Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient

HomeStrokeVol. 41, No. 10Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUBComprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke PatientA Scientific Statement From the American Heart Association Elaine L. Miller, Laura Murray, Lorie Richards, Richard D. Zorowitz, Tamilyn Bakas, Patricia Clark, Sandra A. Billinger and Elaine L. MillerElaine L. Miller Search for more papers by this author , Laura MurrayLaura Murray Search for more papers by this author , Lorie RichardsLorie Richards Search for more papers by this author , Richard D. ZorowitzRichard D. Zorowitz Search for more papers by this author , Tamilyn BakasTamilyn Bakas Search for more papers by this author , Patricia ClarkPatricia Clark Search for more papers by this author , Sandra A. BillingerSandra A. Billinger Search for more papers by this author and Search for more papers by this author and on behalf of the American Heart Association Council on Cardiovascular Nursing and the Stroke Council Originally published2 Sep 2010https://doi.org/10.1161/STR.0b013e3181e7512bStroke. 2010;41:2402–2448Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 2, 2010: Previous Version 1 In the United States, the incidence rate of new or recurrent stroke is approximately 795 000 per year, and stroke prevalence for individuals over the age of 20 years is estimated at 6.5 million.1 Mortality rates in the first 30 days after stroke have decreased because of advances in emergency medicine and acute stroke care. In addition, there is strong evidence that organized postacute, inpatient stroke care delivered within the first 4 weeks by an interdisciplinary healthcare team results in an absolute reduction in the number of deaths.2,3 Despite these positive achievements, stroke continues to represent the leading cause of long-term disability in Americans: An estimated 50 million stroke survivors worldwide currently cope with significant physical, cognitive, and emotional deficits, and 25% to 74% of these survivors require some assistance or are fully dependent on caregivers for activities of daily living (ADLs).4,5Notwithstanding the substantial progress in acute stroke care over the past 15 years, the focus of stroke medical advances and healthcare resources has been on acute and subacute recovery phases, which has resulted in substantial health disparities in later phases of stroke care. Additionally, healthcare providers (HCPs) are often unaware of not only patients’ potential for improvement during more chronic recovery phases but also common issues that stroke survivors and their caregivers experience. Furthermore, even with evidence that documents neuroplasticity potential regardless of age and time after stroke,6 the mean lifetime cost of ischemic stroke (which accounts for 87% of all strokes) in the United States is an estimated $140 000 (for inpatient, rehabilitation, and follow-up costs), with 70% of first-year stroke costs attributed to acute inpatient hospital care1; therefore, fewer financial resources appear to be dedicated to providing optimal care during the later phases of stroke recovery.Because there remains a need to educate nursing and other members of the interdisciplinary team about the potential for recovery in the later or more chronic phases of stroke care, the present scientific statement summarizes the best available evidence and recommendations for interdisciplinary management of the needs of stroke survivors and their families during inpatient and outpatient rehabilitation and in chronic care and end-of-life settings. The guidelines for making decisions regarding classes and levels of evidence are listed in Table 1 and are the same as those used by previous American Heart Association (AHA) writing groups.7 Before reviewing the evidence pertaining to stroke rehabilitation, we first briefly review the World Health Organization’s (WHO) international classification of functioning, disability, and health (ICF),8 which serves as an organizational scaffold for the present statement; provide an overview of the interdisciplinary team approach to rehabilitation; and define the different care settings in which stroke survivors may receive services during the more chronic phases of their recovery. As a reference, a list of abbreviations used within this statement can be found in Table 2. Download figureDownload PowerPointTable 1. Applying Classification of Recommendations and Level of Evidence7*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.†In 2003, the ACCF/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level.Table 2. Alphabetical Listing of Abbreviations UsedADLactivity of daily livingAHAAmerican Heart AssociationFESfunctional electric stimulationHCPhealthcare providerIADLinstrumental activity of daily livingICFInternational Classification of Functioning, Disability, and HealthIRFinpatient rehabilitation facilityLElower extremityOToccupational therapy/therapistPROMpassive range of motionPTphysical therapy/therapistRCTrandomized controlled trialSLPspeech-language pathology/pathologistUEupper extremityWHOWorld Health OrganizationA. The WHO ICF ModelBecause of the complexity and importance of continuity across the rehabilitation care continuum, the WHO’s ICF8 has been adopted as the organizational framework for the present review. The WHO ICF model acknowledges that recovery after stroke (as well as other health conditions) is a multifaceted process that encompasses the interplay of (1) the pathophysiological processes directly related to the stroke and its associated comorbidities, (2) the impact this condition has on the individual, and (3) contextual variables such