Stroke Units
Stroke Units are wards dedicated to the care of acute stroke patients and for stroke patients who need rehabilitation by a multidisciplinary team of health professionals who are trained specifically in the care of stroke patients. There is now good evidence that organized multidisciplinary care is more effective than care in a general medical ward.
Stroke victims need to be treated with dignity. They may have less urgent, yet important needs such as regular care for bladder and bowel functions, hydration and nutrition. When stroke patients are managed in a general ward, other patients with acute needs such as chest pain and asthma, would take up nursing time from the stroke patient. When stroke patients are managed in stroke units, there are fewer deaths, fewer patients remaining in an institution and more independent survivors.
Treating 1,000 patients in a stroke unit rather than in a general ward prevents 56 patients dying or becoming dependent.
Stroke units also provide better opportunity for the relatives to interact with the medical staff and play an effective and active role in patient management and rehabilitation. Establishment of stroke units costs the health budget negligibly but contributes to the quality of health care significantly. It does not require costly equipment, but the training and employment of the team for multidisciplinary care.
Stroke Units in Sri Lanka
In the absence of stroke units, in general, stroke patients are admitted to general medical wards. The physician in charge mostly assures that the risk factors of these patients are brought well under control. But in a majority of instances the pressing problem of beds restricts accommodating these patients in hospitals for an adequate duration for rehabilitation and most are prematurely discharged. 57% of stroke deaths are related to complications. Majority of complications occur in the 2nd or 3rd week after the stroke. Therefore a majority of stroke patients in Sri Lanka, by the time they develop complications, are out of the hospital.
Where do they end up?
Majority of stroke patients who are prematurely discharged are being cared for by untrained family members or managed by physicians at ayurveda hospitals or physicians practising indigenous medicine. My observations revealed that approximately 70% of 3000 beds available at ayurveda hospitals are occupied by stroke patients. Though they do not have organized multidisciplinary care described in medical literature, the Ministry of Ayurveda and Indigenous Medicine provides therapy programmes done by trained masseurs for these patients.
Should the Ministry of Health await the Ministry of Ayurveda and Indigenous Medicine to take over stroke care? Could the burden of stroke be handled by individuals interested in stroke care? Or isn't this the time for a National Initiative to improve stroke services in Sri Lanka?
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| A carer tending to a patient at the Stroke Unit of the National Hospital (file pic) |
In my belief, decent stroke services for all should be a part of the vision of the Ministry of Health by 2020, when a fifth of the community will be more than 65 years. I would recommend a ward (stroke unit) or a designated area for stroke patients in every hospital where there is an appointed physician and a physiotherapist.
As at present there are no social service officers and counsellors appointed to hospitals and medical officers do not have adequate knowledge of the provisions for the disabled, provided by the Ministry of Social Services and Social Welfare. It is the social officers who will assist with financial and accommodation needs, arrange access to appropriate social benefits, provide vocational guidance to disabled persons. If there is a stroke unit, it would be easier for effective coordination with the existing services of the Ministry of Social Services and Social Welfare.
Long-term rehabilitation
There are no community-based rehabilitation programmes in Sri Lanka and once a stroke patient is discharged, he/she is compelled to seek the help of the local physician who practises indigenous medicine or ayurveda. Thereby, we lose the opportunity for secondary prevention in a majority of patients.
Once faced with a stroke, a significant proportion die of another vascular event; further strokes contribute to 25% of deaths. Cost-effective interventions are available for secondary prevention and the potential gains associated with the consistent use of such interventions are very large.
Benefits of quitting smoking, use of aspirin, blood pressure and lipid lowering drugs are largely independent and it is expected when used together, that four-fifths of recurrent vascular events could be prevented. It has been shown that more than 30% of stroke patients in rural Sri Lanka are not on aspirin, and more than 90% are not on statins. Approximately 40% and 75% of stroke patients have not checked their blood sugar and blood cholesterol respectively within the last one year. Data from the NHSL stroke unit indicate that the most important risk factor for young male stroke less than 45 years is smoking.
If stroke clinics for outdoor patients could be established in association with stroke units, patients who are discharged from the hospitals will benefit for both rehabilitation and secondary prevention. There will be better coordination and it would be easier to train family members for home physiotherapy until community-based programmes are established.
The National Stroke Association of Sri Lanka
The burden of stroke is unarguably a national issue and should be addressed by the Government of Sri Lanka. Nevertheless, the contributions that are made for primary and secondary prevention by non-governmental organizations such as the National Stroke Association of Sri Lanka are noteworthy.
The National Stroke Association of Sri Lanka which is the only organization committed for stroke victims has been in existence for the last 10 years. In addition to the education programmes conducted for stroke carers and for primary and secondary prevention, the association has established links with the Asia Pacific Stroke Association and the World Stroke Organization. The association is on the Board of Directors of the World Stroke Organization.
Despite successes in inventing effective new therapies, significant obstacles remain in providing them to the patients. What Sri Lanka needs to optimize stroke care is to appreciate the problem and flaws in the existing system, vision, initiation and guidance. In many instances, these obstacles can be related to a fragmentation of coordination of important stakeholders of stroke care. A little commitment from our part is likely to make a remarkable difference in the quality of life of so many others.
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