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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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1&
$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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1*
$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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