Does a patient who has had a stroke require admission to a Progressive Care Unit (PCU)?

Stroke Patient Care Setting Requirements

Stroke patients should be admitted to a specialized, geographically defined stroke unit with an interdisciplinary team, rather than a Progressive Care Unit (PCU), unless they require specific intensive monitoring or have severe neurological deterioration. 1

Optimal Care Setting for Stroke Patients

• Patients with acute stroke should be treated on an inpatient stroke unit as soon as possible, ideally within 24 hours of hospital arrival 1
• Stroke unit care is associated with significant reductions in death (OR=0.76), death or institutionalization (OR=0.76), and death or dependency (OR=0.80) compared to care in non-specialized units 1
• These benefits persist regardless of the patient's sex, age, or stroke severity 1

When Higher Levels of Care Are Needed

While most stroke patients benefit from stroke unit care, certain clinical situations warrant admission to higher levels of care:

• Patients selected for decompressive hemicraniectomy should be transferred to an intensive care unit or neuro step-down unit for close monitoring prior to surgery 1
• Patients who have received thrombolytic therapy may require more intensive monitoring, though recent evidence suggests they can be safely managed in a stroke unit when nurses have specialized training 1, 2
• Patients with brainstem infarcts, large space-occupying hemispheric infarcts, or fluctuating neurological examinations may require ICU admission 3
• Approximately 20% of all patients with ischemic stroke will require care in an ICU, particularly those who have received intravenous alteplase or endovascular therapy 2

Monitoring Requirements in Stroke Care

Regardless of setting, stroke patients require specific monitoring protocols:

• Neurological assessments should include level of consciousness, worsening symptom severity, and blood pressure at least hourly, or more frequently as the patient's condition requires 1
• Changes in status requiring immediate notification of the stroke team include: level of drowsiness/consciousness, change in Canadian Neurological Scale score by ≥1 point, or change in NIHSS score by ≥4 points 1
• Continuous oxygen saturation monitoring is needed to identify hypoxia and early development of complications 1
• Cardiac monitoring for at least the first 24 hours helps determine possible stroke mechanisms and monitor for arrhythmias 1

Components of Effective Stroke Unit Care

• The core interdisciplinary team should include physicians, nurses, occupational therapists, physiotherapists, speech-language pathologists, social workers, and clinical nutritionists with stroke expertise 1
• Hospital pharmacists should be included to promote patient safety, medication reconciliation, and education 1
• Stroke units should have staffing ratios of ≥3.0 registered nurses per 10 beds, as lower ratios have been associated with higher mortality 1
• The interdisciplinary team should assess patients within 48 hours of admission and formulate a management plan 1

Implementation Considerations

• For facilities without a dedicated stroke unit, priority should be given to clustering patients, forming an interdisciplinary team, providing access to early rehabilitation, implementing stroke care protocols, conducting case rounds, and offering patient education 1
• Standardized stroke orders or integrated stroke pathways improve adherence to best practices 1
• Rapid transfer to a stroke unit from the emergency department is optimal and may be facilitated by prenotification of the stroke team 1

Common Pitfalls to Avoid

• Delaying transfer to a stroke unit, as earlier admission (within 2 days) has been associated with fewer complications 1
• Admitting patients to an intensive care unit solely for monitoring after r-tPA, which may be unwarranted and unnecessarily expensive when appropriate stroke unit care is available 1
• Inadequate staffing ratios on stroke units, as weekend ratios of 1.5 registered nurses per 10 beds have been associated with significantly higher 30-day mortality (15.2%) compared to units with 3.0 nurses per 10 beds (11.2%) 1
• Failing to recognize that approximately 25% of patients may have neurological worsening during the first 24-48 hours after stroke, necessitating close monitoring regardless of care setting 1