as each survivor’s personal and environmental resources. Therefore, the WHO ICF serves as an effective guide for assessing and addressing the functional and societal impact that stroke has at the level of individual stroke survivors and their caregivers, and it has been adopted by many of the healthcare disciplines responsible for providing organized stroke care9 and more broadly by many countries around the world to examine health and disability issues. The Commission on Accreditation of Rehabilitation Facilities also uses the ICF terminology and rubric to assess the quality of rehabilitation care.10 Within the ICF, the impact of stroke is described according to the following dimensions8: Loss of body functions and structures includes impairments of structures and physiological and psychological functions that result as a primary (eg, hemiparesis, cognitive dysfunction) or secondary (eg, contractures, decubiti) consequence of stroke.Activities limitations reflect the difficulties stroke survivors experience in functional task performance, including ADLs and instrumental ADLs (IADLs; eg, difficulties with telephone use due to communication impairments).Participation restrictions refer to problems stroke survivors encounter when reestablishing previous or developing new life and societal involvements (eg, problems returning to work due to mobility and cognitive issues).Contextual factors include the unique personal and environmental variables of each stroke survivor that influence how his or her disability is experienced, as well as access to health care. Personal factors include internal attributes (eg, sex, comorbidities, ethnocultural background), whereas environmental factors are external attributes (eg, family support, social attitudes, architectural barriers, healthcare resources).The Figure illustrates the interactions among these ICF dimensions. Importantly, there is no 1-to-1 relationship among the dimensions; for example, one cannot assume that mild body structure and function deficits will result in mild activity limitations or participation restrictions or that a survivor with numerous facilitative personal and environmental supports will demonstrate few activity limitations. Accordingly, the model underscores consideration of all ICF dimensions when one provides assessment or treatment services to stroke and other patient populations, because failure to consider all dimensions may result in overestimation or underestimation of the effects of stroke on a given survivor and his or her significant others and consequently may lead to the provision of inappropriate treatment services. Indeed, recent trends in stroke rehabilitation research have concentrated on incorporating outcome measures that reflect all ICF dimensions.11Download figureDownload PowerPointFigure. Diagrammatic representation of the WHO’s ICF,8 reflecting interactions between the consequences of disease and contextual factors.The present statement reviews chronic stroke care diagnostic and therapeutic techniques with respect to structure and function, activity, and participation ICF dimensions. Although the WHO ICF model defines activity and participation dimensions separately, the model applies these dimensions as a singular construct when clinically qualifying and quantifying the consequences of a health condition.8 Hence, in the present statement, activity and participation dimensions are also considered as 1 construct when stroke management evidence is reviewed. Finally, given the number and complexity of factors that may affect stroke survivor outcomes, specific personal and environmental factors are reviewed to exemplify why consideration of contextual factors is essential to stroke management. Personal factors include such issues as secondary stroke prevention, medication compliance, depression, and coping, as well as learning capabilities of the stroke patients. The major environmental factor addressed in the present statement is family caregiver education and support.B. The Interdisciplinary Approach to Stroke Management Across Care SettingsThe holistic, comprehensive, interactive approach of an interdisciplinary team is the hallmark of stroke rehabilitation.12 Stroke patients and caregivers are central participants in the rehabilitation process to foster therapy adherence and facilitate optimal community integration and continued quality of life despite residual impairments. With collaborative input from all rehabilitation team members, including stroke survivors and their family, comprehensive and individualized assessment and treatment plans are formulated. Table 3 describes the major disciplines involved in stroke care in the United States and identifies the World Wide Web site of each discipline’s primary umbrella organization. Table 3. HCPs Commonly Part of the Stroke Rehabilitation TeamDisciplineWorld Wide Web SiteDescriptionRN indicates rehabilitation nurse.Certified rehabilitation counselorswww.crccertification.comAssist individuals with disabilities to maximize their vocational and avocational living goals in the most integrated setting possible through the application of the counseling process, including vocational and counseling, case management, referral, and service coordination; identifying and addressing employment and attitudinal barriers; and job analysis, development, and placement services.Neuropsychologistswww.apa.orgSpecialize in brain-behavior relationships and have extensive training in anatomy, physiology, and neuropathology. They identify and treat cognitive and neurobehavioral dysfunction, and through assessment also monitor recovery and thereby enhance community reintegration.Occupational