Journal of the New Zealand Medical Association, 16-May-2003, Vol 116 No 1174
Stroke rehabilitation services in New Zealand
John Gommans, Alan Barber, Harry McNaughton, Carl Hanger, Patricia Bennett, David Spriggs and Jonathan Baskett
In New Zealand, approximately 7000 people will have a stroke every year and fewer than half will be alive and independent at one year. In 2001, there were an estimated 32 000 survivors of stroke in New Zealand.1 As well as the personal burden carried by those with stroke, there is a considerable financial cost to the nation for hospital, community and institutional care. As the population ages, the number affected by stroke is projected to increase significantly in the next 20 years.1
Organised stroke care, especially early and coordinated rehabilitation in a stroke unit, unequivocally reduces both mortality and morbidity following stroke when compared with rehabilitation in general wards.2 The definitions of what constitutes an organised stroke service vary but include a geographically identified stroke unit, a coordinated multidisciplinary team, staff with specialist expertise in stroke and rehabilitation, educational programmes for staff, patients and carers, and agreed protocols for common problems.3–5 A recent survey of acute stroke management in New Zealand identified major deficiencies, with only four hospitals having organised, acute, inpatient care.6 That survey concentrated on the care of patients in the first days after stroke onset.
We have performed a survey of stroke rehabilitation services currently provided in New Zealand. The aim was to obtain an overall picture of stroke rehabilitation services provided and to determine their compliance with guideline recommendations.
A questionnaire was sent to the medical director, or a physician known to have an interest in stroke or rehabilitation, at each of the 48 hospitals identified from an earlier survey of acute stroke management in New Zealand hospitals.6 The questionnaire was designed by the authors to identify some of the key components of stroke rehabilitation contained in published guidelines.2–4,7 Questions were asked about access to organised stroke rehabilitation; staffing mix and expertise; the use of protocols for common problems; guidelines for and audit of stroke rehabilitation; the provision of ongoing rehabilitation after discharge from hospital; and the adequacy of resources. The questionnaire took 10–15 minutes to complete. It was sent out to hospitals in May 2002 and a second copy was sent to those not responding at four weeks. Centres that had still not responded at six weeks were contacted by telephone.
The hospitals were divided into three groups according to the population served: large (urban hospitals serving populations of >180 000), medium (urban or regional hospitals serving populations of 40 000–180 000) and small (regional hospitals serving populations of <40 000). The total population served by each hospital varied considerably. To assist interpretation, the results are therefore presented showing both the numbers of hospitals responding to a particular question and the percentage of the New Zealand population served by these hospitals.
The funding provided for rehabilitation of younger people (aged less than 65 years) with stroke is different to that for older patients. A distinction in the analysis of stroke rehabilitation services has therefore been made between these two groups.
A 100% response rate was obtained from the 48 hospitals surveyed. Thirty seven of 48 hospitals routinely provided inpatient stroke rehabilitation and are the subject of this report. The 11 hospitals excluded from this analysis included one large, urban, acute hospital where stroke rehabilitation is carried out in a different hospital in the same city. There were also 10 small community hospitals where patients requiring inpatient rehabilitation are routinely transferred to a base hospital.
Thirty four hospitals provided general stroke rehabilitation services, predominantly for older patients with stroke. Seven were large urban hospitals (serving 55% of the population), 16 were medium-sized urban or regional hospitals (38% of the population) and 11 small regional or community hospitals (7% of the population). Four of these 34 hospitals also provided separate services for younger stroke patients. A further three hospitals provide rehabilitation services only for younger patients.
Stroke rehabilitation services usually, but not exclusively, for older patients Inpatient stroke rehabilitation was carried out in assessment, treatment and rehabilitation (AT&R) units in 25 of the 34 hospitals (84% of the population) with services not specifically aimed at patients less than 65 years of age. Rehabilitation was carried out in general medical wards in two medium and six small hospitals (7% of the population). Only one large urban hospital (9% of the population) had a designated stroke rehabilitation unit.
