Outcome

Abstract

Objective. To assess outcome at six months post stroke and the unmet needs and adherence to the secondary prevention advice among survivors living at home.

Setting. Stroke Rehabilitation Unit (SRU), Hairmyres Hospital and patients' homes.

Subjects. Survivors living at home who had been managed in the SRU. Results. Of 572 consecutive patients with confirmed acute stroke, 301 were managed in the SRU and 179 of these were reviewed at home between 6 and 9 months post acute stroke incident. One hundred and thirty seven (76%) survivors at home were living with a carer. Sixty‑eight (38%) had had no personal contact with their General Practitioner since discharge from hospital, although 83 (46%) had attended or were attending Day Hospital. Thirty‑two individuals (18%) had resumed smoking. One hundred and forty nine survivors (83%) still required assistance with daily living tasks. One hundred and fifteen patients (64%) required medication advice. One hundred and forty one (79%) had health concerns. Eight subjects had returned to paid employment. Issues raised by survivors included a feeling of being abandoned by the healthcare system, poor access to professional psychological support and a fear of further stroke.

Conclusion There is a need for continuing patient education, improved support for stroke survivors and more active involvement of Primary Care Services in the care of stroke patients following hospital discharge

Key words and phrases : Outcome, functional recovery, unmet needs, acute stroke.

Introduction

The Stroke Service at Hairmyres Hospital comprising 4 acute assessment beds, a 14 bed rehabilitation unit (SRU) and a weekly "fast‑track" / review clinic was established in stages during 1998. The hospital serves a population of approximately 200,000 in South Lanarkshire where the standardised mortality ratio for cerebrovascular disease for all ages is ‑110 (Scotland = 100) '.

Between the establishment of the stroke database in 1998 and the end of June 2000 there were 572 consecutive patients registered with confirmed acute stroke. Twenty nine patients (5%) died in the acute phase and 188 eight patients (33%), were discharged from hospital within one week. Fifty two patients (9%), were managed in an elderly care rehabilitation ward and 301 patients (53%) were managed in the Stroke Rehabilitation Unit (SRU). This report focuses on the outcome in 301 patients who were managed in the SRU and on the needs of survivors living at home.

Home Reviews

As part of the secondary prevention programme and prospective stroke outcome audit established from the outset, survivors living at home and who had been managed in the SRU were reviewed at home at six months post stroke. Patients still in hospital at six months were reviewed at nine months. These reviews at home were carried out by a Primary Care Outreach Liaison Nurse and augmented the scheduled post‑discharge reviews, which take place at the specialist out‑patient clinic or day hospital, on average three months after the stroke incident. The purpose of the home reviews was to assess functional outcome and unmet need as well as adherence to the secondary prevention advice given to each individual during hospital stay, at discharge and reinforced at the three month clinic review.

Stroke Rehabilitation Unit Cohort The SRU cohort comprised 178 men, median age 70 years (range 39‑93) and 123 women, median age 75 years (range 33‑99). The median delay from hospital admission to transfer to SRU was four days and the median length of stay within SRU was 18 days (range 1 ‑ 267 ; mean 31). Prior to admission, eight patients had been resident in sheltered housing, the remainder living in independent housing. Subject to hospital bed pressures, patients remained in the SRU until full in‑patient rehabilitation potential had been attained as judged by inter‑disciplinary review. However, when necessary, patients were transferred from the SRU to an elderly care rehabilitation ward where stroke team management continued whilst there was a reasonable prospect of home discharge. The functional status of patients as assessed using the 20 point Barthel Index (2) and their location at 6 months are shown in the table. Five patients were transferred to adjacent trusts during the course of rehabilitation and all remained in hospital care at six months post stroke incident.

