(Stroke. 1995;26:990-994.)
© 1995 American Heart Association, Inc.
Articles |
Medical Complications During Stroke Rehabilitation
From the Orpington Stroke Unit (L.K., K.W., P.R.) and the Department of Medicine for Elderly People (G.Y.), Bromley Hospitals NHS Trust, Bromley, and the Department of Health Care of the Elderly (L.K.), King's College School of Medicine, London, UK.
Correspondence to Dr L. Kalra, Orpington Hospital, Sevenoaks Rd, Orpington BR6 9JU, UK.
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Abstract |
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 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
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Background and Purpose We sought to evaluate the effect of setting on the rate of medical complications during stroke rehabilitation.
Methods A study of the frequency and nature of medical complications in stroke rehabilitation was undertaken in 245 patients managed either on a stroke rehabilitation unit (n=124) or on general medical wards (n=121). The stroke unit setting was characterized by established protocols for prevention, early diagnosis, and management of complications (eg, aspiration, infections, thromboembolism, pressure sores, depression, stroke progression). Similar protocols did not exist on general medical wards except for thromboembolism, pressure sores, and secondary stroke prevention.
Results Medical complications were documented in 147 patients (60%) and were more common in patients with severe strokes (97%). The frequency of reported complications was similar in both settings. Aspiration (33% versus 20%; P<.01) and musculoskeletal pain (38% versus 23%; P<.05) were more commonly documented on the stroke unit, whereas urinary problems (18% versus 7%; P<.01) and infections (49% versus 25%; P<.01) were more commonly seen on general medical wards. The reported frequency of deep vein thrombi, pressure sores, and stroke progression was similar in both settings. Although depression was reported equally in both settings (34% on the stroke unit versus 27% on general wards), patients on the stroke unit were more likely to be treated compared with general wards (67% versus 36%; P<.05).
Conclusions The study shows that inpatient stroke rehabilitation is a medically active service. Management on specialist units is associated with earlier detection and management of stroke-related problems and prevention of potentially life-threatening complications.
Key Words: complications • rehabilitation • stroke units
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Few studies on medical complications during inpatient stroke rehabilitation have been performed, but they show that 56% to 96% of stroke patients undergoing rehabilitation develop neuromedical complications during their inpatient stay.1 2 3 4 5 6 7 The occurrence of medical problems during rehabilitation has a significant impact on the outcome and cost of stroke management.2 3 5 7 For example, the risks of mortality and institutionalization are significantly increased in patients suffering complications during rehabilitation.2 3 5 The scope of intensive therapy is also limited in medically unstable patients, which may result in longer hospital stays and increased resource use.2 In addition, various studies have shown that approximately 7% to 17% of stroke patients undergoing rehabilitation need to be transferred back to acute care settings, which further increases the overall cost of stroke management.1 2 3 4 5 6 7
The incidence of complications in stroke rehabilitation is influenced by several factors. It is well known that the frequency and type of complications vary with the severity of neurological and functional deficits.1 2 6 7 The number of medical complications has also been shown to have a positive relation to the length of hospital stay,7 although it was not possible to determine whether prolonged hospitalization was a cause or a result of stroke-related complications. The setting in which stroke patients are managed may be an additional contributory factor.4 Several studies have shown lower mortality and shorter lengths of hospital stay associated with stroke unit care.8 9 10 11 12 Although this has been presumed to be indicative of fewer or less serious complications in this setting, there is no direct evidence to support the hypothesis.11 12 Many of these studies suffer from methodological problems, including variability in patient selection criteria, which makes comparisons between settings difficult.11 12 On the other hand, there are concerns that the rehabilitation bias on stroke units may be at the expense of good medical care and that stroke unit management may in fact be associated with more complications compared with general medical wards.
One of the important functions of a stroke unit is the prevention and early detection of medical complications during stroke rehabilitation.8 9 10 Assessing the frequency and type of medical complications that occur within that setting is one way to judge the quality of care delivered in a medical setting. However, it is important to ensure that comparisons of complications between settings are undertaken in comparable patient groups and at the same stage of their management. The opportunity for a preliminary evaluation of the effect of setting on the rate of medical complications during stroke rehabilitation arose during a randomized controlled study comparing stroke management on general medical wards with a stroke rehabilitation unit.13 Data on the frequency and type of medical complications reported during stroke rehabilitation in patients with comparable stroke severity and at the same stage of stroke rehabilitation in either setting were compared to identify differences, if any, between the two settings.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The study was undertaken as an audit for neuromedical complications documented in the hospital records of 245 stroke patients included in a randomized controlled trial on the effectiveness of stroke unit rehabilitation.13 Hospital records (medical, nursing, therapy, and drug treatment notes) of stroke patients managed on general medical wards or the stroke unit were reviewed by a trained audit analyst (K.W.) and peer-reviewed by a consultant physician (G.Y.), neither of whom were connected with the previous study13 or involved in the management of patients in either setting at the time of the study.
