There is strong evidence that organised stroke care reduces mortality and morbidity from stroke [1]

The meta-analysis of trials comparing organised inpatient stroke unit care with an alternative service concludes that acute stroke patients should be offered organised inpatient (stroke unit) care, which is typically provided by a coordinated multidisciplinary team operating within a discrete stroke ward. There is as yet no widely accepted definition of what a stroke unit is and the facilities they should provide. However until trials have been conducted to unpack the 'black box' of stroke units the aim should be to replicate those core service characteristics identified in randomised controlled trials. The concept of a stroke unit has evolved over the past 20 years, but among the features that are common to the units tested in the randomised controlled trials are:

• coordinated multidisciplinary rehabilitation incorporating meetings at least once per week,
• staff with a specialist interest in stroke or rehabilitation,
• routine involvement of carers in the rehabilitation process and
• regular programmes of education and training
• provision of information to patients and carers

The objectives of this paper were to use data from the 2001 National Sentinel Audit of Stroke to describe how stroke units are organised in England, Wales and Northern Ireland, to compare the quality of care provided to patients on stroke units compared to other clinical settings and to compare how the organisation of stroke unit care in reality, compares with the ideal.

Two hundred-and-forty hospitals from England, Wales and Northern Ireland took part in the 2001-02 National Stroke Audit, a response rate of over 95%. These sites audited a total of 8200 patients. There was a stroke unit in 73% of the sites, though only 36% of admitted patients spent any time on a stroke unit. For 80% (192) of sites there was a consultant physician with specialist knowledge of stroke formally recognised as having principal responsibility for stroke services with a median of two sessions weekly. The total number of stroke beds in the hospitals audited was 4055, of which 18% were said to be for acute stroke care, 63% for rehabilitation and 19% in a combined unit. Standards achieved for the organisation of stroke care in hospitals with stroke units were generally better than for hospitals without stroke units.

Only about one half (81/175) of hospitals describing themselves as having stroke units could claim they had all five key features of a stroke unit. One quarter (46/175) of stroke units had 4 of the 5 features with most of these missing a formal link with patients and carers. This leaves one quarter of units (48/175) having at most three key features.

Concordance with the key features of a stroke unit as defined by the Stroke Unit Trialists Collaboration
Clearly therefore, many of the stroke units do not meet even the most basic criteria to justify the title. It is suggested that clear standards be required for the organisation of stroke unit care before the label 'stroke unit' can be awarded. The best way of addressing these issues would be to introduce a formal accreditation system linked to quality standard requirements. Such a system has been developed for acute stroke units in Germany, although does not extend into the rehabilitation sector. If the maximum reductions in mortality and morbidity after stroke, suggested as feasible by the research, are to be achieved nationally it must be recognised that hospitals have to be able to provide adequate levels of staffing and expertise. Currently only 36% of patients are managed on a stroke unit for even part of their stay in hospital. This probably results in several thousand people each year either dying or surviving with significant dependency unnecessarily. The figure seems likely to be even higher if the stroke unit care that is provided is sub-standard.

References
1. Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke (Cochrane Review). In: The Cochrane Library, Issue 4, 2002. Oxford: Update Software.

A G Rudd, A Hoffman, P Irwin
M Pearson and D Lowe
Clinical Effectiveness and Evaluation Unit, Royal College of Physicians London
Qual Saf Health Care. 2005;14:7-12