Stroke Unit – Decision Makers Away with the Fairies

I’ve never been a fan of the term ‘cerebrovascular accident’. The term accident implies that there is no underlying reason for the pathology. Indeed, there was a push some years ago by the BMJ to ban the term ‘accident’ in medicine, as it implies that they are a chance occurrence or an ‘act of God’.

Stroke

It is actually interesting to explore the etymology of the term ‘stroke’. In times gone past, it was not unknown for formerly fit members of the community to head off into the fields or forest for a hard day’s work…then be discovered at the end of the day with a unilateral paralysis and difficulty speaking. Yet there was no visible injury. Hence the concept of having been attacked by the Faery Folk or ‘Elf-struck’ – subsequently contracted to ‘stroke’.

Whilst we learn about the pathophysiology & workup of stroke, I used to be somewhat nihilistic about outcome. I often tell patients and their relatives that one of three outcomes is likely – to get better, to get profoundly worse….or to stay the same. That’s not to say that I skimp on history and examination, appropriate investigations nor aggressive treatment of modifiable of risk factors. As a rural doctor I am well-placed to address risk factors well before people progress to cerebrovascular disease, as well as to have the ‘difficult’ discussions with them & family regarding prognostication if and when a stroke occurs.

All this changed with advances in stroke care.

The topic of thrombolysis in stroke is often discussed in FOAMed circles, with differing opinion on effectiveness between emergency and stroke physicians. One thing though has always seemed clear  the benefit of dedicated stroke pathways offering streamlined access t one-stop investigation and management of stroke patients, as well as use of validated triage systems such as the ROSIER score to enable direction of such patients to the stroke unit.

The best results appear to come from those which are based in a dedicated ward

By doing the LITTLE things well (timely recognition, early assessment and investigation, bundled care), it seems that stroke networks and stroke units offer patients the best chance. This is akin to the ‘aggregation of marginal gains’.

A 2013 Cochrane Review highlighted the benefit of dedicated stroke units. This review of 28 trials, involving 5855 participants, showed that patients who receive stroke unit care are more likely to survive their stroke, return home and become independent in looking after themselves.

So – best care is to send your stroke patient to a stroke unit. Or so I thought.

I recently admitted a stroke patient. Prior to this she was independent in her own home. She has controlled hypertension and a pacemaker. She’s had a previous stroke, managed in a tertiary hospital stroke unit, from which she made a full functional recovery after some weeks in rehabilitation. So when she presented, several hours after likely onset of her second stroke, it seemed only sensible to send her away to a stroke unit. She and family are loathe to leave the community, but understood that her best chance of recovery lies with all the benefits that a stroke unit can offer, not least rehab. So they are prepared to take a trip to the tertiary hospital for best care.

I spoke to a very lovely stroke registrar who apologised profusely and told me that, due to funding cuts, the stroke unit is now only able to accept patients under the age of 70.

That’s right – 70 years of age

Let’s face it – this is a financial decision, not a clinical one. Age doesn’t factor into the ROSIER score. It certainly didn’t factor into my patient’s eligibility for stroke unit care on the last occurrence. Whilst I can understand denying stroke unit care on the basis of poor premorbid function and poor chance of meaningful recovery, it seems nonsensical to exclude patients from stroke unit care on basis of age alone.

I have no doubt that my patient will be well cared for on a general medical ward. They may even receive visits from the same stroke physicians, physiotherapists and speech therapists as on the stroke unit. But studies suggest that it is the provision of a defined geographically separate unit dedicated to stroke care is the deciding factor in improving functional discharge.

As clinicians we may obsess over implementation of tools such as the ROSIER score, pros/cons of thrombolysis and need for bundled care in stroke networks and stroke units. But ultimately all this comes to nought if there are no beds, and decisions to admit to a stroke unit are made on basis of age, not other clinical criteria.

The stroke registrar encouraged me to make a noise about the limitations on beds. For most people, this issue will not be one that concerns them – until a family member is affected. Meanwhile politicians do not have to look these patients in the face. An honest political system would be prepared to put these issues front and centre, to acknowledge that rationing is needed and to explain why, despite encouragement to work until 70 until you are eligible for a pension, if you have a stroke in retirement you won’t get stroke unit care.

Making decisions based on age alone and not premorbid function seems inherently ageist – and is a policy I find hard to defend.

Should age alone be a reason to deny stroke unit care?

What do YOU think?

Is age alone a valid cutoff for stroke care?

If you are going to argue that equivalent care can be offered on a general medical ward, then it begs the question – why have stroke units? Has Cochrane got it wrong?

 

One Comment

  1. Tim
    Completely agree about ageism in all forms of care. Functional status is key. There a re many octogenarians out there who do amazing things and contribute beyond their means to the community – what other measure should we use?

    My old ICU mentor had a very dark sense of humour and was well suited to his career! HE impressed upon me that knowing a patient’s DOB / age was a poor predictor of anything useful, but… knowing when they were going to die was a much more useful statistic.

    A previously well 75 yo with a CVA will often make a functional recovery. A 29 yo binge-drinking, head-injured, dirt biking yobbo may not – and yet all the bells and whistles are spent. My mentor would suggest that some young people are “very old” – i.e. are likely to die soon.

    It is a bit rough when monetary policy determines care. Although our system has limited resources – it should be a case-by-case basis in which we allocate resources – not an arbitrary age-cut off. Isn’t that why we have Stroke Unit registrars? To make this assessment based on function, current disability and all the other subtleties that go into the “art of medicine”?
    Otherwise we could free up some money by replacing said Registrars with computers or clerks with algorithms !

    Anyway – good piece. Keep it up – you still have a decent 10 years left in ya fella!

    Casey

    Reply

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