The diagnosis of stroke was based on history and clinical examination. Patients with first as well as recurrent strokes were included in the study. CT scanning was not routinely undertaken except when indicated by defined criteria.13 Stroke patients were admitted to general medical wards during the acute phase of their illness for initial management and stabilization. All stroke patients still in the hospital 2 weeks after the acute episode (including those who had severe stroke and poor prognosis) were randomized for management on general medical wards or a 13-bed stroke unit.13 Patients were randomized with the use of the Geigy table of random numbers. The randomization was computerized, so that the system patient number on entry dictated the rehabilitation setting in which the patient was to be managed. The stroke unit and the general medical wards were within the acute hospital complex.
Despite different settings, all stroke patients received nursing care, physiotherapy, and occupational therapy appropriate to their disability. Input was also provided by the speech therapists, social workers, and nursing home placement officer for patients unable to return home. Both settings had well-established and similar protocols for prevention of pressure sores and secondary prevention of stroke and had heparin prophylaxis for deep vein thrombosis. In addition, the stroke unit was characterized by guidelines for prophylaxis, early detection and management of aspiration, chest infection, urinary catheterization, urinary tract infection, pulmonary embolism, hand/shoulder pain, and depression. These guidelines were based on recommendations published in the literature.14 15 16 17 18 19 20 21
A list of index medical complications commonly associated with stroke was compiled for the audit.14 15 16 17 18 19 20 21 These included aspiration (persistent chest signs and no pyrexia or leukocytosis in patients with suspected swallowing problems), chest infection (abnormal chest radiograph and persistent chest signs, pyrexia, or leukocytosis), urinary catheterization, urinary tract infection (proteinuria, leukocytes in urine, and positive bacteriology), deep vein thrombosis (clinical features with positive ultrasound or a positive venogram), pulmonary embolism (positive ventilation-perfusion scan), musculoskeletal pain, and pressure sores. Index neurological complications included depression (clinical diagnosis and/or positive screening test), agitation, seizures, thalamic pain, and stroke progression. These complications were deemed to be present if documented in medical, nursing, or therapy notes during the period between randomization (2 weeks after stroke) and discharge, which corresponded to the rehabilitation phase of the illness. Additional data were sought from auditing the laboratory and diagnostic imaging reports for abnormal results as well as from drug treatment records for evidence of pharmaceutical intervention. All positive or doubtful identifications were peer-reviewed for verification by the consultant physician (G.Y.) as described. The detection of complications was by consensus, and interrater reliability was not formally tested.
In addition to data on neuromedical complications, details of age, sex,
neurological deficit, mobility,22 and functional
status23 were recorded. We grouped patients according to
expected prognosis at the time of randomization on the basis of
severity of impairment based on motor, proprioceptive, balance, and
cognitive measures using the Orpington Prognostic Score
(OPS).24 25 Possible scores ranged from 1.6 (best
prognosis) to 6.8 (worst prognosis). The prevalence of diabetes
mellitus, heart disease (other than hypertension), chronic pulmonary
disease, arthritis, and preexisting dementia was also recorded. Data
were available for mortality and the length of hospital stay in both
groups. Data collection was facilitated by an integrated
multidisciplinary data collection system.26 Group
homogeneity was analyzed with 
2 tests for sex,
neurological deficits, recurrent strokes, prognostic grouping, and
comorbidity in each group. Age on admission, motor power, and Barthel
Index of activities of daily living (ADL) scores on initial assessment
were analyzed by the Mann-Whitney test. Medical and neurological
complications, mortality, and destination on discharge were analyzed by
the 2 test. Statistical analysis was not
undertaken if any cell had 0 value. The length of hospital stay was
analyzed by the Mann-Whitney test.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Of the 245 patients included in the study, 124 patients were managed on the stroke unit and 121 on general medical wards. The baseline demographic characteristics of the patients managed on the stroke unit were comparable to the patients treated on general medical wards.13 Ischemic heart disease, diabetes mellitus, chronic pulmonary disease, arthritis, and dementia were the most common coexisting illnesses and were equally frequent in both patient groups. The extent of neurological deficit, mobility, and functional abilities at the initial assessment in patients managed on the stroke rehabilitation unit were comparable to those managed on general wards.13 Patients with moderately severe impairment and an intermediate prognosis formed the largest patient group, accounting for nearly 60% of patients in both settings.
