Stroke Reference Group
Recommendations for Stroke
Rehabilitation
Presentation to the Rehab/CCC Expert Panel
March 24,2011
Presentation Overview
• Proposed Evidence Based Best Practice
Standards/Metrics
• Considerations
• Phase 1 Action Items
• Discussion
“Time is Function”
• Brain is “primed” to “recover” early poststroke
• Delays in starting rehab are detrimental to
recovery (Biernaskie et al., 2004).
• Day 5 admission = marked improvement
• Day 14 admission = moderate
improvement
• Day 30 admission = no improvement vs.
controls
Emergency Care
•Best Practice Standard:
• Emergency Department
Evaluation and
Management of Patients
with TIA and Ischemic
Stroke
• Acute Thrombolytic
Therapy
• Acute Stroke Paramedic
Prompt Card Protocol
• Minimize LOS
•Proposed Metrics:
• LOS
• For all pts admitted to
stroke unit
• CT Scan within 24
hours of admission
Acute Care and Rehabilitation
in the Acute Phase
•Standard:
• Patients admitted to hospital
because of an acute stroke or
transient ischemic attack
should be treated on an
interprofessional stroke unit
[Evidence Level A].
• Alpha FIM completed on Day
3
• Discharge planning
• Mobilization within 24 hours of
admission
• Prevention and management
of Complications Following
Acute Stroke
•Metrics:
• % admitted to stroke unit
• Onset to rehab:
• Ischemic Strokes- Day 5
• Hemorrhagic strokes-Day
7
• Alpha FIM completed Day 3
• % of pts with ALC days
• All cause readmission rates
• % of pts with Alpha FIM
categories who were d/c to
planned rehab destination
• % d/c to inpatient rehab
Inpatient Rehabilitation
•Standard:
• Stroke Rehabilitation Unit
• Minimum of 3 hours of direct
individualized therapy per day
• 7 day/week service
• 7 day/week admission process
• Rehabilitation ALC has priority
access to LTC
•Metrics:
• Provincial workload definition
of direct minutes of therapy
per day( therapist vs assistant)
• Discharge destination
• ALC LOS
• ALC rates per X patients
• All cause readmission rates
• FIM efficiency by RPG
NB: For Every 13 patients treated in a stroke rehab unit, 1 patient
is saved from death or dependence
Ambulatory
Rehabilitation/Community Care
•Best Practice Standard:
• Ambulatory rehab model
(CCAC, community based,
hospital based)
• Decrease admission of mild
strokes through increased
access to early outpatient
rehab for those with high early
FIM
• Access to enhanced attendant
care/supports in early
discharge phase for ALC pts
• Outpt or enhanced CCAC
therapy visits: 2-3 visits/week
for 12 weeks
•Metrics:
•
•
•
•
CCAC referral date
Time to first CCAC visit
FIM Efficiency
Readmission rate
Therapy is Cheap; LOS is Not
• Outpatient therapy improves short-term functional
outcomes
• It is relatively inexpensive (1 PT/1 OT/0.5 SLP/0.5 SW =
cost of 1 inpatient rehab bed)
• Reduces re-hospitalization and allows earlier discharge
home
• Estimated savings is $2 for every $1 spent on outpatient
therapies
• Only 3% of stroke rehab referrals from acute care
were sent to day hospital / ambulatory care*
*E-Stroke data 2009/2010
Is it possible/ Current
initiatives?
• High variability seen across the province as far
as onset days to rehab- a number of centres
are doing quite well and even some
freestanding centers e.g. St Johns Rehab 7
day admission & service
• Toronto Central LHIN clinical efficiency task
group endorsed- detailed work to look at both
streamlining Acute and Rehab care
• Pilot studies of enhanced outpatients have
shown expected benefits ( Southwest and
South east Ontario)
What is the Critical Mass?
Action Items to Accelerate Best
Practices and Impact ALC
• Early Access:
• Mobilization within 24 hours of admission
• Alpha FIM completed on Day 3
• Alpha FIM score > 80 = outpt rehabilitation
• Alpha FIM score 40-80= inpatient rehabilitation
• Alpha FIM score 40-60= ? Inpatient rehabilitation
• Alpha FIM score <40= options for restorative/ongoing
assessment
• Onset to Rehab:
• Ischemic strokes= Day 5
• Hemorrhagic strokes= Day 7
• Rehabilitation has same priority level as acute care for
access to LTC
Action Items to Accelerate Best
Practices and Impact ALC
• Intensification:
• 7 day a week admission process
• 7 day a week service
• Minimum 3 hours direct therapy per day
• Appropriate Settings:
• Acute and Rehabilitation Stroke Units
• Ambulatory and Community Rehabilitation
• Performance Management/Benchmarking:
•
•
•
•
Establish accountabilities based on targets/metrics
Support inclusion of Alpha FIM in CIHI DAD
Define workload measurement system provincially
Establish Ambulatory care database
Discussion