A Consensus on Stroke

Abstract

Background and Purpose-Research evidence supporting Early Supported Discharge (ESD) services has been summarized in a Cochrane Systematic Review. Trials have shown that ESD can reduce long-term dependency and admission to institutional care and reduce the length of hospital stay. No adverse impact on the mood or well-being of patients or carers has been reported. With the implementation of many national and international stroke initiatives, we felt it timely to reach consensus about ESD among trialists who contributed to the review. Methods-We used a modified Delphi approach with 10 ESD trialists. An agreed list of statements about ESD was generated from the Cochrane review and three rounds of consultation completed. ESD trialists rated statements regarding team composition, model of team work, intervention, and success. Results-Consensus of opinion (Ͼ75% agreement) was obtained on 47 of the 56 statements. Multidisciplinary, specialist stroke ESD teams should plan and co-ordinate both discharge from hospital and provide rehabilitation in the community. Specific eligibility criteria (safety, practicality, medical stability, and disability) need to be followed to ensure this service is provided for mild to moderate stroke patients who can benefit from ESD. Length of stay in hospital, patient and carer outcome measures and cost, need to be routinely audited. Conclusions-We have created a consensus document that can be used by commissioners and service providers in implementing ESD services. Our aim is to promote the use of recommendations derived from research findings to facilitate successful implementation of stroke services nationally and internationally. (Stroke. 2011;42:1392-1397.)

A Synthesis of Peer-Reviewed Literature on Team-Coordinated and Delivered Early Supported Discharge After Stroke

“…4 One way to meet this recommendation would be to set evidence-informed screening criteria such that patients meeting all criteria are automatically considered for ESD and patients meeting one or more are considered on a case-by-case basis. The inclusion and exclusion criteria (and resulting cohorts of patients) in the studies identified here offer a few examples of criteria that may be useful in this decision-making process.…”

“…The importance of flexibility in decisions regarding ESD has regularly been mentioned by ESD experts. 4,20 Although a patient may meet all of the physical and cognitive characteristics of a typical ESD candidate, few clinicians would feel comfortable discharging patients to an unsuitable home environment (or no home at all). In these cases, the best interest of the patient should be the most important factor in decisions regarding ESD suitability.…”

“…Early supported discharge (ESD), in which rehabilitative care is provided in the community as an alternative to remaining in the hospital, has gained popularity around the world as a less costly way to rehabilitate moderately and mildly disabled stroke patients. Trials performed to date on ESD suggest that, when provided to appropriate patients, it can reduce the risk of death or dependency, 3 admission to institutional care, 3 length of hospital stay, [3][4][5][6] and the overall cost of services 3,5,7 compared with traditional in-hospital rehabilitation. Accordingly, ESD has been included in the Canadian Best-Practice Recommendations for Stroke.…”

“…3 In a consensus report on the topic, an international panel of experts on ESD unanimously agreed that specific eligibility criteria for early supported discharge should be used and that eligibility decisions should be based in part on the patient's level of disability and medical stability. 4 The panel also unanimously agreed that identification of patients suitable for ESD should be made by the ESD team and that flexibility in the criteria is essential. However, the panel did not reach unanimous agreement about what role factors, such as Barthel Index (BI) scores, ability to transfer from bed to chair, or cognitive function.…”

Mobile team reintegration-rehabilitation: An activity outside. Results of 3 years of functioning to the Pole Saint-Helier

“…Although most of these missions seem admitted by all, there is no consensus today at the national level on their mode of operation and in particular on their vocation to provide the care or not. Internationally, there is the action of these teams of early supported discharge (ESD) with a focus mainly on the stroke literature [3][4][5][6] with a recent review of the literature Cochrane has shown the value of ESD (which include three types of care activities in France : inpatient, home hospitalization and mobile teams) including the length of hospital stay, independence and home support to 6 months, satisfaction and access to extended activities of daily living 3 .…”