Stroke Reference GroupRecommendations 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 post-stroke

• 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