Stroke units
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7359.291 (Published 10 August 2002) Cite this as: BMJ 2002;325:291All rapid responses
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I note Sergio Sennaro's point the difficulty of matching the number
of acute stroke beds to the number of patients. The case for operating an
unselective policy has been fully made in the original leader. The
logisitic difficulties can be reduced by operating a flexible
configuration of beds on a ward where the bed complement is shared between
acute stroke beds and acute general medical or medicine for the elderly
beds. Management support for this is essential. We, for example,
negotiated that on a 22-bedded acute elderly ward, up to 12 shall be used
by acute stroke patients at any one time. We liaise daily with the bed
manager to ensure that at least one acute stroke bed is kept available
each week day for stroke patients to be admitted direct and that at least
two are kept available for the weekend. During busy spells we use all 12
beds, but during quieter speels we may use only 3, the rest being
available for acute elderly general medical patients. On the
rehabilitation side we have a 15 bedded rehabilitation ward that is used
primarily by patients with stroke, but which takes general orthopaedic,
medical or surgical rehabilitation patients when there are no stroke
patients waiting for rehabilitation (1).
This system has worked well for our workload of 240 acute strokes per
year, and has meant that very few patients are admitted elsewhere in the
Trust. The upper limit of beds required for any one hospital depends on
the number of strokes per year, so that a hospital admitting 900 strokes,
assuming an average length of stay of 10-12 days, requires a 30-32 bedded
acute stroke ward to ensure that most patients with acute stroke are
admitted into acute stroke beds. The exact number of rehabilitation beds
depends on local factors such as availability of community rehabilitation
services and the response times of social services in setting up packages
of care or institutional placement.
The advantage of flexible bed reconfiguration is that bed usage is
maximised, competition between general medical and stroke units is
reduced, and stroke unit treatment for every person becomes a more
achievable ideal.
(1) Intercollegiate Stroke Working Party. National Sentinel Stroke
Audit 2001/2 Trust report. Clinical Effectiveness and Evaluation Unit.
Royal College of Physicians, 2002.
Competing interests: No competing interests
The Editor
Sir
Congratulations on the inclusion of the editorial on stroke units by
Sheldon Stone. It was powerfully written and right to the point.
The Stroke Association is so concerned with the results of the Royal
College of Physicians' third national sentinel audit, that we are
currently running a campaign 'It's Just Not Good Enough'. A petition will
be presented to 10 Downing Street in the Autumn and we would encourage
anyone who has a concern about stroke patients' care to sign it and
circulate to colleagues.
Copies are available by contacting us on 0207 566 1508.
The evidence about the benefits of organised stroke care are now well
-known. People are dying or suffering disability when they should not be.
The provision of appropriate stroke care for all stroke patients must be
implemented more quickly.
Yours faithfully
Eoin Redahan
Director of Public Relations
The Stroke Association
Competing interests: No competing interests
The primary objective of stroke units is to limit the degree of
cerebral damage and its consequences but limiting the degree and duration
of impaired intracerebral mitochondrial oxidative phosphorylation. In so
doing increasing oxygen delivery and uptake may be complemented by
reducing the metabolic need for ATP resynthesis. The most effective way of
reducing the metabolic need for ATP resynthesis is to cool the brain. By
cooling in addition all other organs in the body the likelihood of
developing organ dysfunctions and failures should also be reduced. The
problem with an effective degree of hypothermia is that it causes cardiac
arrest.
If Westaby's intracardiac pump is able to maintain an adequate level
of oxygen delivery during hypothermic cardiac arrest then it could add
greatly to the current management of stokes and other acute intracranial
pathology including head injuries. Has this been considered and/or tried?
If the Westaby's pump is able to improve management of acute
intracranial pathology then who should be responsble for inserting and
managing the pumps? The problem with having cardiologists and/or cardiac
surgeons responsible is that it would create an unacceptable conflict of
interest for hearts are harvested from these patients for heart
transplantation. The same applies to those specialists involved in all
other organ transplants, unless the organs are harvested from live donors
or animals.
Competing interests: No competing interests
Sirs,
in an excellent editorial (BMJ 2002;325:291-292, 10 August), Sheldon Stone
analyses the real situation of stroke units, and underscores their
beneficial results, due to improving outcome by concentrating patients in
a unit with appropriate expertise, although the failure to achieve
appropriate standards of clinical care, because of the lack of capacity to
admit “all” patients, involved by stroke. Really, now-a-days, it is not
possible unfortunately to treat in a stroke unit every person
with a stroke, surely followed by remarkable success (mortality reduction
by a third). Consequently, it is necessary to select patients, for
instance, those, who most likely can benefit even a treatment in general
wards.