therapistswww.aota.orgFocus on the “skills of living” necessary for independent and satisfying living. OT services include customized treatment programs to perform daily activities, comprehensive home and job site evaluations and adaptation recommendations, performance skills assessment and interventions, adaptive equipment recommendations and training, and family and caregiver education.Rehabilitation nurses (RNs)www.rehabnurse.orgManage complex medical issues, provide ongoing patient and caregiver education, and establish care plans to maintain optimal wellness. RNs use a holistic approach to fulfill patients’ medical, environmental, spiritual, vocational, and educational needs via principles from other disciplines and their own unique medical expertise (bowel, bladder, and skin management). In all care settings, RNs function as coordinators/case managers, collaborators, and counselors. A registered nurse with at least 2 years of practice in rehabilitation who passes the Association of Rehabilitation Nurses examination can earn the Certified Rehabilitation Nurse distinction.Physical therapistswww.apta.orgExperts in examining and treating neuromuscular problems that affect the abilities of individuals to move. PTs practice in many settings and with all age groups.Physicianswww.aapmr.orgUsually coordinate the rehabilitation team and manage medical conditions pertaining to stroke and comorbidities. A physician may be a physiatrist (ie, specializing in physical medicine and rehabilitation and thus restoration of function in individuals with problems that range from simple physical mobility to more complex cognitive issues).Recreational therapistswww.atra-online.comProvide treatment services and recreation activities to individuals with disabilities to facilitate independent physical, cognitive, emotional, and social functioning by enhancing individuals’ current skills and assisting new skill development for daily living and community function. Besides discharge planning for community reintegration, they help individuals develop or redevelop social, discretionary time, decision-making, coping, self-advocacy, and basic skills to enhance overall quality of life.Social workerswww.naswdc.orgAssist individuals, groups, or communities restore or enhance their capacity for social functioning, while creating societal conditions favorable to their goals. Requires knowledge of human development and behavior; social, economic, and cultural institutions; and interactions among these factors. Social workers help prevent crises; counsel individuals, families, and communities to facilitate coping with everyday stresses; and identify resources to allow individuals with disabilities to remain in the community.SLPswww.asha.orgAssess speech, language and other cognitive functions, as well as swallowing, and provide interventions and counseling/education to address language and speech disorders (eg, aphasia, apraxia of speech, dysarthria, and cognitive-communication impairment). SLPs also intervene when swallowing and cognitive disorders exist. They provide services to all age groups and in all care settings.Because stroke is a complex disease process that requires the skills of an interdisciplinary team, nurses frequently play a central role in care coordination throughout the recovery continuum. For example, a prospective observational study of 54 US rehabilitation facilities with a geographically stratified random sample found that a 1% increase in the number of certified rehabilitation nurses on units was associated with an approximately 6% decrease in patient length of stay.13 This finding suggests the value-added benefit of nurses with this specialty expertise. Furthermore, because across care settings, nurses commonly have the most direct contact with stroke patients and their caregivers, they are often called on to implement management techniques developed by other rehabilitation team members. Consequently, nurses should be familiar with the variety of services and procedures provided by the other disciplines that are central to stroke rehabilitation teams.There is strong evidence that organized, interdisciplinary stroke care will not only reduce mortality rates and the likelihood of institutional care and long-term disability but also may enhance recovery and increase ADL independence.5,14–19 Most stroke research, however, has focused on acute and postacute care, with less attention given to the more chronic recovery phases. As survivors progress beyond acute intensive care, they are confronted with the impact of stroke on their daily life. Whereas initial acute management focuses on pathophysiological processes at the body structure and function level, subacute and chronic phases tend to shift the focus to improving performance of functional tasks at the activity level and to facilitating community integration, including addressing vocational and avocational needs, at the participation level. Throughout the poststroke recovery continuum, personal and environmental factors modulate and influence outcomes and each individual’s structure and function, activity, and participation status.6 To manage these multifaceted and evolving aspects of stroke recovery, interdisciplinary care is required,5 with the attributes of this care not only changing over time for a given stroke survivor but also varying by national healthcare delivery systems and care standards. Table 4 summarizes the representative patterns in poststroke healthcare delivery in the United States by setting and time elapsed since the stroke.20–23 In addition, the predominant interdisciplinary team features are listed for each setting and poststroke phase. Next, we briefly review the inpatient, outpatient, chronic care, and end-of-life settings in which stroke survivors might receive rehabilitation and other healthcare services. Table 4. Admission and Discharge Estimates and Interdisciplinary Team Features Across the Poststroke Care Continuum*PhaseAdmissionLength of Stay (Mean±SD)Interdisciplinary Team FeaturesSD indicates standard deviation; MD, physician; SW, social work; and SNF, skilled nursing facility.