Stroke Rehab and Recovery Guidelines Webinar

It is now my pleasure to turn today’s program over to Stephanie Mohl, vice president of
the American Stroke Association. The floor is yours. Stephanie Mohl:
Thank you, Ginneen. On behalf of the American Stroke Association,
a division of the American Heart Association, it is my pleasure to welcome you to today’s
webinar, Guidelines for Adult Stroke Rehabilitation and Recovery, Moving From Paper to Practice. As Ginneen said, my name is Stephanie Mohl
and I’m the vice president of the American Stroke Association. We appreciate you taking time out of your
busy schedules to help acknowledge the serious problem of stroke and the importance of rehabilitative
care in aiding a stroke patient’s recovery. Stroke is not only the number 5 killer of
Americans, but it is also the leading cause of serious long-term disability. Although we have made significant progress
over the last two decades in the acute treatment of strokes with corresponding reductions in
disability, the majority of stroke survivors still need at least some rehabilitative care
on either an inpatient or an outpatient basis. Like many of you, stroke has taken a toll
on my own family. Two of my grandparents and an uncle have had
strokes, and my Pop-pop died of his stroke. I have seen firsthand the difference that
high quality rehab can make in helping stroke survivors achieve their full potential. And regrettably, I have also seen the consequences
when stroke patients don’t receive the quality and amount of rehab they need and deserve. So I am proud that the American Heart Association
American Stroke Association is helping to promote the delivery of high quality stroke
rehabilitative care by issuing its first ever evidence-based guidelines for adult stroke
rehabilitation and recovery last year. In just a moment, I’m going to introduce
two of the authors of these guidelines, but before doing that, I want to acknowledge the
support of Kindred Hospital Rehabilitation Services in making today’s webinar possible. Kindred is a national sponsor of the American
Stroke Association’s Together to End Stroke initiative, which strives to educate stroke
patients and caregivers, health professionals, and the public that stroke is preventable,
treatable, and beatable. It is now my pleasure to introduce Dr. Sally
Brooks, the Chief Medical Officer for Kindred Rehabilitation Services. Dr. Brooks joined Kindred Healthcare in 2009. Prior to her career as a physician-executive,
she practiced in ambulatory and inpatient settings focusing on older adult care. Dr. Brooks, thank you for Kindred’s support
and for joining us today. I’ll turn the microphone over to you for brief
remarks. Dr. Sally Brooks:
Thank you very much and I thank all of you who are participating in this webinar today,
very important subject. And we just wanted to point out the reason
we’re involved in this program is to ensure that patients with stroke are treated in the
right setting, at the right time. We are seeing payers push back on access for
appropriate patients to rehabilitation and certainly these guidelines reinforce that
all patients with stroke deserve a referral and evaluation for acute inpatient rehabilitation. The medical complexity of a patient with a
stroke requires the daily physician oversight, rehabilitation nursing, and multidisciplinary
team to provide the higher frequency and intensity needed to recover from a stroke. So we thank you very much for participating
and now stay tuned for our speakers today. Stephanie Mohl:
Thank you, Dr. Brooks. It is now my honor to briefly introduce today’s
distinguished speakers. Dr. Joel Stein is a physician who specializes
in physical medicine and rehabilitation. He currently serves as a sign-in Baruch professor
and chair of the Department of Rehabilitation and Regenerative Medicine at the Columbia
University College of Physicians and Surgeons, Professor and Chief of the Division of Rehabilitation
Medicine at Weill Cornell Medical College, and Physiatrist-in-Chief at New York Presbyterian
Hospital. He was the Vice Chair of the writing group
for the guidelines. Our next speaker, Sue Pugh, has been a nurse
for more than three decades. She is certified in rehabilitation and neuroscience
nursing and is presently a Patient Care Manager at John Hopkins Bayview Medical Center, for
their neuroscience unit, intermediate care unit, and intensive care unit. She was also a member of the writing group
that authored the Stroke Rehabilitation and Recovery Guidelines. Dr. Stein and Ms. Pugh will now provide an
overview of some of the most significant recommendations in the guidelines, with particular emphasis
on the rehabilitation program recommendations. Welcome, Dr. Stein. Dr. Joel Stein:
Thank you very much for that kind introduction and I’d like to thank the Heart Association
for organizing this event, and Kindred, for sponsoring it. What I will be covering today will include
a brief introduction to the guidelines, and then pursuing that I’ll go into the different
categories of recommendations that are included in the guidelines, and then focusing in, in
depth on the rehabilitation program in particular, and then of course, we’ll hear from Sue Pugh
about some of the practicalities of implementing these guidelines and finally, we’ll have ample
time for questions and answers. So I think most of the participants are probably
familiar with the demographics of stroke in the U.S. but I think it’s worth restating. This is a huge problem. There are roughly 800,000 new strokes that
occur in the U.S. each year. While the age adjusted incidents of stroke
and the mortality rate has gone down, the total number of strokes has remained relatively
constant because the population at risk, that is to say the older population in the U.S.,
has continued to grow, resulting in roughly the same number of strokes over the last number
of years. As was noted earlier, the majority of stroke
survivors do require some degree of rehabilitation after hospitalization. It’s estimated about two-thirds require
some form of rehabilitation. This is the classification of the recommendations
and level of evidence that was used for the guidelines, and really has two components
to it. One is, the strength of the evidence which
can be level A, B or C. Level A evidence being the strongest evidence, for example, from
