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
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