Medical complications were documented in 147 (60%) of the 245 stroke patients included in the study, with no significant differences in frequency attributable to the setting. Complications were least frequently seen in patients with mild deficits and good prognosis (OPS, <3). Medical problems were recorded in 6 (19%) of the 31 patients on the stroke unit and 4 (13%) of the 32 patients on general wards in this group. Complications included urinary tract infections, musculoskeletal pain, and depression. Chest infection was documented in one patient on general wards who was also known to suffer from chronic bronchitis. Complications were most frequently reported in stroke patients with very severe deficits and poor prognosis (OPS, >5). Index complications were recorded in 17 of the 18 patients on the stroke unit and in all 18 patients on general medical wards. Nineteen (53%) of the 36 stroke patients in this group died during their inpatient stay. Mortality was relatively higher on general medical wards compared with the stroke unit (12 versus 7). In patients with moderately severe deficits and intermediate prognosis (OPS, 3 to 5), complications were recorded in 49 patients (65%) on the stroke unit and in 53 patients (75%) on general wards.
There was no significant difference in the total number of
complications (n=201) seen in patients managed on the stroke unit
compared with the number of complications (n=207) seen in patients on
general wards. There were, however, significant differences in the type
of medical complications documented between the two settings
(Table
). Complications such as aspiration and
musculoskeletal pain were more frequently documented on the stroke unit
and accounted for nearly 63% of all medical complications reported in
this setting. Evidence for chest infections, urinary catheterizations,
and urinary tract infections was more commonly present in the
medical records of patients managed on general medical wards,
accounting for 67% of all medical complications in this setting. There
were no significant differences in the reported frequency of deep vein
thrombi or pulmonary emboli between the two settings.
Ventilation-perfusion scans for possible pulmonary emboli were
undertaken in 14 patients on the stroke unit compared with 3 patients
on general wards (P<.05). None of the patients on the
stroke unit were transferred to general medical wards for management of
complications because a full range of acute medical and nursing care
was available on the stroke unit.
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There were no significant differences in the documented frequency of
neurological complications between the two settings (Table
). There was
a higher reported incidence of depression on the stroke unit, but this
did not achieve statistical significance. The median time from
randomization to diagnosis was 16 days on the stroke unit compared with
34 days on general medical wards (P<.01). Treatment with
antidepressants had been commenced in 28 (67%) of the depressed
patients on the stroke unit compared with 12 patients (36%) on general
wards (P<.05). The numbers of patients extending their
stroke or suffering another stroke were similar in both settings
(Table).
Stroke unit management was associated with a shorter duration of hospital stay and lower institutionalization rates.13 27 28 Multiple regression analysis with stepwise deletion showed a significant relationship between the frequency of complications, prognostic grouping (partial correlation coefficient [B]=.44, P<.001), and duration of hospital stay (B=.28, P<.01). Frequency of complications was not influenced by age, sex, or management setting. Multiple regression analysis also showed that institutionalization and Barthel Index of ADL at discharge were not influenced by the frequency of complications.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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This study confirms that medical complications are frequent during stroke rehabilitation5 6 7 and occur in approximately 60% of patients undergoing rehabilitation. It is therefore both inaccurate and misleading to consider inpatient stroke rehabilitation a medically quiescent process that does not require ongoing medical input. The overall frequency of complications or the number of patients affected did not appear to be influenced by management setting. Complications were more frequently recorded in patients with severe strokes (94%) compared with patients with mild to moderate deficits (16%). There appeared to be significant differences in the type of complications observed between general medical wards and the stroke rehabilitation unit. The type of complications recorded on the stroke unit (eg, aspiration, musculoskeletal pain, depression) suggested greater awareness of stroke-related problems, whereas more severe and potentially life-threatening complications (eg, urinary problems, chest infections) were more frequently reported in stroke patients managed on general medical wards.
The study was designed as a preliminary exploration of the effect of setting on complications that occur during stroke rehabilitation. Although it was only possible to compare the records of identified complications between the two settings, the study was prospective and randomized, for which all outcome variables were defined in advance.13 It is important to acknowledge that it would have been impossible to totally "blind" the auditors as to the setting of patient management because this can easily be deduced from the medical, nursing, and therapy notes of individual patients. However, we reduced observer bias by using two independent observers not involved with the original trial or with stroke service provision. The potential for error was also reduced by basing the definition of complications on accepted criteria14 15 16 17 18 19 20 21 and defining them before undertaking the audit. The accuracy of the study was further enhanced by comparing nursing, therapy, and pharmaceutical records, in addition to medical notes, to ensure that no events were missed because of poor record keeping. Despite these precautions, it is still possible that some of the patients may have suffered complications that were not recorded in any of their hospital records. This is more likely to have happened on general medical wards compared with the stroke unit, principally because the detection and reporting of complications would have been encouraged by the existence of protocols in the stroke unit setting. Therefore, it is possible that this study underestimates the number of complications on general medical wards and that there may have been a significant difference in the number of complications between general medical wards and the stroke unit if all events had been accurately recorded.