*Table reflects representative trends for stroke healthcare delivery in the United States.20–23 Actual care delivery varies by region and healthcare third-party provider.Hospital-based care Acute intensive careOnset to hoursSubarachnoid hemorrhage: 9.2 ±12.3 h Intracerebral hemorrhage: 5.1 ±9.2 h Ischemic stroke: 1.8 ±12.3 hMD care required High nurse staffing Life support OT/PT/SLP possible if medically stable Acute care2–3 dSubarachnoid hemorrhage: 11.3 ±11.6 d Intracerebral hemorrhage: 8. 0 ±9.2 d Ischemic stroke: 6.3 ±6.8 dMD care required High nurse staffing Close physiological monitoring Limited OT, PT, SLP SW for discharge planning Inpatient rehabilitation care5–7 dMean of 8–30 d; median of 15 dMD care required Decrease nurse staffing Minimum therapy need of 3 h OT/PT/SLP SW for discharge planning Psychiatry as neededSkilled nursing facility care Inpatient SNF rehabilitation5–7 d after strokeDependent on individual stroke severity (with maximum of 100 d)MD monthly visit required Decreased nursing staffing OT/PT/SLP as needed Long-term careDependent on stroke severity, individual resources, multiple comorbiditiesVariable depending on care needs (eg, long-term care vs palliative/end-of-life)Decreased nursing staffing Predominately skilled nursing assistant care Therapy on consultation basisCommunity-based rehabilitation, including home health care Early supported discharge services20–30 d1–44 moClinic visits by MD or nurse OT/PT/SLP appropriate for mobility, ADL, and communication goals Psychiatry as needed Chronic outpatient rehabilitation>4–6 mo Variable onset based on individual resources and functional needsVariable termination based on individual resources and functional needsCare coordination/referral transitioned to primary care provider (MD, nurse practitioner) Interdisciplinary therapy or psychiatry care as needed1. Definition of Inpatient Care Settings in the United StatesAn inpatient rehabilitation facility (IRF) offers hospital-level care to patients needing intensive, interdisciplinary rehabilitation programs to upgrade their ability to function.24 In an IRF, stroke survivors must have medical comorbidities that require 24-hour availability and close supervision of a physician and a registered nurse with specialized training or experience in rehabilitation. Additionally, these patients must require and receive at least 3 hours a day of occupational therapy (OT) or physical therapy (PT) for no fewer than 5 days per week. Exceptions can be made if (1) other skilled rehabilitation modalities (eg, speech-language pathology [SLP] or prosthetic-orthotic services) can be combined with OT and PT to meet the 3-hour per day requirement, or (2) an IRF is the only reasonable means by which a low-intensity rehabilitation program may be executed. IRF admissions are justified only when the rehabilitation team determines that significant functional improvement can be expected within a reasonable time period and the patient can return to a community setting after IRF discharge rather than being transferred to another inpatient or residential facility (eg, skilled nursing or long-term acute care facility).The interdisciplinary team in the IRF patient’s care must document evidence of frequent, direct, and medically necessary physician involvement in the patient’s care at least every 2 to 3 days during the patient’s stay, as well as evidence of a coordinated program through team conferences held at least every 2 weeks. Documentation must also assess the patient’s progress or problems impeding progress, consider possible solutions to such problems, and reassess whether the initial rehabilitation goals are still attainable or require modification based on progress or performance. Decisions concerning discharge planning and adjustments in goals or the prescribed treatment program must be reported.Another inpatient rehabilitation setting is the skilled nursing facility, an institution or a distinct part of an institution in which the primary focus is the provision of either rehabilitation services or skilled nursing care and related services to residents requiring medical or nursing care.25 When located within a nursing home or hospital, the skilled nursing facility must be physically distinguishable from the larger institution (eg, a wing, separate building, or 1 side of a corridor). In a skilled nursing facility, stroke survivors must require daily skilled nursing or rehabilitation services that can be provided only on an inpatient basis (Table 4) and require the skills of qualified HCPs (eg, nurses, SLPs). Even if a stroke survivor is not expected to reach full or partial recovery, skilled services within a skilled nursing facility can be requested to maintain or prevent deterioration of the patient’s current medical status.Inpatient rehabilitation may be provided in a long-term-care hospital, a facility with a mean Medicare inpatient length of stay of at least 25 days that provides extended medical and rehabilitation care to clinically complex patients with multiple acute or chronic comorbidities.26 In addition to comprehensive rehabilitation, stroke survivors in these facilities may receive a range of post–acute care services (eg, ventilator-dependent