This difficult selection-problem parallels another, really
essential in the war against stroke: stroke primary prevention, due to the
fact that prevention is better than treatment. In my opinion, in stroke
prevention, as well as in all other similar prevention “enterprises”,
there is a fundamental mistake at starting point: we dare speak of
“global” prevention in individuals not correctly selected, independently
from the real efficaciousness of diet, etymologically speaking, and/or
drugs therapy e.g., ACE inhibitors, but especially ignoring or overlooking
the actual existence of different biophysical-semeiotic “constitutions”,
which involve exclusively some individuals, but surely not “all”:
“diabetic constitution” (1), for example, "hypertensive, dyslipidemic,
arteriosclerotic constitution”, a.s.o. (See the site, HONCode ID N° 233736
http://digilander.libero.it/semeioticabiofisica). In addition, as far as
some ACE inhibitors action mechanisms are concerned, we have to consider
their favorable and very “complex” influences also on the microcirculation
of brain, analogously to what occurs in the kidney, under such treatment.
In a few words, we must know that, in healthy people, the microcirculatory bed
shows autonomous and autoctonus, non-linear dynamics in both small
arteries and arterioles (vasomotility), according to Hammersen, as well as
in nutitional capillaries and post-capillaries venules (vasomotion) (1,
2). By contrast, in individuals “at real risk” for well-defined disorders,
such as stroke, microcirculation deterministic chaos is already slightly
and characteristically impaired since the first two decades of life in
defined biological systems, clearly in a “silent” form, i.e.,exclusively
in those tissues, which “can” in the future be affected by precise
diseases (Congenital Acidosis Enzyme-Metabolic Histangiopathy = conditio
sine qua non of the most serious human diseases) (4). Ultimately, in
diseased organs such as “chaotic-deterministic” microcirculatory behaviour
is almost completely lost and consequently local parenchymal oxygenation
appears worsened, reduced, due to a large variety of factors, when
evaluated at the bed side by the aid of Biophysical Semeiotics.
Interestingly, some, but not all, ACE-inhibitors act ameliorating blood-
flow in brain, kidney, heart, a.s.o., microcirculatory bed, beside their
more known action on the large arteries.
Sergio Stagnaro MD. Active Member NYAS.
1) Stagnaro S. Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002
Jan 24;346(4):297-298. letter [PubMed –indexed for MEDLINE].
2) Stagnaro-Neri M., Moscatelli G., Stagnaro S., Biophysical Semeiotics:
deterministic Chaos and biological Systems. Gazz. Med. It. Arch. Sc. Med.
155, 125,1996.
3) Stagnaro-Neri M., Stagnaro S., Deterministic chaotic biological system:
the microcirculatoory bed. Theoretical and practical aspects. Gazz. Med.
It. – Arch. Sc. Med. 153, 99, 1994.
4) Stagnaro S., Istangiopatia Congenita Acidosica Enzimo-Metabolica. Una
Patologia Mitocondriale Ignorata. Gazz Med. It. – Arch. Sci. Med. 144,
423, (Infotrieve)
Competing interests: No competing interests
education as a preventive tool/use of tPA for stroke
As a British journalist specializing in health issues and living in
the USA, I was interested to learn more about the progress of stroke
treatment in the UK. My own interest stemmed initially from my mother’s
stroke, and the fact that - even though she was eventually hospitalized
and received adequate care - she was left to face the consequences of
severe right-hemisphere paralysis without any real hope of recovery or
rehabilitation.
Since this happened, I have been following the progress of stroke
treatment in the USA and particularly in California where I live. Tissue
plasminogen activator (tPA) is used in an increasing number of hospitals
since stroke protocols were pioneered at Stanford Medical Center and San
Jose’s Good Samaritan Hospital, both of which have specialized stroke
teams for emergency treatment of stroke-in-progress, as well as special
units for after-care and rehabilitation. Although tPA is of course not
appropriate in all cases, the fact that more doctors are being trained to
use it for stroke is very heartening. I have interviewed several of them,
as well as patients whose futures have been dramatically affected when
stroke paralysis and other symptoms were reversed by the drug.
As a journalist, my main interest is in helping educate people to
understand the risk factors, and even more to recognize the signs of
stroke or TIA so that they see a neurologist and get appropriate treatment
without delay. As Sergio Stagnaro (who responded to this article) pointed
out, prevention seems by far the best approach. This is especially true as
stroke must be one of the few conditions where a potential medical
catastrophe can be averted or alleviated, at least partially by means of
patient education and co-operation. (However, the treatment options need
to be available too.)
The Peninsula Stroke Association (www.psastroke.org) is a California-
based nonprofit organization, which has undertaken to educate the public
about stroke, as well as offering support and advocacy for stroke
survivors and their families. Aside from the American Heart Association at
the national level, it is one of the few organizations I know of that is
employing education as a preventive tool in the community.
Though outcomes can be much improved by more specialized post-stroke
care, it seems that until tPA is in wider use in Britain, stroke will
remain the dark, apparently fateful event that has throughout history
robbed people of life, or of life as they knew it.
Yours sincerely,
Diana Reynolds Roome
Competing interests:
None declared
Competing interests: No competing interests