randomized controlled trials, level C the weakest level of evidence for example from
consensus or expert opinion and level B being intermediate, perhaps from case series or
less robust research design. The recommendations fall in four categories. Class l recommendations are the strongest
recommendations. These are treatments or care that is highly
recommended, and should be routine part of stroke care. Class IIA are the suggested or worth considering. Class IIB are the reasonable, and Class III
are the inadvisable or harmful. And those are important to reflect as we go
through the guidelines that we’ll focus on today because some of these have greater
or lesser degrees of evidence, and are stronger or less strongly recommended. In terms of the guidelines themselves, this
is a substantial effort that was put into creating this, and it’s quite a lengthy document,
which is part of why I think you’re fortunate to have hopefully a digest of it today. These were published in May of 2016. They are 72 pages long in published manuscript
form and they contain 227 specific recommendations. Thankfully I will not be reading through each
of those recommendations today but I encourage you all to do so at some point. They are all important but obviously we don’t
have time to go through them in detail. There were 18 authors on this document. And it’s almost a thousand references. And when last I checked last month, this document
had been downloaded about 78,000 times. So this really has very quickly become disseminated
and used by many people in not just in the U.S. but abroad, as an important source document
for recommendations as well as the evidence supporting those. In terms of the categories of recommendations,
I’m just going to run through these briefly. Each of these contain multiple detailed recommendations
that we don’t have enough time today to go into. But I do encourage you to look through guidelines
to delve in more deeply. The first section is the Rehabilitation Program,
and that is the section actually we will be focusing on the most today. So I will skip that for the moment as we’ll
return to it shortly. Another important parse of the guidelines
related to the Prevention and Medical Management of Comorbidities. There are many aspects of stroke that stroke
survivors contend with beyond the direct effects of the stroke. Those include issues such as deep venous thrombosis,
skin breakdown, pain, depression just to mention a few of them. Those are very much a part of the rehabilitation
program and care that stroke survivors need and therefore there are a substantial number
of guidelines that specifically address these. Another very important area that is addressed
in the guidelines is the assessment of stroke. Stroke survivors have difficulties often in
multiple domains. They may have difficulty with their motor
abilities, their ability to move, they may have difficulty with their ability to feel
things, their sensation, they may have difficulty performing activities of daily living, and
difficulties with communication and cognitive issues to name a few and that’s not a comprehensive
list. So it’s very important that the first step
of any effective treatment and rehabilitation program is that these individuals be fully
assessed and for that reason, assessment is an important part of the guidelines, with
a number of very specific recommendations about when various aspects of a stroke survivor
should be assessed and what types of assessments are appropriate. Then there are the sensorimotor impairments
and activities. And these are the sorts of limitations that
we often think of as being kind of the essence of stroke rehabilitation. For example, individuals who have weakness
after stroke, difficulty walking, inability to use their upper limbs, difficulty with
aphasia, or dysarthria, or swallowing difficulties. These are the very specific deficits and there
are quite a substantial amount of literature that address what the appropriate exercise
therapies are for example, what sorts of treatment would be appropriate for people who have difficulty
communicating or with swallowing, and these are a very important part of the guidelines
with numerous detailed recommendations. Lastly, is the issue of transitions and community
rehabilitation. This is an often neglected part of stroke
rehabilitation and return to the community. What we find often is that as medical caregivers,
we’re very focused on the immediate medical issues and the return to home, making sure
people are able to manage safely in their home environment. But what happens after that often does not
receive sufficient attention. Issues such as recreation and leisure activities
are often given insufficient attention. Return to driving. Return to sexual activity. And the issues of family and caregiver impact
to stroke are all addressed in this section of the guideline. This is a section with relatively limited
evidence and I think that reflects that there hasn’t been sufficient research in that, but
important guidelines often based on consensus and best practice and I encourage everyone
to review these guidelines as well. Now I’m going to focus more in detail on
the issue of the rehabilitation program itself and this is really about the organization
of care, how do we provide rehabilitation for people, in what setting, with what resources. The first stage of rehabilitation begins in
the acute care hospital. Patients may be in the ICU initially and then
perhaps in a hospital floor bed. And the question of what rehabilitation people
should receive and at what stage is very important, but as yet, still somewhat unclear in some
ways and controversial. There is a general statement that patients
should receive rehabilitation at the intensity commensurate with their anticipated benefit
and tolerance. That’s a fairly general statement. It’s means that when someone’s able to and
capable of receiving and benefiting from rehabilitation we should give them those services but it
doesn’t provide a lot of detail about what those are because, frankly, there is not yet
enough scientific literature on that. The other issue which is much more specific
and an important Class 3 recommendation comes out of a large, randomized trial called the
