Quality of stroke care within a hospital: effects of a mobile stroke service

Stroke is the second-largest cause of death in developed countries and the major cause of disability.1 Of the estimated 44 000 people who have strokes each year in Australia,2 a third will die within a year,2 and almost half of the survivors will be disabled.3 Organised stroke services reduce mortality and dependence compared with conventional stroke care,4 and stroke units, in which a multidisciplinary team provides focused management in a geographically localised area, are the gold standard.5 In Australia, about 90% of stroke patients are treated in hospital,6 but only 23% of hospitals have a formal stroke service.7

The Australian guidelines for stroke units include patients being placed in a geographically defined unit; the presence of a coordinated multidisciplinary team (stroke physician, nursing staff, occupational therapist, physiotherapist, speech pathologist, dietitian, social worker and, where possible, psychologist); access to ongoing professional education; regular team meetings for care and discharge planning; and use of agreed evidence-based management protocols.8 Smaller hospitals may lack these resources, but efforts are made to provide the necessary care. A mobile stroke service (MSS),4 involving a multidisciplinary team that cares for stroke patients dispersed throughout a hospital, can be an intermediary step for many centres.

In 1998, a prospective, multicentre evaluation of stroke services (Stroke Care Outcomes: Providing Effective Services [SCOPES]) commenced in Australia.9 SCOPES evaluated clinical practices, models and outcomes of care in an effort to provide evidence and delineate factors that make stroke units more effective. Fifteen quality indicators were identified. These included:

• activities within 24 hours: brain imaging, swallowing assessment, allied health assessment, neurological observations;

• documentation of premorbid function and discharge needs; and

• management practices: enteric feeding if nil orally for more than 48 hours, measures to avoid aspiration, deep-vein thrombosis (DVT) prophylaxis, fever management and use of antiplatelet medication at discharge, as well as occupational therapy, speech therapy and physiotherapy within 48 hours.

Stroke units perform better than other models of care in adherence to quality indicators, and participants whose treatment adheres to all applicable indicators are more likely to be alive at discharge.9

In 2000, an MSS was started at a 260-bed medical centre in the eastern suburbs of Melbourne. The primary aim of our study was to use the quality assessment framework from SCOPES as part of an audit process. We compared quality of care following the introduction of the MSS with historical controls. The audit results were then benchmarked against the SCOPES stroke units9 as a method of providing a quality assurance program for future stroke management at our hospital.

Accurate diagnosis of stroke type and mechanism is important, as these have implications for long-term outcome and risk of stroke recurrence.16 Carotid doppler ultrasound, computed tomography brain imaging and transthoracic echocardiography were available at the hospital in both periods. The hospital does not have on-site facilities for MRI or transoesophageal echocardiography. The increased use of these investigations reflects the increased vigilance by the stroke physician in determining cause to enhance preventive and treatment strategies.

Discharge disability and destination varied substantially between the two groups. Although home rehabilitation programs have been in place since 1998, intensive home rehabilitation programs only started in August 1999. The number of beds available doubled in 2000, and regular in-service education sessions have taken place. This might partly explain why more patients were discharged home with support services in the MSS group.

Limitations of this study include reporting bias, where activities that formed our quality indicators may have been carried out but not documented, or where researchers applied subjective judgements. Completion of care pathways in 47% of MSS group patients made assessment of adherence to indicators easier. Conversely, adherence may have been underestimated in the control group. The study was not powered to detect differences in outcome, yet the differences were statistically significant. In some instances, such as utilisation of MRI, small numbers affected statistical accuracy.

As we have emphasised, localised stroke units are the gold standard. However, not all hospitals have the required resources. We initiated the stroke service with one neurologist employed to provide neurological services 5 hours a week. There were no other increases in resources, despite plans for extra allied health staff, increased training for nursing staff and specialised equipment. The support and enthusiasm of the hospital staff made it possible.

We suggest that a localised stroke unit with the institution of a stroke liaison nurse and increased specialist physician sessions would lead to a better stroke service in this hospital. Regular in-service education in acute stroke management is needed, especially as the hospital has rotating medical registrars from other hospitals, as many peripheral centres do.