The consensus statement  was proposed by the chairperson in the session, Associate Professor Lars Thomassen, Bergen, and the session secretary dr Magnus Thorén, Stockholm, together with the speakers in the session. The statement was then finally approved by the participants of the meeting, after listening to the different presentations.

The speakers in this session were Professor Didier Leys, Lille, Associate Professor Risto Roine, Turku, and dr Tommy Anderson, Stockholm.

Can the European Experts Survey on the Main Components of Stroke Unit Care guide the stroke community to form adequate levels of stroke care?

Which new requirements on the organisation of stroke care are caused by   new developing treatment options such as neurointerventional procedures?

Should new levels or forms of organised stroke care be evaluated in randomised trials?

Background, stroke units

According to the Stroke Unit Trialists Collaboration (SUTC) and the European Stroke Initiative (EUSI), a stroke unit is defined as an organised inpatient area that exclusively or near exclusively takes care of stroke patients and is managed by a multi-disciplinary team of specialists who are knowledgeable about stroke care.

The Cochrane review by the Stroke Units Trialists’ Collaboration summarises data from randomised or quasi-randomised trials from the 80’s and 90’s (1). These trials included stroke patients receiving organised and dedicated in-patient stroke unit or conventional care in general wards. The trials have convincingly shown that stroke patients managed in organised stroke units have a lower case-fatality and disability, and are more likely to return home, as compared with those managed in general wards.  This favourable outcome was shown to be independent of the patients’ age, sex and stroke severity, and was most apparent in stroke units based in a dedicated ward. According to the Stroke Units Trialists Collaboration, certain features appear to improve outcome, including: a structured program for acute evaluation, physiological monitoring and medical treatment; an immediate start of mobilisation and early rehabilitation; a multidisciplinary team of medical, nursing, physiotherapy, occupational therapy, speech therapy and social worker staff coordinated at regular meetings; a coordinator of the team; an educational program for the staff; involvement of the patient and the family in the care and rehabilitation process.

The stroke unit is ideally suited for research trials, e.g., novel and promising, but unproven, interventions such as body cooling. In order to implement good clinical practice and maintain equitable care and consistency, stroke units should be regularly assessed and evaluated by use of quality assurance programs.

Since the completion of the earlier stroke unit trials, there have been developments in facilities, diagnostics and treatments.
 
 

Levels of organised stroke care

The European expert survey on the Main Components of Stroke Unit Care (2, 3) evaluated three levels of care where stroke patients are admitted in routine:
 
- Comprehensive stroke centres (CSC)
- Primary stroke centres (PSC)
- Any hospital ward (AHW)
 

Comprehensive stroke centres (CSC)
CSC:s were defined as centres with necessary staffing, infrastructure, expertise, and programmes 

- to provide appropriate diagnosis and treatment for stroke patients who require a high intensity of medical and surgical care, specialised tests or interventional therapies, 

- to act as referral centre for other hospitals in their area, and 

- to be an educational resource for health care professionals

Primary stroke centres (PSC)

PSC:s were defined as centres with necessary staffing, infrastructure, expertise and programs to provide appropriate diagnosis and treatment for most stroke patients. Although PSC provide high quality care, some patients with rare disorders, complex strokes, or multi-organ diseases may need more specialised care and resources that are not available in PSC
 

Any hospital wards (AHW)

AHW:s were defined as any hospital where general acute care is provided.
 

Components of different levels of stroke care

The following components were regarded by more than 75% of the experts to be essential for the different levels of stroke care:
 
For CSC:s: Multidisciplinary team, stroke trained nurses, physiotherapy start within 2 days, brain CT-scan 24h/ 7 days, CT priority for stroke patients, extracranial Doppler sonography, extracranial duplex sonography, transthoracic echocardiography, automated ECG, pulsometry and blood pressure monitoring, i.v. rt-PA protocols 24h /7 days, carotid surgery, angioplasty and stenting available, in-house emergency department, collaboration with rehabilitation centres, stroke faculty, stroke pathways and clinical research. Carotid surgery, angioplasty and stenting, i.a. thrombolysis, and neurosurgical procedures are considered as procedures to be performed in CSC:s only.
 
