Stroke Units

National Stroke Foundation Policy Position

The National Stroke Foundation (NSF) advocates for all hospitals with over 75 patients per year
to have a stroke unit in place and to increase the accessibility of their stroke unit to all patients
requiring treatment for stroke. Furthermore, the NSF recommends that smaller hospitals that
admit fewer strokes (< 75 per year), especially those lacking access to fundamental diagnostic
equipment, such as a brain CT, should have formal networks and written agreements in place to
transfer stroke patients to a Comprehensive or Primary Stroke Service (hubs) and/or support
(e.g. via telemedicine) where there is a decision to not transfer the patient (e.g. due to patient
preference or palliation).

Background to stroke units

Stroke unit care significantly reduces death and disability after stroke compared with conventional care
in general wards.2 There are different types of stroke units 1,2 depending on the setting in which patients
are treated. These include:

 Acute stroke ward: acute unit in a discrete ward (usually discharged within seven days)

 Comprehensive stroke unit care: combined acute and rehabilitation unit in a discrete ward

 Stroke rehabilitation unit: a discrete rehabilitation unit for stroke patients who are
transferred from acute care 1-2 weeks post-stroke

Another common unit described in the literature is a:

 Mixed rehabilitation ward: rehabilitation provided on a ward managing a general caseload.

Stroke units are the most effective therapy available for acute stroke. They can save lives and reduce
the level of disability.3

According to the NSF’s guidelines for stroke unit care:4

 All people with stroke should be admitted to hospital and be treated in a stroke unit with a
multidisciplinary team.

1
There is a full list of hospitals that have stroke units on the NSF website (http://strokefoundation.com.au/stroke-
care-units/).
2
Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of
Syst Rev 2013 CD000197.
3
Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of
Syst Rev 2013 CD000197.
4
National Stroke Foundation. Clinical Guidelines for Stroke Management 2010. Melbourne Australia.
  All people with stroke should be admitted directly to a stroke unit (preferably within three hours
of stroke onset).
 Smaller hospitals should consider stroke services that adhere as closely as possible to the
criteria for stroke unit care. Where possible, patients should receive care in geographically
discrete units.
 If people with suspected stroke present to non-stroke unit hospitals, transfer protocols should
be in place and used to guide urgent transfers to the nearest stroke unit hospital.

The minimum requirements for a SU are:

1. Co-located beds within a geographically defined unit

2. Dedicated, interprofessional team with members who have a special interest in stroke and/or
rehabilitation. The minimum team would consist of medical, nursing and allied health (including
OT, PT, SP, SW & DT)
3. Interprofessional team meet at least once per week to discuss patient care.
4. Regular programs of staff education and training relating to stroke. (e.g. dedicated stroke in
service program and/or access to annual national or regional stroke conference)

In Australia, stroke units are regarded as the core element of a stroke service 5. Stroke services are
categorised based on the characteristics they have. As well as providing additional elements of service,
some of these stroke services have the additional responsibility of providing support to smaller centres.

Stroke unit care facts

The 2013 audit of stroke services6 across Australia found that:

 Almost 12,000 Australians who suffer a stroke each year cannot access basic stroke care.
 Access to stroke unit care is not improving, with 58% of patients with stroke reported to be on a
stroke unit on the day of the 2013 National Stroke Foundation Acute Services Audit compared
to 60% in 2011.
 Only 71% of patients treated in a stroke unit hospital received care on the stroke unit at any
time during their admission.
 The median number of stroke unit beds in hospitals admitting >100 patients per year has
dropped from eight to five in 2013 (compared to 2011).
 Hospitals admitting >100 patients with stroke per annum reported on the day of the survey 394
stroke patients were on stroke units despite reportedly having 566 stroke unit beds. This
suggests around 30% of stroke unit beds were not holding stroke patients, although anecdotal
evidence suggests that stroke unit beds have been used by other patients at times.
5
National Stroke Foundation. National Acute Stroke Services Framework 2015, Melbourne. Australia
6
National Stroke Foundation, Acute Services Audit 2013,
http://strokefoundation.com.au/site/media/NSF_Audit_OrgReport_2013_web2.pdf
  The majority (94%) of hospitals admitting >100 stroke patients per annum admitted patients
directly to the stroke unit.
 The number of stroke units have actually increased from 2011 to 2013 (when there were only 5
centres recommended to have a stroke unit which didn’t have one). However, even though
stroke units numbers are increasing access overall hasn’t improved.

Access to stroke unit care

Access to stroke unit care (SUC) continues to be the most significant issue in effectively treating stroke
patients. Whilst there has been significant improvement since the Australian Stroke Coalition identified
SUC as an issue in 2009 when it sat at 51%, there is still great need for improvement as recent
National audits still report access as only 58%.

A survey undertaken by the ASC in 2010 involving 56 (50 with a stroke unit) hospitals throughout
Australia (ASC 20117) identified the following issues as the greatest barriers to patients accessing the
stroke unit:
 Bed availability (77.8%),
 Bed management (57.1%),
 ED culture (33.3%),
 Colleagues ('SU consultants') practice/application of guidelines (31.7%)
 Poor stroke unit staffing (30.2%)

The greatest facilitators for patients accessing a stroke unit were:

 Proactive staff (86.4%),
 Education (83.3%),
 Written Hospital SU admission policies/culture (68.2%),
 Registrar with responsibility for stroke (63.6%)
 Use of site specific Stroke Unit guidelines (63.6%)

A systematic, evidence-based quality improvement approach to identifying and resolving barriers to SU

access is still clearly required to maximise the benefits of SUC.

Cost-effectiveness

The lifetime costs of first-ever stroke have been estimated to be more than $2 billion in Australia. 8

Evidence on the cost effectiveness of stroke units from Australia is limited to a study comprising 488
patients from Melbourne. The investigators determined that care delivered in geographically localised
units was cost-effective compared with general medical wards or mobile stroke (in-patient) teams.
7
ASC 2011, Why patients are not receiving stroke unit care – Barriers and enablers to stroke unit access, Poster
presentation at Stroke Society of Australasia Annual Scientific Meeting 2011

8
Cadilhac DA, Carter R, Thrift AG, Dewey HM. Estimating the long-term costs of ischemic and hemorrhagic stroke for
Australia: new evidence derived from the North East Melbourne Stroke Incidence Study (NEMESIS). Stroke.
2009;40(3):915-21.
Moreover, the additional cost in providing stroke units compared with general medical wards was found
to be justified given the greater health benefits in terms of delivering best practice processes of care
and avoiding severe complications.9

The incremental cost-effectiveness of stroke units over general wards was $9,867 per patient achieving
thorough adherence to clinical processes and $16,372 per patient with severe complications avoided,
based on costs to 28 weeks.

The implementation of a stroke unit leads to more efficient and effective care for stroke patients and
reduces costs by decreasing average length of stay.

9
National Stroke Foundation. Clinical Guidelines for Stroke Management. 2010. Melbourne Australia.