AVERT trial, which is contained in the references for the guidelines. I encourage you to look at the original paper. This was a study looking at the very early
mobilization of stroke survivors within the first 24 hours after stroke. And to many people’s, including my own,
surprise, it turned out that aggressive mobilization within the very early, the first 24 hours,
was actually associated with an unfavorable outcome relative to patients who received
more typical care. This does not mean that all patients need
to be at bed rest for 24 hours, but it does mean that aggressive efforts to ambulate patients
in that first 24 hours, for example, are not recommended. So this is a somewhat counterintuitive finding
because of the evidence in other disorders, for example, in patients with medical or surgical
issues in the ICU where early mobilization has been found to be useful. In stroke it appears that at least the first
24 hours is a period of relative rest and that’s an important recommendation from the
guidelines. In terms of the organization of the stroke
rehabilitation program and care, this is the slide that just details most of the typical
members. I will say that no list of team members is
always entirely complete and I apologize in advance to anyone omitted. I note that therapeutic recreation for example
is omitted and I apologize for that. It is a team that is constituted based on
the individual needs of the patient and certainly we expect that in individual cases, there
will be additional members. But generally speaking, physician leadership,
with someone who is dedicated to stroke rehabilitation is important, typically a physiatrist or rehab
physician, or a neurologist with a focus in this area, but occasionally geriatricians
or internists with a focus on this, rehabilitation nursing, and we’ll be hearing from Sue Pugh
shortly, PT, OT, and speech therapies, of course, social work, psychology, and the like. In terms of the types of rehabilitation care
that are available. So some patients, of course, can go home directly
after stroke with home care or sometimes directly going to outpatient rehabilitation services. When that is feasibility, that is preferred. I think we can all agree from our experience
in healthcare that if you can be home safely, you should be home and the guidelines are
consistent with that. But for those substantial number of individuals
who are not able to return directly home, there are three or four levels of care that
are most relevant. The first of these is inpatient rehabilitation
facilities or sometimes inpatient rehab hospitals, these are sometimes free standing facilities,
sometimes they are hospital-based specialty units. These provide relatively intensive medical
oversight with 24 hour nursing care, a daily physician visit, and at least three hours
of therapy per today. I’ll come back to what that three hours consists
of in a few minutes. Skilled nursing facilities have — provide
a lower level of medical supervision and nursing support, typically a lot of variation, the
regulations specifies the minimum but of course many facilities provide more than the minimum. There is not typically daily supervision by
a physician, unless the patient is medically unstable and by and large patients tend to
receive between a half hour and an hour and a half of therapy per day with obviously exceptions,
including some facilities that will provide considerably more. Medicare typically covers up to 100 days for
a qualifying patient in a skilled nursing facility and there’s a lot of variation from
facility to facility in terms of the resources and the organization of care. Nursing homes are long term care facilities,
typically patients with stroke would require some period of time in skilled nursing facilities
first, often these are co-located in different floors within the same facility and therefore
patients would segue way from one to the other if they needed long term care. And long term acute care hospitals are a special
type of hospital for patients with chronic, ongoing, substantial medical needs, often
dealing with ventilator weaning or other complex medical issues. They do care for some stroke patients and
typically they are defined in part by an average length of stay of greater than 25 days. Some of the specific elements that we would
like to highlight here, one is that some sort of formal assessment of patient’s rehabilitation
need is advisable and important. It is critical that patients really receive
a careful evaluation by trained personnel to make sure that they receive the appropriate
rehabilitation services, since these different levels of care provide different levels of
service and meet different patients’ needs. Multiple transitions of care are typical for
these patients and it is essential that we are attentive to that and make sure that there
is a good continuity of care and communication among the different levels and that’s really
important. And then there have been significant changes
within the Medicare program in particular, in the use of various types of post-acute
care. In general the utilization for the Medicare
population as a whole has been rising although there is not a lot of detailed information
about how that’s affected the stroke population in particular. At this point in terms of the first setting
where patients go for their rehabilitation services, posthospitalization, nationally
about 32% of patients go to skilled nursing facilities initially, about 22% go to inpatient
rehabilitation facilities, and about 15% go directly to Home Health, relatively small
numbers get outpatient rehabilitation services. And LPAC also is a relatively small number
that is omitted from this. These are some specific recommendations about
the organization of post-stroke rehabilitation care. And the first of these is that stroke patients
who require post-acute rehabilitation should receive organized, coordinated, inter-professional
care. You can see that has a strong recommendation,
Class l, Level of Evidence A. It sounds a little bit like motherhood and apple pie but
the fact is that this level of organization and coordination is not present in all places. It is important that the caregivers coordinate
care among each other. So simply having a nurse caring for the patient,