Table 1. Stroke Rehabilitation Unit: patient outcome at 6 months post stroke

	Number of patients	Age in years Median (range)	Barthel score median (range)
Independent housing	182	70(41-90)	19(0-20)
Sheltered housing	9	76(65-84)	17(6-19)
Residential Accommodation	5	82(62-92)	14(10-17)
Nursing Home	13	80(62-92)	5(0-16)
Continuing in-patient Rehabilitation / care	47	75(33-93)	7(0-19)
Deceased	40	78

Nine month outcomes in SRU patients

The 47 patients who remained in hospital at six months included 7 who had been readmitted, 3 of whom had suffered a further stroke. By nine months post stroke, a further 16 patients had been discharged to independent housing (median Barthel score 10), 1 patient to sheltered care, 1 to residential care, 21 to nursing home care and 6 patients required continuing NHS care (median Barthel score 0). A further 2 patients had died.

Analysis of Home Reviews

Of 208 survivors discharged to independent or sheltered housing from the SRU, 179 were reviewed at home between 6 and 9 months post stroke incident. Sixteen survivors had moved to the care of relatives outwith the hospital catchment area, three refused a visit, three could not be contacted and seven were again in hospital. Of those reviewed at home, 86% (88/102) men and 64% (49/77) women were living with a carer. Sixty‑eight (38%) had had no personal contact with their General Practitioner (median time since discharge 5 months), although 83 (46%) had attended or were attending Day Hospital. Thirty‑two individuals (18%) had resumed smoking. One hundred and thirty nine survivors (82%) living in independent housing and all 10 resident in sheltered housing stated that they still required assistance with daily living tasks. Eighty subjects (45%) had been supplied with some form of aid or appliance to assist activities of daily living (excluding walking aids).

One hundred and twenty seven patients (71%) sought advice on how to access support from voluntary services and 136 (76%) required further social services advice, usually in relation to benefits. One hundred and fifteen patients (64%) required medication advice, mostly on compliance and dosing issues and 141 (79%) had health concerns including missed hospital appointments and podiatry, dental and ophthalmic issues which had been superseded by the stroke incident but were now regaining importance in patients' lives. There were 21 men aged less than 65 years and 9 women aged less than 60 years in paid employment prior to the stroke incident; 6 men and 2 women had returned to work.

Additional issues raised by survivors included:

A feeling of being abandoned by the healthcare system following discharge from hospital. Some expressed anger and resentment.
Poor access to professional psychological support.
Lack of confidence in resuming social activities particularly among younger survivors, even those who had made a good physical recovery.
The unforeseen impact of role reversal on survivors and partners.
Profound fear of a further stroke incident.

Discussion

Stroke is the most important single cause of severe disability in people living in their own homes in the United Kingdom .(3) It has been estimated that 47% of patients surviving a stroke will be physically dependent on others 4. Stroke accounts for 12% of deaths and almost 5% of all NHS expenditure in Scotland,

This study confirms that support after discharge from hospital following a stroke can still be inadequate 5. Stroke patients and their families may experience a number of practical difficulties due to lack of information about their condition 6 and poor knowledge of services and benefits available 7,8, When interviewed at home stroke victims and care givers in this study were generally satisfied with the hospital phase of care, but many were unhappy with service provision and support following discharge. Continued rehabilitation therapy and support through day hospital attendance was valued although there were criticisms about transport and journey times.

Within the SRU, staff took considerable time to inform patients and care givers about stroke both verbally and with appropriate literature which they were encouraged to read and discuss. Secondary prevention advice was reinforced at clinic review and during day hospital attendance. Despite having experienced a stroke and having the subsequent exposure to secondary prevention education, many survivors failed to heed advice and reverted to their previous lifestyle. Some patients felt that it was too late to do anything about risk factors.

The extent to which patients and carers benefit from stroke education in hospital is uncertain.(9) Follow up services following discharge from hospital are poor and services that are delivered tend to have a paucity of provision beyond a narrow focus on basic rehabilitation 10. The intervention of Specialist Stroke Health Advisors and Support Workers following discharge from hospital has been shown to improve the adjustment of stroke patients and carers to changes associated with their stroke and this form of supportwas valued by the subjects described in this report. 11,12,13

This study again confirms the significant morbidity and mortality associated with stroke and confirms the need for continuing patient education, improved support for stroke survivors and more active involvement of Primary Care Services in the care of stroke patients following hospital discharge.

Outcome, functional recovery and unmet needs following Acute Stroke. Experience of patient follow up at 6 to 9 months in a newly established Stroke Service.

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