Organized Inpatient (Stroke Unit) Care for Stroke
Organized stroke unit care is a form of care provided in hospital by nurses, doctors, and therapists who specialize in looking after patients with stroke and work as a coordinated team. This care has been provided in different ways, including: (1) a ward dedicated to patients with stroke; (2) through a mobile stroke team; or (3) within a generic disability service (mixed rehabilitation ward).
This update review aimed to assess the effect of stroke unit care when compared with alternative forms of care for people after a stroke.
We searched the trial registers of the Cochrane Stroke Group (January 2013) and the Cochrane Effective Practice and Organisation of Care Group (January 2013), MEDLINE (2008 to September 2012), EMBASE (2008 to September 2012), and CINAHL (1982 to September 2012). In an effort to identify additional published, unpublished, and ongoing trials, we searched 17 trial registers (January 2013), performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists.
We included only randomized controlled clinical trials comparing organized inpatient stroke unit care with an alternative service. After formal risk of bias assessment, we have now excluded quasi-randomized trials that were previously included.
Data Collection and Analysis
Two review authors initially assessed eligibility and trial quality. We checked descriptive details and trial data with the coordinators of the original trials. The primary outcomes were death, death or institutional care, and death or dependency (Rankin score, 3–6) at the end of scheduled follow-up.
We included 28 trials, involving 5855 participants who compared stroke unit care with an alternative service. More organized care was consistently associated with improved outcomes. Twenty-one trials (3994 participants) compared stroke unit care with care provided in general wards. Stroke unit care showed reductions in the odds of death recorded at final (median 1 year) follow-up (odds ratio, 0.87; 95% confidence interval, 0.69–0.94; P=0.005), the odds of death or institutionalized care (odds ratio, 0.78; 95% confidence interval, 0.68–0.89; P=0.0003), and the odds of death or dependency (odds ratio, 0.79; 95% confidence interval, 0.68–0.90; P=0.0007; Figure). Sensitivity analyses indicated that the observed benefits remained when the analysis was restricted to securely randomized trials that used unequivocally blinded outcome assessment at a fixed period of follow-up. Improved outcomes with stroke unit care were independent of patient age, sex, initial stroke severity, or stroke type, and seemed to be better in stroke units based in a discrete ward. There was no indication that organized stroke unit care resulted in a more prolonged hospital stay.
This update confirmed that patients who receive organized inpatient care in a stroke unit are more likely to survive and to be, independent and living at home 1 year after the stroke. The benefits were most apparent in units based in a discrete ward. There was no systematic increase in the length of hospital stay. The observed benefit is sufficiently large to warrant efforts of widespread implementation of stroke unit care. Further research is needed to understand the key components and how best to implement such care (especially in low-income settings).
This article is based on a Cochrane Review published in The Cochrane Library 2013, Issue 9 (see www.thecochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library should be consulted for the most recent version of the review.
The full text of this review is available in The Cochrane Library (for subscribers http://dx.doi.org/10.1002/14651858.CD008076). The full article should be cited as: Langhorne P, on behalf of the Stroke Unit Trialists’ Collaboration. Organized Inpatient (Stroke Unit) Care for Stroke. Cochrane Database Syst Rev. 2013. Issue 2.
- Received October 24, 2013.
- Accepted November 20, 2013.
- © 2013 American Heart Association, Inc.