a physical therapist, an OT and a physician without coordination among them and communication
is insufficient to really provide the type of care that is recommended by the guidelines. The next recommendation here is that patients,
stroke survivors, who qualify for and have access to IRF care should receive treatment
in an IRF in preference to a SNF. So this is saying and I think this is perhaps
the most — among the more controversial or novel anyway aspects of the guideline, is
that if you meet the criteria for IRF care, and you’ve had a stroke, that really, if
you can, you should have that. Now there are situations where there simply
are no IRFs in the region. There are parts of this country where there
are insufficient numbers of IRFs or they are very far away and a family may not be able
to manage that. It may be too far to send them to a distant
city. There may be situations where they lack coverage
for this in their insurance, for whatever reason. And, of course, there are patients who don’t
meet the criteria. And those I’ll talk about a little bit more
in a minute. But not everybody is able to participate adequately
in an IRF care or requires IRF care. And for that reason, this specifies that it’s
patients who qualify for and have access to it. The organization of care in the outpatient
setting and home based setting is also referenced. There’s not a lot of evidence on this but
there is a belief that this is an important component of receiving appropriate post-stroke
care. And then early supported discharge which is
really more relevant in some areas than others, is appropriate for patients who have relatively
mildly disability. This is essentially intensive home care services
often involving physician visits for example to the home environment. Unfortunately, this is not widely available
in most parts of the U.S. Let’s just focus a little bit more on the
issue of IRF vs. SNF care. So we talked about three hours of therapy
for IRF care but I think it’s really important for those who don’t work in IRFs and have
less familiarity with that to understand what that means. What this does not mean is three hours of
aerobic exercise, sweating on the elliptical in the gym. And, unfortunately, I think patients are sometimes
scared off from IRF care by well-meaning caregivers who feel that they are too frail or too elderly
or not able to participate fully and will say, “Well, you have to participate in three
hours.” And patients imagine literally three hours
in the gym. In reality that three hours include things
such as speech therapy, which may be dedicated to working on swallowing, maybe dealing with
aphasia, if patients have those issues; it involves performing your tasks of daily living,
under the supervision and training of an occupational therapist. That could include hygiene tasks, dressing
tasks, daily tasks that are relatively low energy expenditure but very important for
independence in the home environment. And in terms of the physical therapy it often
means getting out of bed, practicing transfers, learning how to manage your wheelchair and
it is not all intensive exercise in the gym. Nonetheless, there are patients who cannot
tolerate that or are not medically ready for that. SNF care, skilled nursing facility is appropriate
for patients who have limited rehabilitation potential, for example, due to substantial
premorbid disability, premorbid dementia, patients who are very frail or medically fragile,
for other reasons perhaps unrelated to their stroke, and are unable to tolerate the intensity
of rehabilitation that’s given in the IRF. Patients who have very mild deficits, maybe
they are just very slightly unsteady but for whatever reason they’re not able to go directly
home, maybe they have medical needs that require supervision, maybe they lack supports in the
community and those patients may be appropriate for a skilled facility as well. And then as I mentioned, patients who lack
geographic access to an IRF. Lastly, there are patients who have completed
care in an IRF but are unable to return directly home because of continued disability and because
of perhaps family supports that are limited. So for those reasons, is not unusual, although
it is certainly not the norm, for patients to complete a course of care in an IRF and
then transition to a skilled nursing facility prior to return home. So I will stop there. And I will be happy to turn this over to Sue
Pugh who will talk about reading between the lines and how we really can take these guidelines
and turn them into practical change in patient care. Sue. Sue Pugh:
Thank you, Dr. Stein. And I too want to thank the American Heart
and Stroke Association for their support of this. Rehab is such an important component to the
recovery of stroke patients. And I really appreciate that they saw the
value of this, and agreed to the creating of this guideline, and then for this webinar
and all the many, many resources they have related to this. So, my part of the presentation is called
“Reading Between the Lines” because part of what’s frustrating about some of the recommendations
that Dr. Stein mentioned is that they don’t always have a lot of recommendations about
things that we all know that we do, we think is the right thing to do, we consider it best
practice, but there isn’t a lot of research that actually supports that. So I saw this quote and thought it was really
apropos for this part is the most important thing in communication is hearing what isn’t
being said. The art of reading between the lines is a
lifelong quest of the wise. Sometimes that’s what we have in healthcare
is we have to read between the lines. So there are lots of recommendations in the
guidelines. And being a nurse, I’m bringing forward
some of the ones that are certainly important from a nursing perspective as well as hitting
on lots of different topics. But I thought we’d get bowel and bladder
management out of the way first. This is a huge driver of some patients actually
going into different type settings because of their inability to manage this. So when we looked at bladder management and
bowel management, there wasn’t an enormous amount of literature out there. From bladder perspective, you know, assess
pre-stroke, urological issues and remove the Foley catheter within three hours. Again, Class I left level of evidence B, that’s
