Stroke Care in Europe - The Role of Stroke Units

Abstract

The stroke burden upon society is increasingly high. We expect around 1,800 new stroke cases and 600 stroke recurrences per one million people per year. Due to the changing age structure of most populations, these numbers are set to increase in the future. An organised stroke unit is an infrastructure that provides certain key processes for acute stroke patients. Stroke unit care constitutes a highly effective treatment. It decreases mortality, disability and the need for institutional care. 2 This is true of all age groups and any stroke type or severity. Elderly patients and those with severe strokes benefit most. 3 The number needed to treat at organised stroke units has been calculated to be as low as 15 to avoid one death or disability. 3 This number may in fact be even lower, as thrombolysis with tissue plasminogen activator (tPA) 4 and multimodal automated monitoring 5,6 were not available in the trials of the Stroke Unit Trialists' Collaboration. A major component of the beneficial effect of stroke unit care is the increasing number of patients treated with thrombolytic therapy. The concomitant improvement of expertise leads to better outcomes and fewer complications. 7–10 Several recent publications have confirmed that organised stroke care leads to shorter hospital stay, fewer complications and a better functional outcome. 6,11–14 This is why the recent Helsingborg Declaration clearly stated that " all patients in Europe with stroke will have access to a continuum of care from organised stroke units in the acute phase to appropriate rehabilitation and secondary prevention by 2015. " 15 Other recent papers argue for the same ideal. 16–18 Five factors are particularly important for stroke units to have a beneficial effect: the dedicated stroke unit, i.e. care is confined exclusively to acute stroke patients; the multidisciplinary team approach, including physicians, nurses, physiotherapists, occupational therapists, speech and swallowing therapists, social workers and neuropsychologists, all specialised in stroke treatment; the comprehensive stroke unit concept delivering both hyperacute treatment and early mobilisation and rehabilitation by the same multidisciplinary team; automated multimodal monitoring of vital functions within the first 72 hours; and thrombolysis within the time limits of up to three hours and beyond in selected patients. European Stroke Initiative (EUSI) investigators 19 recently performed an interrogation of 83 European stroke specialists from 18 countries to establish what, in their opinion, are the essential components and necessary facilities on the various levels of hospital care where acute stroke patients are routinely treated. One hundred and seven potential components collected from the relevant literature were proposed for evaluation. Experts had to judge the items using a numerical scale ranging from 1 (irrelevant) to 5 (absolutely necessary). Items were derived from six categories: personnel, diagnostic procedures, monitoring, invasive treatments provided, infrastructures and protocols and procedures. Components considered as 'absolutely necessary' by at least 50% of the experts were classified as essential for acute stroke care in comprehensive stroke centres (CSCs) (see Table 1). The two upper levels defined on the basis of their answers corresponded to CSCs and primary stroke centres (PSCs). 19 Eight components were considered as absolutely necessary by more than 75% of experts for PSCs: a multidisciplinary team; stroke-trained nurses; brain computed tomography (CT) scan available 24/7 (i.e. always); 4 CT priority for stroke patients; extracranial Doppler sonography; automated electrocardiogram (ECG) monitoring; intravenous (IV) recombinant (r)t-PA protocols 24/7; and in-house emergency department (see Table 2). These findings define what should be part of modern stroke care, as the opinion of the experts was based on the state-of-the-art technology and the latest scientific evidence in stroke research. A third level of stroke care was also defined, but this was considered the minimum, suboptimal level of care for stroke patients (see Table 3). The aspect of telemedicine in acute stroke care had to be removed due to disagreement between experts. The above classification, with the two highest levels of care recommended for acute stroke patients, is close to the ideas of the Brain Attack Coalition (BAC), 20 the Swiss, 21 the German and the Finnish ideals, 17,22,23 but does not perfectly match the models developed in the UK and Scandinavia. What is the reality for acute stroke sufferers in Europe? The answer to this important question was provided by a subsequent study from the same group with a Europe-wide investigation of a large random sample of hospitals. 24 The objective of this study was to find out how many European hospitals are able to provide an appropriate level of care. The level of stroke care was analysed in 886 hospitals in 25 © T O U C H B R I E F I N G S 2 0 0 7 Stroke 24 a report by