The higher frequency of aspiration observed on the stroke unit may have been due to underreporting or underdiagnosis of this complication on general medical wards. Chest infection is a frequent sequela of aspiration in stroke patients,6 and failure to recognize aspiration may have made a significant contribution to the higher frequency of chest infections on general wards. The lower incidence of chest infection in patients with comparable neurological deficit on the stroke unit suggests that staff on the stroke unit were more aware of swallowing problems associated with stroke and more likely to intervene with preventive measures. The number of patients clinically diagnosed to have aspiration, even on the stroke unit, was considerably less than the 49% to 77% diagnosed by videofluoroscopy in other studies, suggesting a possible role for this investigation in improving routine stroke care.17 21
The rate of urinary catheterizations and urinary tract infections was significantly higher on general wards compared with the stroke unit and may have been due to failure to agree to a continence policy in this setting. Many of the catheterizations on general medical wards were undertaken to facilitate "nursing" of dependent patients rather than for active management of continence in stroke. The significantly lower incidence of catheterizations in patients with similar neurological and functional disability on the stroke unit suggests that some of these procedures were perhaps not justified, and a different approach may have been more appropriate. It is also likely that the high number of catheterizations contributed significantly to the increased incidence of urinary tract infections on general medical wards.
There was a trend toward increased diagnosis of depression on the stroke unit, probably due to the routine use of the Hospital Anxiety and Depression Scale29 in the setting. Depression on the stroke unit was diagnosed earlier and patients were more likely to receive antidepressant treatment compared with general wards, which may have affected outcome.19 20 Despite evidence to suggest that depression is underdiagnosed in stroke patients undergoing rehabilitation,19 the documented diagnostic rate for both settings compared well with the 25% to 30% reported in the literature.20
Most of the differences observed between the stroke unit and general wards were due to medical rather than neurological complications. Neurological complications may be due to irreversible brain damage and hence may not be responsive to the intensity or nature of care received by stroke patients. On the other hand, medical complications appear preventable and may reflect the quality of appropriate care received by patients during the rehabilitative phase. The role of the length of hospital stay in the etiology of complications in stroke rehabilitation was difficult to assess. Although multiple regression analysis showed a direct relationship between the length of hospital stay and the frequency of complications, it was not clear whether longer hospital stays were a cause or an effect of complications in stroke. In some medical records it was apparent that the occurrence of complications had prevented or delayed participation in therapy programs, lengthening hospital stay, whereas in other cases complications occurred in patients awaiting placement or care packages before discharge. It is likely that the relationship between the length of hospital stay and stroke complications is complex and needs further investigation.
Several recent studies have shown that management of stroke patients on specialist units is associated with reduced mortality, less institutionalization, better functional outcome, and shorter lengths of hospital stay.11 12 13 There is also a suggestion that this improvement in outcome is achieved without incurring substantial additional therapy costs.10 13 However, because stroke unit care entails a complex "black box" of interventions consisting of many interrelated components, the mechanisms that contribute to improved outcome on stroke units are still unclear. Preliminary attempts to unravel the black box of stroke unit interventions suggest that appropriate patient selection,8 10 13 timing and type of therapy,10 13 30 attitudes of the rehabilitation staff,2 31 mechanisms for expediting discharges,13 27 and patient motivation are important. This randomized controlled study suggests that stroke unit management has an important influence on the nature of complications associated with stroke, which may be another factor that contributes to their effectiveness in patient care. Protocols for common stroke-related complications (as seen on the stroke unit) appear to result in increased awareness of these events during rehabilitation, leading to early detection and appropriate management of minor complications and the prevention of major or potentially life-threatening complications.
Received January 13, 1995; revision received February 9, 1995; accepted March 7, 1995.
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R.J. Davenport, M.S. Dennis, I. Wellwood, and C.P. Warlow Complications After Acute Stroke Stroke, March 1, 1996; 27(3): 415 - 420. [Abstract] [Full Text]
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P. M. Pedersen, H. S. Jorgensen, H. Nakayama, H. O. Raaschou, and T. S. Olsen Frequency, Determinants, and Consequences of Anosognosia in Acute Stroke Neurorehabil Neural Repair, January 1, 1996; 10(4): 243 - 250. [Abstract] [PDF]
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L. Kalra and J. Eade Role of Stroke Rehabilitation Units in Managing Severe Disability After Stroke Stroke, November 1, 1995; 26(11): 2031 - 2034. [Abstract] [Full Text]
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