probably one of the strongest recommendations that we have and really the piece that kind
of took it to the next cart was, so we know we need to do an assessment and we know we
need to take out the catheter, but then what do we do to help them become continent? And this is where you kind of have to read
between the lines because there really wasn’t any research or literature out there regarding
stroke specifically. What was out there was studies about how to
deal with incontinence in, you know, adults. So, cognition for spin stroke does play a
part in prompted voiding and public floor muscle training can be reasonable to try. Those would be great things to try but again
you’ve got to understand if your patient has the cognition to be able to actually manage
that. Once you realize that they don’t have the
cognition, well, then we’re in a whole different area of how do we manage the bladder situation. So what I put as between the lines is that
we really need to do research. This is something that we have a call or a
need to do. Lots of different people do lots of different
things but there really isn’t a whole lot out there, really there is nothing out there
that says what to do. From a bowel management perspective, the only
real thing that we could really find from an evidence perspective was to assess prior
bowel patterns. That we look at what the patient had before. And what they were doing before to kind of
help drive forward what you do. And again, really what would be the things
to do between the lines is, you know, look at the recommendations are to help people
with bowel continence for adults. What do you do to try to manage someone? But again, cognition is going to play another
piece into it. Stool consistency is clearly important, so
looking at patients’ nutritional status. You know, because if they have loose stools,
that’s obviously more difficult to control than if their stools are more firm, how much
food are they taking in. Again, looking at best practices, but unfortunately
don’t have a lot of data to support that. From the perspective of follow-up care, we
do know that it’s really important that the patients have follow-up care once they
leave the organized support systems of the healthcare environment. We know that the family and the patient need
training and education. We all know that this is something that’s
so important. We also all know that when a patient, you
know, we have recommendations and education of the things that they’re supposed to do
that we provide in the acute care hospital, that gets reinforced in the rehabilitation
environment, which gets reinforced in the home healthcare environment. There’s all these places of reinforcement
and when they come back in for that follow-up appointment with hopefully a rehabilitation
provider, someone who actually knows to ask about specifically about stroke, the needs
of the stroke patient, the family support, and what we know that they need is that kind
of follow-up. But so often, the things that we’ve been teaching
them all along they come in and they’re just like I don’t remember anybody telling
me that. And sometimes that means that the patient
hasn’t really followed up on the important aspects of what they needed to be following
up on and making sure happen. They’ve stopped taking their aspirin and
they’ll say well, nobody told me to take it. And we all know that we all told them to take
it but for whatever reason they just didn’t get that piece followed up. So at that follow-up appointment, again, you
know, we recommend that we follow up on the things that we know should have been discussed
during their different settings. We need to evaluate these patients for social
isolation, we have issues related to returning to work. There are recommendations in the guidelines
about the returning to work, because of lots of reasons that it’s good for them to get
back into that type environment from an isolation perspective. And, of course, we need to do an assessment
of their cognitive, their perception, physical and motor abilities in order to really determine
if they are going to be able to return to work. We also should evaluate proposed stroke depression. We should also evaluate for anxiety. There are lots of different inventories to
use to actually evaluate the PHQ-2 is actually recommended for screening for post-stroke
depression. That’s a Class I level of evidence B. So that
is a good tool to use and that does seem to work well in stroke. But then, of course, the next question is,
so then we do this, and what do we do once we find out the patient is depressed? There are recommendations in the guidelines
related to medications that might be of benefit to the stroke patient. You know, looking at whether they need counseling. Again, I think one of the things that we all
know is that someone who understands the specific needs of the stroke patient and the family
would be important. But again, are all those resources always
available and in their community? From a sexuality standpoint, one of the things
that I thought was particularly interesting about sexuality is that it really is recommended,
it was Class IIb Level of Evidence B which obviously isn’t super-strong evidence but
it is a limited amount of evidence that’s out there, this is what it indicates is that
we really should discuss prior to discharge from the hospital, you know, their — ask
questions about sex and their sexuality related to that transitioning to home. What was out there is that things we should
ask them about are if they have any safety concerns, have they had any changes in their
libido, and questions about physical limitations, the emotional consequences of stroke. All of those things are things to ask them
about that can relate back to sexuality. And then, again, what we recommend is that
after they are home and maybe have had an opportunity now to actually do something with
this, from a sexual perspective, and then what kind of issues have they encountered? And then once again, we now ask these questions. So who are we going to make referrals to? Sometimes it could be to an actual physical
therapist or occupational therapist related to positioning. It could be related to their having — they
need to be reassured that no one’s going to get hurt. Or other things like, you know, actual emotional
