Introduction: Stroke unit care is an established intervention for all stroke patients where the benefits derive from having a system which integrates acute reperfusion with secondary prevention and rehabilitation as needed. While most stroke units are staffed by dedicated stroke neurologists, in many parts of the world non-neurologist stroke physicians are in charge of stroke care.
Hypothesis: As the benefits of a stroke unit are due to an organized system, we hypothesize that irrespective of the physician looking after the stroke, the more organized the system, the better the outcome.
Methods: To test this hypothesis, a cohort study comprising of consecutive ischemic stroke patients presenting to a tertiary stroke centre between 2000 - 2015 was analysed. During this time, there was an evolution of stroke systems from admitting strokes under general medical units, to admitting strokes to a dedicated centre where stroke patients are looked after by a single stroke specialist. The specialists are geriatricians who work under the governance of a stroke neurologist director. Outcomes such as mortality, length of stay, discharge destination were analysed.
Results: 4794 stroke patients were analyzed. Median length of stay (LOS) prior to appointment of a stroke director was 7.3 days. An immediate reduction of 1.2 days to 6.3 days LOS (p=0.02) occurred in the first year after this appointment (2009-2010). Since SU care began (2010-2014), LOS has further reduced to 4.7 days (p=0.001), with mortality (OR=0.72, 95% CI=0.56-0.91, p=0.007) and transfers to aged care facilities (OR=0.50, 95% CI=0.38-0.67, p=0.001) also significantly decreasing. Transfers to rehabilitation hospitals also significantly increased from 19.6% to 34.5% (p=0.007).
Conclusion: In this large cohort study involving a tertiary stroke centre with regional responsibility for stroke care, we demonstrate that stroke outcomes improve with better governance and adherence to strict protocols. The most dramatic improvement occurs following the appointment of a stroke director and outcomes continue to improve even when the physician looking after a stroke is a non-neurologist. Hence it is the comprehensive system and not the type of physician that makes the difference.