Inpatient Stroke Management Guidelines
Patients admitted to hospital with acute stroke should be treated on a specialized inpatient stroke unit as soon as possible, ideally within 24 hours of hospital arrival, as this is associated with reduced mortality and improved functional outcomes. 1
Stroke Unit Care
Organization of Stroke Units
- Stroke units should be geographically defined hospital units dedicated exclusively to the management of stroke patients 1
- For facilities without dedicated stroke units, focus care on priority elements including:
- Clustering stroke patients together
- Implementing interdisciplinary team approach
- Providing early rehabilitation access
- Following stroke care protocols
- Conducting regular case rounds
- Delivering patient education 1
Interdisciplinary Team Requirements
- Core team should include healthcare professionals with stroke expertise:
- Physicians
- Nurses
- Occupational therapists
- Physiotherapists
- Speech-language pathologists
- Social workers
- Clinical nutritionists/dietitians 1
- Hospital pharmacists should be included to promote medication safety, reconciliation, education, and discharge planning 1
- Additional team members may include:
- Discharge planners/case managers
- Neuropsychologists
- Palliative care specialists
- Recreation therapists
- Spiritual care providers 1
Initial Assessment and Management
Timing of Assessment
- Interdisciplinary team should assess patients within 48 hours of admission 1
- Standardized, validated assessment tools should be used to evaluate stroke-related impairments and functional status 1
Assessment Components
- Dysphagia screening
- Mood and cognition evaluation
- Mobility assessment
- Functional status assessment
- Temperature monitoring
- Nutritional status
- Bowel and bladder function
- Skin integrity
- Venous thromboembolism risk 1
Monitoring Parameters
- Temperature: every 4 hours for first 48 hours
- Neurological status: hourly for first 48 hours
- Blood pressure: every 1-4 hours for first 48 hours
- Oxygen saturation: every 1-4 hours for first 48 hours
- Blood glucose: every 1-4 hours for first 48 hours 2
Acute Medical Management
Blood Pressure Management
- For patients who received thrombolysis:
- Maintain BP <180/105 mmHg for 24 hours after treatment
- For patients without thrombolysis:
- Cautious reduction if BP >220/120 mmHg 2
Fever Management
- Treat temperature >37.5°C promptly 2
- Regular monitoring and antipyretic therapy as needed
Glucose Management
- Monitor blood glucose regularly
- Treat hyperglycemia to maintain normoglycemia 2
Venous Thromboembolism Prophylaxis
- Implement early prophylaxis for patients with restricted mobility
- Use low-dose subcutaneous heparin or low molecular weight heparins 2, 3
- For patients with contraindications to anticoagulants, use intermittent pneumatic compression devices or elastic stockings 3
Early Complications Prevention
Dysphagia Management
- Screen all stroke patients for dysphagia before initiating oral intake
- Implement appropriate dietary modifications based on assessment 2
- Provide training to caregivers on safe swallowing techniques 1
Early Mobilization
- Begin mobilization between 24-48 hours if no contraindications exist 2
- Contraindications include recent arterial puncture, unstable medical conditions, low oxygen saturation, and lower limb fracture 2
Bladder and Bowel Management
- Implement protocols to prevent urinary tract infections
- Establish regular bowel routine to prevent constipation 2
Quality Improvement
Stroke Care Protocols
- Implement standardized protocols and order sets for stroke management 1
- Healthcare institutions should organize multidisciplinary quality improvement committees to review and monitor stroke care quality benchmarks, indicators, evidence-based practices, and outcomes 1
- Establish a stroke care data repository to identify gaps in quality care 1
Certification and Monitoring
- Certification of stroke centers by independent external bodies is recommended 1
- Regular auditing of stroke care outcomes should be conducted 1
Rehabilitation and Discharge Planning
Early Rehabilitation
- All patients should be assessed by rehabilitation professionals within 48 hours of admission 2
- Begin rehabilitation as early as possible based on patient stability 2
Discharge Planning
- Begin discharge planning during initial admission assessment 2
- Before discharge, assess patients to determine need for home visits 1
- Involve patients, caregivers, general practitioners, and community care providers in developing care plans 1
- Provide specific training for caregivers before discharge, including personal care techniques, communication strategies, physical handling techniques, and ongoing prevention 1
Special Considerations
In-Hospital Stroke
- Hospital inpatients who develop stroke should be assessed promptly and receive appropriate access to acute stroke care 1
- Implement protocols for rapid recognition and management of in-hospital strokes 1
- Educate all healthcare providers in symptom recognition using tools such as FAST (Face, Arm, Speech, Time) 1
Implementation Challenges
- Access to stroke unit care varies by region, with comprehensive stroke centers typically providing better access than primary stroke centers 1
- Systems improvement to increase the number of patients cared for on stroke units is imperative 1
- For facilities without teleradiology capabilities, FDA-approved teleradiology systems are recommended for timely review of brain imaging in patients with suspected stroke 1