counseling for them related to this. Another thing is we should be evaluating and
paying very close attention to the patient and family caregiver and really the support
system of the patient. We know that these individuals do need support. And they do need to be followed up on. There have been some studies out there indicating
that, you know, once a patient has a stroke that, you know, the support system also has
some concerns that develop as a result of this. And in order to really help these individuals
with transition, support should likely include the minimum of providing education, providing
them with training, counseling and really a support structure for the patient and the
caregiver. For the caregiver to possibly need respite
care, or knowing that, you know, yes, they are out there struggling and there are issues
with living with someone with a stroke and that they have the support that they need
to help them deal with the issues that they are encountering. And, of course, another very important component
is financial assistance. People once they get home need different things
done. They need ramps built, they need sometimes
home modifications, they need some minor home modifications, and some of these people don’t
have funding to be able to do that. And so helping them being able to figure some
of those things out as well as financial support, if the stroke patient was the primary caretaker
and the primary source of financial stability in the household, then how do they survive
after this? And again, all of these recommendations were
— they were of such minor research out there and evidence to support, again, these are
all things that we all face and encounter but knowing what it is that we should do and
what really works best is really left to still be decided. Another thing is the follow-up to the rehabilitation
care. One of the things that I know the families
encounter and the support systems encounter is how do you make a decision about where
your loved one should go? Dr. Stein has very much elaborated on the
evidence indicating that if someone qualifies for in-patient rehab that they should go to
in-patient rehab. But there are lots of questions that need
to be answered, again, as far as distance, people if they have the opportunity should
go and visit a facility or setting prior to making a decision. Understanding what their insurance will cover
and what it won’t cover. The question of being close to home versus
going to an environment where they can receive better services but are so far away from the
family that they won’t be able to visit often and provide support. American Heart and Stroke Association have
“Making Rehabilitation Decisions.” It’s a pamphlet that helps families be able
to make the decision of where should we take our loved ones, you know, that would be best
for them. So this is an excellent resource out there
to use. There are also other tools available for you. We have lots of quick sheets, an activation
kit, patient planning list, patient decision-making guides. All of these are out there and it’s right
there — if you go to the, these are out there and can be downloaded
and printed for patients as resources. And actually, one of the recommendations is
that as different providers we should all have resources available and handy for our
patients and families to help them not only hear the words that we tell them and try the
educate them with, but actually hand them something that they can take with them. So now we’re going to go over the conclusion. Stroke rehabilitation requires a sustained
and coordinated effort from a large team, including the patient and his or her goals,
family and friends, other caregivers, and everyone involved. It’s important to have the full team weigh
in on what are the best things for the patient, what direction should they go in. Communication and coordination among these
team members is paramount so that we’re all on the same page. Certainly I’ve sat through team conferences
where one department is saying we think this person needs to have this kind of support,
another person says no, we think they need minimum assistance. And they think they just need more rest and
then once they have more rest they’re able to do more. We’ve got to be communicating with each other
so that we’re all on the same page and giving the same message. It really creates effective and efficient
rehab and it really is what underlines the entire guideline of how all of us play a part
in the recovery and success of the patient and families. There are so many other recommendations but
we don’t really have time to go over all the rest of them. So I think what we’re going to do now is turn
this over to Kayla and Kristina to discuss and take some of your questions, and we’ll
go from there. Kristina Wait:
Thank you, Sue. This is Kristina Wait, everyone, from the
American Stroke Association. And I’ll be reading your questions that
you have posted online so that Sue and Dr. Stein can have an opportunity to provide you
with some further information. Ginneen, do you mind reviewing one more time
for everyone the instructions for asking Q&A? Operator:
Thank you. As a reminder, if you’d like to ask a question,
please click on the green “Q&A” button in the lower left-hand corner of your screen,
type your question in the open area, and click “Submit.” And I’ll turn it back for your Q&A session. Kristina Wait:
Thank you, Ginneen, appreciate that. We have a tremendous number of questions that
have come through so I’m hopeful we can get through all of them. If we’re not able to, we will certainly
find a way to provide answers to everyone post-call so that you have the information
you need. So the first question that has been asked
from the audience is: What is the percentage of people who get back to level prior to stroke? Comparing an IRF to a SNF? Sue or Dr. Stein, which one of you would like
to take that question? Dr. Joel Stein:
Sure, I can take that. It’s not an easy question to answer. The reality is that most of the patients who
go to these levels of care have significant disability as a result of their stroke. And as a result, I would say relatively few
achieve full recovery during the time they spend in the facility. I often tell the patients who are being referred
