acute stroke team

#ifferent specialists collaborate in stroke careand are available on request to advise on

specific stroke-related issues.

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Stroke rehabilitation units

+troke rehabilitation units only accept patients

after the acute phase of the disease) that is,!ith a delay of usually * days or more, and

focus e%clusively on rehabilitation.

Comprehensive stroke units

omprehensive stroke units combine acute and

rehabilitation stroke care. comprehensive

stroke units have to be able to deliver the !idevariety of specialied care needed by patients

!ith serious cerebrovascular disease

comprising health care personnel !ith specific

e%pertise in a number of disciplines


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/andatory components and goals

• $t is mandatory to establish algorithms that

determine patient evaluation, any

diagnostic !orkup, treatment,

rehabilitation procedures, as !ell as staff

responsibilities and duties.

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Responsible physician

The physician should have broad kno!ledgeabout pathologies underlying stroke as !ell as

the functional problems related to this disease.

Type of organization

#ifferent types of stroke unit organiation can be

$dentified. $t is acute stroke units or intensive

care units. There is also non-intensive strokeunits or stroke rehabilitation units.

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Infrastructure and facilities to run a stroke

unit minimal amount of diagnostic tools should be

available on site, namely 2-hour cranial

computer tomography T4 scan facility, a 2-

hour neurosonology e%amination on request,routine laboratory tests, cerebral angiography,

and intensive care unit.


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5vidence of efficacy

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Dedicated stroke unit

This is a disease-specific service provided by a

discrete stroke !ard or stroke team !orking

e%clusively in the care of stroke patients.

Controlled randomized trials

+everal controlled randomied trials aimed to

sho! the efficacy of different types of stroke unitcare. 6y itself the results of each trial give a

very heterogeneous picture, and no definite

conclusion can be dra!n.


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Effect on death

This analysis is based on the service

comparisons !ithin the original trials !here anovel intervention !as compared !ith the

contemporary conventional care alternative

services4.

Effect on death or institutional care

The second outcome e%amined !as the odds

ratio of death or condition requiring institutionalcare at the end of follo!-up median 7 1 year

after stroke4.


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Effect on death or dependency

The third outcome e%amined in the meta-analysis !as the combined adverse outcome of

being dead or dependent in activities of daily

living at the end of follo!-up.

Age

s the severity of stroke is not age-related, age

should not be taken into account for decision-making as far as admission to a stroke unit is

concerned. 8riority should be given to patients

!ith certain specific syndromes.


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1"

ong!term follo"!up

The effect of stroke unit treatment !as still

present 1 years after admission for an initial

stroke.

#umber needed to treatThe risk difference for each outcome !as

calculated as the absolute difference in

outcome in each trial pooled for all available

trials. This information !as used to calculate

the number needed to treat to prevent one

adverse event.


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$atient satisfaction and %uality of life

T!o trials recorded outcome measures related

to patients’ quality of life. $n both cases, there!as a pattern of improved results !ithin the

stroke unit survivors !ith the results attaining

statistical significance in the Trondheim trial.

ength of stay

The length of stay is mainly determined

by local conditions and organiation. $t seemsnot !arranted to claim that stroke patients

should stay in one place from entry until

discharge.


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$re!hospital treatment

There are virtually no data on admission

path!ays. 6y empirical decision making itseems rational to avoid any delay in transfer of

patients to an adequate institution.

Avoiding hospitalization after strokeThe authors have not been able to identify any

significant differences in patient or care-givers’

outcomes. 9urthermore, despite an apparent reduction

in the number of patients admitted to hospital, there!as no overall reduction in hospital bed use, !hich

suggests that the novel intervention4 services are not

cheaper and might be even more costly than

conventional care


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Discharge and rehabilitation

ny type of follo!-up treatment has to be

carefully planned. $t is important to ad:ust andcoordinate patients’ daily requirements in cases

of discharge home.

Effect of organization

former meta-analysis of the effect of different

path!ays for stroke care, did not sho! a

statistically significant effect of different forms of

hospital organiations.


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5conomic issues

•+troke units appear to improve outcomes,but at !hat cost;


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5stablishing guidelines and education

• $nstitutional guidelines are mandatory to

any clinic that treats stroke patients.

• >uidelines have to implement specifically

local habits and have to consider the

possibilities of the present infrastructure. $t

is not only important to create guidelines,

but also to disseminate them and to teachtheir application.

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ontinous evaluation process

• ?nce a stroke unit care path!ay is

established, quality control of the care

given is mandatory. The availability of data

dra!s the attention to possible failuresand enables changes !here required.

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onclusions

• $t can be stated that patients receiving

organied in-patient stroke unit4 care are

more likely to survive, regain

independence and return home than thosereceiving contemporary conventional care.

• +troke units appear to improve outcomes,

but at !hat cost;


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THANK YOU

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ppt mira bab 58

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