Twenty two of 34 hospitals (57% of the population) employed identified lead stroke rehabilitation physicians (Table 1). In most hospitals, the lead physician was a geriatrician. The lead physicians in two hospitals were rehabilitation specialists. Of the remaining 12 hospitals (43% of population) without a lead physician, four were large urban hospitals (33% of the population) and seven had geriatricians on staff. Twenty three of 34 hospitals (70% of the population) had a multidisciplinary team (MDT) expert in stroke rehabilitation. However, in 13 of these 23 hospitals (32% of the population), the MDT spent less than half of their time caring for stroke patients.
Table 1. Summary of results by hospital group*
*excludes facilities specifically for patients <65 years
AT&R = assessment, treatment and rehabilitation; DVT = deep vein thrombosis
Most hospitals had protocols or guidelines for the assessment of some of the complications commonly following stroke (Table 1). Fewer hospitals had protocols or guidelines for nutritional support, prevention and management of shoulder pain, prevention of deep vein thrombosis (DVT) or the assessment of mood.
Twenty six hospitals (84% of the population) had access to driving assessment services. Only 11 (33% of the population) had vocational retraining schemes. Regular education sessions were provided for staff in 25 hospitals (84% of the population), and patients and families in 15 hospitals (63% of the population). Almost all hospitals (93% of the population) provided written information for patients and families. Nine hospitals (24% of the population) had an organised community support programme to facilitate early discharge. Only three hospitals (11% of the population) provided a written, secondary prevention plan for individual patients.
Eight hospitals (28% of the population) had conducted audits at a patient level and nine hospitals (26% of the population) had conducted service audits. Most of the audits used were self-generated. Only five hospitals (30% of the population) kept a stroke register. Fourteen hospitals (59% of the population) monitored basic patient outcome measures such as discharge destination. Fourteen hospitals (49% of the population) measured attainment of activities of daily living by the time of discharge. Twenty three hospitals indicated a willingness to participate in a national audit programme.
Most hospitals had outpatient, day hospital, and community- or home-based rehabilitation services available (Table 1). Twelve of 34 hospitals (40% of the population) routinely reviewed all patients after discharge from inpatient or outpatient rehabilitation services. Patients or their caregivers could refer themselves for review in 20 hospitals (69% of the population). Thirteen hospitals (31% of the population) did not routinely follow up patients or allow self-referral for review after discharge.
Respondents from 14 of 34 hospitals stated that they had inadequate medical staffing (54% of the population) or bed numbers (55% of the population). Twenty eight hospitals (81% of the population) identified inadequate access to psychologists, and 11 hospitals (38% of the population) perceived nursing numbers to be insufficient. Respondents also reported a lack of speech language therapists (14 hospitals, 42% of the population), social workers (9 hospitals, 40% of the population), physiotherapists (10 hospitals, 27% of the population), and occupational therapists (9 hospitals, 27% of the population).
Stroke rehabilitation services specific for younger patients Seven hospitals (serving 60% of the population) provided separate services for the rehabilitation of younger people with stroke. Three of these hospitals (37% of the population), all in urban areas, were dedicated facilities for younger patients only. Six of these seven services were led by rehabilitation specialists. Four services were delivered in a specialised neuro-rehabilitation ward and three in an AT&R unit. None of the stroke rehabilitation services for younger people were provided in a stroke-specific unit.
The major finding of this study is that most New Zealanders do not have access to stroke-specific, organised, inpatient stroke rehabilitation. This is despite clear evidence that specialised, inpatient stroke care reduces the risk of death or institutionalised care when compared with conventional care (although this benefit was most significant when compared with general wards rather than geriatric AT&R wards).2 Only 18 people need to receive this organised, inpatient stroke care to prevent one person from dying or being dependent at one year.8 The survival benefits and improved functional outcomes are sustained for at least five years.9,10 New Zealand experience suggests that changing to a stroke rehabilitation unit from an AT&R unit may also add ‘value’ and significantly reduce length of stay.11 It is of concern that only a small proportion of the population has access to hospitals with a designated stroke rehabilitation unit. We note that a stroke-specific rehabilitation unit has previously been established in New Zealand but this unit ceased to function as such as a result of health restructuring despite being a source of stroke expertise and published research.12
New Zealand and international guidelines recommend that coordinated, specialist multidisciplinary teams, including a lead stroke physician, should provide stroke rehabilitation.3,4,7 It is of concern that 43% of the population are admitted to hospitals with no identified lead stroke rehabilitation physician, despite the presence of an on-site geriatrician in almost all of these hospitals. Lead physicians were less likely to be identified in the larger hospitals. It is possible that the lead clinicians in the medium-sized or small hospitals were nominated by default as the only relevant person available instead of as a true reflection of their status.
