Comparison of Two Systems for Stroke Rehabilitation in a General Hospital

Abstract

This study was designed to compare the effectiveness of stroke rehabilitation therapy in a specialized Stroke Unit with that provided on the medical service of a general hospital (Rhode Island Hospital). The 8-bed Stroke Unit is staffed by a multidisciplinary team, and a weekly conference is held for evaluation and planning. On the basis of data obtained from the hospital records, two groups of patients were studied: 224 who were treated in the Stroke Unit, and 110 who were evaluated and approved for admission to the Unit but were not accommodated. A rigid "first come, first served" policy for admission to the Unit was observed. Hypothesis testing was performed with reference to the patient's medical condition, socioeconomic status, demographic characteristics, and difficulties during hospital stay to determine whether the groups were comparable. A patient was considered to have improved if his condition decreased in severity between the time of admission to therapy and the time of discharge. Severity was rated as: mild (level one), moderate (level two), severe (level three), and profound (level four). No significant difference in rehabilitation results was found between the two treatment systems at severity levels two (moderate) and four (profound). However, the Stroke Unit attained significantly better results with level-three patients (severe stroke). This group received more sessions of physical therapy and remained in the hospital longer than did the level-three patients treated on the general medical service. Physicians referred patients selectively to the Stroke Unit, althoug the Unit had no policy of screening patients for admission, and this may have had some influence on the achievement of better results with level-three patients. Level-four patients did not do well in either setting.

A review of stroke rehabilitation and physiotherapy.

“…8 Several groups have conducted controlled trials comparing the outcome of patients from stroke units with those from medical wards. The first such study 9 reported no benefit for mildly and severely affected patients but a significantly better outcome for patients with moderate disabilities. Feigenson and colleagues 10 showed in a similar trial that patients admitted to a stroke unit were more likely to be discharged home and were able to walk better.…”

Stroke rehabilitation units: concepts, evaluation, and unresolved issues.

“…8 Another definition which has been suggested is "a geographic location within the hospital designated for stroke and stroke-like patients who are in need of rehabilitation services and the skilled professional care that such a unit can provide." 9 A major advantage which has been put forward for having a special unit is the opportunity of developing a collaborative policy for stroke rehabilitation. 10 Such a policy should include a comprehensive assessment of all aspects of patients' illness and disability, close collaboration between the different disciplines involved, identification and awareness of objectives of rehabilitation and an educational role.…”

A randomized trial of team care following stroke.

“…Comparative studies evaluating the effects of these units have, with one exception, 7 determined that patients achieved better functional outcomes. 8 " 10 Patients cared for in these units were sometimes, 8 but not always, 9 " more frequently discharged to home. In-hospital mortality, 7 "" and length of stay" were not positively influenced, but the units appeared to be effective in promoting family participation in patient care and the rehabilitation process.…”

“…Both studies 9 l0 compared care provided by a multidisciplinary team in specialized stroke units with care delivered on general medical wards. The Garraway study 10 only admitted patients who had a good prognosis for survival but who were unlikely to achieve independence without remediation.…”

“…These investigators found that a significantly higher proportion of patients from the stroke unit were assessed as independent at discharge than from the medical units. In the McCann and Culbertson study, 9 all levels of severity were admitted and patients were categorized as to severity. The stroke unit attained significantly better results with "severely" involved but not with the "moderately" or "profoundly" involved patients.…”