What is the inpatient management of acute stroke?

Inpatient Management of Acute Stroke

All patients with acute stroke should be treated in a dedicated stroke unit with specialized interdisciplinary care to significantly reduce mortality, improve functional outcomes, and increase the likelihood of returning home after stroke. 1

Immediate Management and Admission

• Admit patients to a stroke unit as soon as possible, ideally within 6 hours of hospital arrival 2
• For in-hospital strokes, implement immediate assessment by a physician with stroke expertise, urgent neurovascular imaging, and assessment for eligibility for intravenous alteplase and/or endovascular thrombectomy (EVT) 2
• Establish clear protocols for stroke care in all hospitals, especially in units with higher-risk patients 2

Stroke Unit Structure and Team

• Implement a geographically defined hospital unit dedicated to stroke patients with dedicated stroke beds 2
• Form an interdisciplinary stroke team including:
  • Physicians with stroke expertise
  • Specialized nursing staff
  • Physiotherapists
  • Occupational therapists
  • Speech-language pathologists
  • Pharmacists
  • Additional team members: discharge planners, neuropsychologists, palliative care specialists, and peer supporters 2, 1

Initial Assessment (First 48 Hours)

• Complete interdisciplinary team assessment within 48 hours of admission 2
• Use standardized, valid assessment tools to evaluate stroke-related impairments 2
• Assessment components must include:
  • Dysphagia screening (before any oral intake)
  • Mood and cognition
  • Mobility and functional status
  • Temperature monitoring
  • Nutrition needs
  • Bowel and bladder function
  • Skin breakdown risk
  • Venous thromboembolism risk 2

Monitoring and Management

• Implement hourly assessments (or more frequent as needed) of:
  • Level of consciousness
  • Neurological status using standardized scales
  • Blood pressure
  • Oxygen saturation (maintain >94% only when hypoxic)
  • Temperature (treat if >37.5°C)
  • Blood glucose (treat if >155 mg/dl) 1, 3

Diagnostic Investigations

• Perform neurovascular imaging without delay for all stroke patients 2
• Consider prolonged ECG monitoring (up to 30 days) for patients with embolic stroke of undetermined source where atrial fibrillation is suspected 2
• Repeat CT scans when deterioration in neurological status occurs 1

Complications Prevention

• Implement standardized protocols for:
  • Venous thromboembolism prophylaxis using intermittent pneumatic compression devices 2
  • Dysphagia screening before any oral intake
  • Early mobilization (but not frequent mobilization in the first 24 hours)
  • Blood pressure management according to institutional protocols 2, 1

Rehabilitation Planning

• Complete a formal, individualized assessment to determine rehabilitation needs within 72 hours of admission using standardized protocols (e.g., alpha-FIM) 2
• Begin rehabilitation as early as possible based on patient stability 3

Special Considerations

For In-Hospital Strokes

• Implement the same rapid response and care protocols as for patients admitted from the emergency department 1
• Recognize that in-hospital strokes have worse outcomes than community-onset strokes 1

For Patients Requiring Palliative Care

• Assess appropriateness of life-sustaining measures
• Reassess medications and consider cessation of those no longer necessary
• Implement comprehensive symptom management including pain, respiratory distress, and psychological needs 2
• Discuss organ donation with families when appropriate 2

Common Pitfalls to Avoid

• Delayed recognition and treatment of in-hospital strokes
• Failure to implement standardized protocols for stroke assessment and management
• Inadequate monitoring for neurological deterioration
• Overlooking the need for specialized stroke unit care for all stroke patients, regardless of stroke severity 1
• Delayed transfer from emergency department to stroke unit
• Failure to implement elements of stroke unit care in centers without formal stroke units 2

By implementing these evidence-based recommendations, healthcare facilities can optimize outcomes for patients with acute stroke through rapid assessment, appropriate interventions, and comprehensive care delivered by specialized interdisciplinary teams.