What are the guidelines for inpatient treatment of stroke?

Inpatient Stroke Management Guidelines

All acute stroke patients should be admitted to a specialized stroke unit as soon as possible, ideally within 6 hours of hospital arrival, to significantly reduce mortality and improve functional outcomes. 1, 2

Stroke Unit Care

A stroke unit is defined as a geographically defined hospital unit dedicated to the management of stroke patients with the following key components:

• Core interprofessional team with stroke expertise including:
  • Physicians with stroke expertise
  • Specialized nursing staff
  • Occupational therapists
  • Physiotherapists
  • Speech-language pathologists
  • Social workers
  • Clinical nutritionists/dietitians
  • Hospital pharmacists 1, 2

For facilities without a dedicated stroke unit, focus care on priority elements including:

• Clustering stroke patients together
• Forming an interprofessional team
• Implementing stroke care protocols
• Conducting regular case rounds
• Providing patient education 1

Initial Assessment and Monitoring

• Complete interdisciplinary team assessment within 48 hours of admission 2
• Perform neurovascular imaging without delay for all stroke patients 2
• Consider prolonged ECG monitoring (up to 30 days) for patients with suspected embolic stroke of undetermined source 1, 2
• Monitor vital signs including:
  • Temperature every 4 hours for first 48 hours, then as per ward routine 1
  • For temperature >37.5°C, increase monitoring frequency, initiate temperature-reducing measures, and investigate possible infections 1

Venous Thromboembolism (VTE) Prophylaxis

For patients at high risk of VTE:

• Start thigh-high intermittent pneumatic compression (IPC) devices or pharmacological prophylaxis immediately if no contraindications 1
• If using IPC, apply within first 24 hours and continue until patient becomes independently mobile, is discharged, or reaches 30 days 1
• Consider low-molecular-weight heparin (enoxaparin) for ischemic stroke patients; use unfractionated heparin for those with renal failure 1
• Anti-embolism stockings alone are not recommended 1
• Early mobilization and adequate hydration should be encouraged 1

Mobilization Protocol

• All patients should be assessed by rehabilitation professionals within 48 hours of admission 1
• Do not initiate frequent, out-of-bed activity within 24 hours of stroke onset 1
• Begin mobilization between 24-48 hours after stroke onset if no contraindications 1
• Contraindications include:
  • Recent arterial puncture for interventional procedures
  • Unstable medical conditions
  • Low oxygen saturation
  • Lower limb fracture or injury 1

Continence Management

• Avoid indwelling catheters due to risk of urinary tract infection 1
• If used, assess catheters daily and remove as soon as possible 1
• Screen all stroke patients for urinary incontinence/retention and fecal incontinence/constipation 1
• Use portable ultrasound to assess post-void residual 1
• Implement bladder training programs for incontinent patients 1
• Establish appropriate intermittent catheterization schedules based on post-void residual 1
• Implement bowel management programs for patients with persistent constipation or bowel incontinence 1

Discharge Planning

• Begin discharge planning during initial admission assessment 1
• Continue planning throughout hospitalization 1
• Anticipate discharge needs to facilitate smooth transitions 1
• Conduct daily/bi-weekly patient care rounds with the interprofessional team 1
• Provide formal, coordinated patient and family education 1

In-Hospital Stroke

• Hospital inpatients who develop stroke should be assessed promptly and receive appropriate access to acute stroke care 1, 2
• Implement protocols for rapid recognition and management of in-hospital strokes 2

Common Pitfalls and Caveats

1. Delayed Recognition: Failure to recognize stroke symptoms promptly can lead to worse outcomes, especially for in-hospital strokes 2

2. Inadequate VTE Prophylaxis: Anti-embolism stockings alone are insufficient; use IPC devices or pharmacological prophylaxis 1

3. Premature Mobilization: Very early mobilization (within 24 hours) may be harmful based on recent evidence 1

4. Prolonged Catheterization: Indwelling catheters increase infection risk and should be removed as soon as possible 1

5. Lack of Standardized Protocols: Failure to implement standardized protocols for stroke assessment and management can lead to worse outcomes 2

By following these evidence-based guidelines for inpatient stroke management, healthcare providers can optimize recovery, prevent complications, and improve outcomes for patients with acute stroke.