For PSC:s:  Multidisciplinary team, stroke trained nurses, brain CT-scan 24h/ 7 days, CT priority for stroke patients, extracranial Doppler sonography, automated ECG monitoring, i.v. rt-PA protocols 24h/ 7 days, and in-house emergency department. 
 
For AHW:s: The following components were regarded by more than 50% of the experts to be important, but not absolutely necessary, for AHW:s: Emergency department staff, brain CT-scan 24h/ 7days, CT priority for stroke patients, in-house emergency department, collaboration with outside rehabilitation centre, stroke care maps for patients admission, prevention programs, and stroke pathways.

 
Discussion

The European Expert Survey Study provides information on the opinion of a selected group of stroke experts regarding the major components of well-organised acute stroke care. The European survey guide can give recommendations and set standards for first class stroke centres but local development and prerequisites is probably the single most important factors that determine the level of care. Different centres vary concerning access to neurointensive care, first class neuroradiology service and neurointerventional procedures. 

There is  a shift in paradigm regarding modern stroke treatment where a much more active approach with rapid, minimally invasive angiography and perfusion studies guides the clinician to the adequate treatment modality placing less emphasis on the detailed time since onset. This then leads to proper treatment where in addition to intravenous thrombolysis, thrombectomy plays an important role, both as a compliment in situations of failed intravenous therapy as well as a first line treatment. Even so, as the efficacy of any given treatment is largely dependent on time since stroke onset, it is still highly important to admit and treat the patients as early as possible.

In our opinion, the level of care as described for AHW is unacceptably low. All patients should be treated in centres with level of care as CSC:s or  PSC:s. The minimal components essential for all centres are in our opinion: brain CT- or MR- scan 24h/ 7 days, CT priority for stroke patients, i.v. rt-PA protocols 24h/ 7 days, in-house emergency department, automated ECG monitoring, multidisciplinary team and stroke trained nurses. CT- or MR- angiography should be part of the initial work-up in order to find potential candidates for endovascular therapy and/or referral to a CSC. All CSC:s should have access to a 24h/7days neuro-endovascular unit.

In the future, selection of patients for referral to CSC:s will be of importance. As stated in the European Expert Survey, some patients may need more specialised care or resources than those available in PSC:s . For AHW:s, telemedicine may be a useful tool for accurate diagnosis and treatment as well as for selection of patients to be referred to higher levels of care.

The big challenge for the future is how stroke-care should be organised bearing in mind the large differences between hospitals and centres regarding Neurological Intensive Care Units as well as competence in general neuroradiology and neurointerventions. The European Expert Survey may provide important help for this purpose for health authorities in the implementation of the national organisation of stroke care. 
 
There may be  public pressure to implement new treatment modalities fast, and sometimes before, prospective randomised trials have been finished and evaluated. If possible, new treatment modalities, but rarely organisational aspects of care,  should be evaluated in such trials. Careful implementation of new treatment modalities, even in the absence of randomised controlled trials, may be justified in CSC:s..
 

Conclusions:

- The European Experts Survey provides important information on the structure of organised stroke care

- Stroke patients should be treated in centres corresponding to Comprehensive Stroke Centres or Primary Stroke Centres. The level of care described for Any Stroke Ward is unacceptably low for treatment of stroke patients. (Grade C)

- The benefit of stroke units has been documented in randomised controlled trials. The need of Comprehensive stroke units is caused by new , highly specialised, treatment interventions and does not necessarily need evaluation in randomised trials.

References:

1. Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev. 2002;(1):CD000197

2. Leys D, Ringelstein EB, Kaste M, Hacke W; European Stroke Initiative Executive Committee. The main components of stroke unit care: results of a European expert survey. Cerebrovasc Dis. 2007;23(5-6):464

3. Leys D, Ringelstein EB, Kaste M, Hacke W; Executive Committee of the European Stroke Initiative. Facilities available in European hospitals treating stroke patients. Stroke. 2007 Nov;38(11):2985-91