for either of these levels of care, I emphasize that the goal of inpatient rehabilitation
is not to complete their recovery and rehabilitation process, but to get to the point where they
can be home safely and managed in a home environment with the expectation that they’ll be ongoing
rehabilitation there. Most patients actually are pleased to realize
they’re going to get home as soon as they can and continue on an outpatient basis rather
than trying and stay until they’ve really maximized their full recovery. But I would say it’s a minority of patients
who achieve their premorbid level by the time of discharge. Kristina Wait:
Thank you, Dr. Stein. I think another question you can probably
weigh in on is: The role of dementia in prescribing post-acute care. What role does dementia play in choosing a
care setting and does it exclude someone from inpatient rehabilitation? Dr. Joel Stein:
Sure. So, dementia obviously has varying degrees. And there are patients who are diagnosed with
early dementia who have some mild memory difficulties. They have trouble with short-term memory,
remembering what they did yesterday or what they had for breakfast but are still able
to learn new material or still able to manage independently in the community but carry this
diagnosis. And I think we need to be careful to understand
that dementia is a process as much as it is a diagnosis. Patients who are severely demented, those
who are unable to communicate, unable to learn new things, unable to manage their own care
are obviously not candidates for attempted rehabilitation. Patients with mild early dementia who are
experiencing some cognitive struggles but are still able to manage in a home environment
with minimal support, those are certainty appropriate and frequent recipients. And I’ll point out, there are many patients
who are simply never formally diagnosed but is not uncommon when you probe a little bit
to realize that grandma was having a few memory issues prior to this and an assessment might
in fact make a diagnosis but they were mild enough that it really wasn’t affecting her
function very much. So, I think it’s important that that not be
a label used categorically to exclude patients from any particular type of care. Kristina Wait:
Thank you Dr. Stein. We have a question from an acute care therapist
who asks: Are there are any objective measures that show where the patient should go for
rehab after discharge? She shares that often they use their clinical
judgment in having worked in different settings they may have a more qualitative perspective
on who should go to an IRF versus a SNF. But are there any objective measures out there
that can help make that decision? Dr. Joel Stein:
Oh dear, someone asks the most — question that I could come up with. So this is something I’m personally very
interested in trying to define. These do not exist, simply stated at this
point. And frankly, this definition that was used
for the guidelines was sort of an operational definition that if you meet the criteria you
should go. That means that patients who meet IRF criteria
should not generally be sent to SNFs unless there is no alternative. But it doesn’t really help the clinician at
the bedside very much in saying, well, does this patient truly meet criteria? Because those criteria are somewhat subjective. And I would say we should give the benefit
of the doubt would be my general thinking. I think it’s distressing to think of some
individuals who could benefit who were not offered this more intensive level of care. But we do need to define more specific formal
criteria. I will say that I’ve been involved in some
research looking at things such as ABL scales, like Barthel Index or the FIM, which is very
similar. And those at least don’t seem to be sufficiently
predictive to say who’s going to go to IRF versus SNF by themselves nor is the NIH stroke
scale sufficient to make that determination. It’s one component but it’s not the only
component. Very astute question. Kristina Wait:
Great. So, you know, we saw on one of the early slides
in the presentation, the chart that shows how we define at the American Heart Association,
American Stroke Association our levels of classification for our guidelines. And when you have a question wanting more
information about those levels of classification, the question is, can we explain the grading
system used for Class I Level of Evidence, what is the A, B or C mean? Dr. Joel Stein:
I’m happy to answer that one as well. Generally speaking, Level A evidence would
be from large, randomized trials, often more than one or at least one large one. So these are the highest level of evidence. They’re hard to find in rehabilitation,
to be honest. But these are the sort of evidence, for example,
that are used to determine that tPA is appropriate for acute stroke management and more recently
the clinical trials that were used to establish that clot retrieval interventions are appropriate. That’s Level I evidence. But that’s hard to find. Level A evidence, excuse me. Level B evidence would be more typical of
what we see in rehabilitation. Smaller studies, perhaps several of them,
they may be observational in nature. A lot of the IRF vs. SNF literature, for example,
is not randomized but is based on observational research where data sets that are obtained
in the course of routine care are examined and analyzed to determine what the various
contributors to care were. And then Level C evidence is the least strong
evidence which includes, for example, case reports, expert opinion, consensus statements,
is not based on as formal evidence but may be very evident to everybody that it’s important. A good example of Level C evidence would be
the use of parachutes for people jumping out of airplanes. That’s a joke but I know it’s hard to laugh. Kristina Wait:
I chuckled on this end, Dr. Stein. [Laughing] Sue Pugh:
One other thing that I just want to mention about that is if folks go and download the
actual guidelines, like two to three pages in, the actual — there’s like a graph that
indicates the difference between Class I and all the different classes and the different
levels and it’s actually very detailed and it’s there as a reference. So when you are reading some of the recommendations
you can go back and refer to what they each mean. Kristina Wait:
