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| Journal of the New Zealand Medical Association,
16-May-2003, Vol 116 No 1174
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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.
MethodsA 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. ResultsA 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.
DiscussionThe 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: john.gommans@hawkesbaydhb.govt.nz
References:
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