care, pain management, other chronic disease care).2. Definition of Outpatient Settings in the United StatesRehabilitation services outside of an institution may take place in 2 environments. A home health agency is a public agency or private organization (or a subdivision of such an agency or organization) that focuses on providing skilled nursing and other therapeutic (eg, OT, SLP), medical, social, and home health aide services.27 Under current US law, home health services are reimbursed under a prospective payment system that provides a 60-day episode rate and includes all covered services. Services may be recertified for an additional 60 days if they continue to be justified. To be eligible for home health services, a physician must certify that the stroke survivor is confined to his or her home, with exceptions for medical (eg, outpatient hemodialysis, attending an adult day center to receive medical care) or nonmedical (eg, occasional trip to the barber, attending an infrequent family or unique event) purposes. Home health services may be performed in assisted living facilities, group homes, or personal care homes but are not reimbursed if the services are duplicative of another facility’s or agency’s services.Outpatient therapies may also take place at hospital-based or free-standing facilities.28 A physician must certify outpatient OT, PT, and SLP services. The physician must state that he or she has established a plan for therapy services, reviewed the plan periodically, and recertified the treatment at least every 30 days. Services must be reasonable and necessary, restorative in nature, and complex and sophisticated enough that they can only be performed safely and effectively by or under the supervision of a qualified HCP. In general, therapist input is required to establish maintenance program services if the services are to maintain function only.Comprehensive outpatient rehabilitation facilities also offer rehabilitation services.28 At a minimum, these facilities provide physician, PT, and social or psychological services. They may additionally offer OT, SLP, respiratory therapy, nursing care, prosthetic and orthotic services and devices, drugs and biological agents that cannot be self-administered, issuing of durable medical equipment, and a single home visit to evaluate the potential impact of the home environment on rehabilitation goals.3. Definition of Chronic Care Settings in the United StatesChronic care settings focus on supporting and providing external resources that may be necessary to manage the stroke survivor’s level of health successfully. These services may be preventative, diagnostic, and/or therapeutic, including counseling and educational services, and must be prescribed by a physician or other qualified HCP.29 On admission, initial evaluations are performed to determine the needs of the individual, as well as discharge plans, which may include posthospital extended care and hospice services that are reasonable and necessary.4. Definition of End-of-Life Settings in the United StatesFor some patients, strokes may be a terminal life event. When it becomes apparent that a patient may die within a short time, it is essential that an appropriate plan for end-of-life be established. Because of the unique principles that guide end-of-life care, issues and procedures that pertain to end-of-life stroke care, including ramifications for interdisciplinary rehabilitation practice, are described separately in the last section of the present statement. Importantly, however, many of the stroke management procedures appropriate for inpatient, outpatient, and chronic care settings that are reviewed in the next section of this statement are also used to address the needs of terminal patients. Therefore, inclusion of an end-of-life section is consistent with the overall purpose of the present statement, with a focus on educating nurses and other interdisciplinary team members who contribute to the more chronic phases of the stroke care continuum.In summary, stroke care and rehabilitation may take place in a number of inpatient, outpatient, and chronic care settings, including settings that provide end-of-life care.30 Next, evidence is reviewed regarding organized, interdisciplinary stroke care across these settings and with respect to first, the body structure and function dimension of the ICF model, and second, the activity and participation ICF dimensions. The roles of nursing and other interdisciplinary team members are also highlighted in the review of this evidence.II. ICF Dimensions Across the Inpatient-to–Chronic Care ContinuumA. Approach to Body Structure and Function Issues1. Deficits Associated With Poststroke Motor Control (ie, Upper- and Lower-Extremity Motor Issues, Dysphagia, and Bowel and Bladder Issues)a. Upper- and Lower-Extremity Motor IssuesDespite improved survival rates and rehabilitative efforts, most stroke survivors will continue to experience motor deficits that can reduce satisfactory engagement in activities and participation.31 These deficits can include decreased postural control, balance deficits, hemiparesis, and neuromuscular incoordination of the upper extremities (UEs) and lower extremities (LEs). In turn, such poststroke motor issues compromise engagement in activities and participation because of reaching deficits, loss of deftness (which disrupts object manipulation), asymmetrical gait patterns, decreased walking speed, and increased energy expenditure (which challenge ambulation).32–34The stroke population is at a higher risk for falls than the general population, with fall rates as high as 50% in community-dwelling stroke survivors.35 Although d