Thank you, Sue, I appreciate you advising that as a reference for everybody and noting
that those details are provided for future reference. The next question we have then is: What is
your take on TIA or stroke cases which do not necessarily end up with disability? Should those stroke cases still have an evaluation
by a rehab team? Dr. Joel Stein:
That issue was not specifically addressed in the guidelines as far as I can recall but
I think my clinical recommendation would be if someone is truly at baseline, if all their
symptoms have resolved and they’re functioning well in the baseline in the community, then
no it’s not needed. But I think you have to make sure both of
those are met because there are people who are struggling in the first place and now
show up for medical attention and it would be a shame not to address their baseline needs
while they are in the hospital. Kristina Wait:
Thanks. Sue, you talked about in your presentation
bowel and bladder management and other post-stroke conditions. We have a question asking: Do you have recommendations
for depression, anxiety, medications, bowel, bladder management programs to support post-stroke
recovery? Sue Pugh:
So in the guidelines, there actually is a section that actually addresses medications
following depression. And the recommendations are Class IIa, Level
A, which says that a trial of an SSRI is reasonable to consider for these patients. So when you’re talking about the depression
and anxiety you could use — you could try an SSRI. Of course if that is something that is medically
something they can take that would be something to consider. As far as the bowel and bladder goes, there
are so many different things to really consider. In my own personal practice, because certainly
there was not a lot in the literature, one of the things that I find is always, always,
always overlooked is literally what is the patient taking in and putting out. And that people don’t always understand that
when they drink five cups of coffee, that coffee is a diuretic, how much fluid they’re
taking in, and then what are the ramifications about what comes out? And I always work with people just understanding,
you know, that what goes in has an effect on what comes outs. And then, you know, actually as they talked
about looking at from a cognitive perspective, if the patient is capable of being trained
and learning something, literally the sensation of the full bladder, getting them to the restroom
on a frequent basis, you know, sometimes people talk about toileting someone every two hours. If they eat a meal, the toileting should be
sooner after the meal versus, you know, you wouldn’t necessarily make them wait two hours
afterwards when by the sheer fact that they have had a meal they would need to require
toileting. There are lots of things to consider. But I don’t want to take up the rest trying
to answer this question because there are just so many different recommendations that
you can look at and I really recommend going out there and looking at treatment for incontinence
for adults and then look at what those recommendations are because at this point there is no literature
that says what specifically we should do for strokes. So we really have to go on what you would
do for just adults in general. Kristina Wait:
Thanks, Sue. And take a short breath but not too long because
I’m going to ask you another question that’s directed for you. Somebody asked: As an in-patient stroke coordinator,
what advice do you have for assisting the bedside nurse with discharge education if
someone is going to rehab? The observation is the bedside nurse might
not do as much in depth education prior to the patient going home, and knowing that for
this particular person, they have 25% of their population going to an IRH. They are curious to know from your perspective
how a stroke coordinator can facilitate that process. Sue Pugh:
Well, I think that it’s really different everywhere. Because it depends on how many stroke coordinators
you have, what’s their availability to be able to do any sort of help and assistance
to the bedside nurse. I think that at the very least, something
that a stroke coordinator could do is provide educational materials, you know, actually
something in writing for the staff nurses to be able to grab and reference and use. I think that a lot of times, you know, the
bedside nurse wants to provide good education, may not always have all the time but may understand
some of the detail of the case but doesn’t have something to be able to hand someone
and give it to them. Because, as I mentioned before, the number
of patients who actually follow all the recommendations really through and thoroughly, is just that
there’s so much that they’re learning and they’re so overwhelmed with so much information,
that actually giving the something is something to really hold on to and take in. So that’s really an excellent thing to have
as a resource for the bedside nurse. And then if the stroke coordinator can actually
make themselves available to, you know, actually help with the discharge instruction, I certainly
think that — I don’t think there’s a staff nurse that would say no, I don’t want you
to do that. I think they would love the help. It’s just usually a matter of who has the
time to do it. Kristina Wait:
Thank you, Sue, very appreciative. And we have many, many, many, many more questions
that are being asked. Which I think speaks to the quality of information
Sue and Dr. Stein, you have provided to our attendees today. We will do our best to try to gather answers
to some of these questions and provide back to our participants in some way post-call. Before everybody hangs up, I’d like to give
Ginneen, our web specialist, an opportunity to close this out. We will be having a survey go out after this
call, and if you could take a few moments to answer the survey we’d be very appreciative. The American Stroke Association is happy that
we were able to provide with you this learning opportunity. And thank you for supporting our mission and
providing patients with better outcomes. Ginneen? Operator:
Again, thank you all for joining us today. We hope you found this presentation informative. This concludes our program and you may all

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