This survey has also identified a perceived lack of resources for stroke rehabilitation. Respondents for rehabilitation services covering between 40% and 50% of the population have indicated a lack of beds, and nursing and medical staffing. Between one quarter and one half of the population are admitted to hospitals where there are inadequate numbers of key members of the multidisciplinary stroke rehabilitation team. It is not surprising that two thirds of the population are treated by MDTs that either lack expertise in stroke or that spend most of their time treating non-stroke patients. It is not clear from this survey whether the perceived lack of resources accurately reflects the needs of these services.
Almost three quarters of the population are reliant for stroke care on hospitals that do not audit their stroke rehabilitation service. The variation in service delivery in New Zealand suggests an ad hoc approach to the care of many stroke patients, while the limited use of audit indicates that the opportunity to identify and address local deficiencies in stroke care is often missed. The widespread access to rehabilitation units and use of some appropriate protocols within AT&R units was encouraging. However, further work is required so that all units have appropriate protocols for the conditions commonly encountered after stroke.5
Access to specific rehabilitation services for younger people with stroke was available to less than two thirds of the population. The evidence from the stroke unit trials supports the management of all patients in a stroke-specific rehabilitation area irrespective of age. For those district health boards with existing, separate younger person rehabilitation facilities, decisions will need to be made to ensure prompt access to the most appropriate services for all people with stroke.
Questionnaires offer a convenient means of rapidly surveying clinical practice in a large number of hospitals. However, questionnaires may be problematic. The most appropriate clinician within an institution may not be targeted and responses to a survey may also not reflect actual practice.13 Attempts were made to contact specialists with a known interest in stroke rehabilitation at each institution, but this was not always possible and many questionnaires were addressed to the medical director. We did not attempt to verify responses but it was made clear that the survey was confidential and that no hospital would be identified. With a 100% response rate it is reasonable to assume that the responses reflect the current state of stroke rehabilitation services throughout New Zealand.
In summary, there has been a failure to implement best practice in New Zealand for stroke rehabilitation. The evidence in favour of organised inpatient care, especially in a stroke rehabilitation unit, is overwhelming, and achieving this goal should be the highest priority for all involved in the management of patients with stroke.3 The situation in New Zealand is unlikely to change without a commitment at the highest levels to produce an organised approach to the care of all patients with stroke. This will require each district health board to establish stroke services that integrate acute care and rehabilitation (both inpatient- and community-based), and clearly identify a lead clinician who will be responsible for that service.
Author information: John Gommans, General Physician and Geriatrician, Hawke’s Bay Hospital, Hastings; P Alan Barber, Neurologist and Stroke Physician, Auckland Hospital Stroke Service, Auckland; Harry McNaughton, Rehabilitation Specialist, Wellington Hospital, Wellington; H Carl Hanger, Geriatrician, The Princess Margaret Hospital, Christchurch; Patricia Bennett, Clinical Research Coordinator, Auckland Hospital, Auckland; David Spriggs, General Physician and Geriatrician, Auckland Hospital, Auckland; Jonathan Baskett, Geriatrician, North Shore Hospital, Auckland.
Acknowledgements: Supported by the Julius Brendel Trust (PAB and PB) and Hawke’s Bay Hospital Research Unit (JG).
Correspondence: Dr John Gommans, Hawke’s Bay Hospital, Private Bag 9014, Hastings. Fax: (06) 878 1319; email: email@example.com
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