Stroke Rehab and Recovery Guidelines Webinar

Author: American Heart Association:1

Operator: It is now my pleasure to turn today’s program over to Stephanie Mohl, vice president of the American Stroke Association. The floor is yours. Stephanie Mohl: Thank you, Ginneen.

On behalf of the American Stroke Association, a division of the American Heart Association, it is my pleasure to welcome you to today's webinar, Guidelines for Adult Stroke Rehabilitation and Recovery, Moving From Paper to Practice. As Ginneen said, my name is Stephanie Mohl and I’m the vice president of the American Stroke Association. We appreciate you taking time out of your busy schedules to help acknowledge the serious problem of stroke and the importance of rehabilitative care in aiding a stroke patient's recovery. Stroke is not only the number 5 killer of Americans, but it is also the leading cause of serious long-term disability. Although we have made significant progress over the last two decades in the acute treatment of strokes with corresponding reductions in disability, the majority of stroke survivors still need at least some rehabilitative care on either an inpatient or an outpatient basis. Like many of you, stroke has taken a toll on my own family.

Two of my grandparents and an uncle have had strokes, and my Pop-pop died of his stroke. I have seen firsthand the difference that high quality rehab can make in helping stroke survivors achieve their full potential. And regrettably, I have also seen the consequences when stroke patients don't receive the quality and amount of rehab they need and deserve. So I am proud that the American Heart Association American Stroke Association is helping to promote the delivery of high quality stroke rehabilitative care by issuing its first ever evidence-based guidelines for adult stroke rehabilitation and recovery last year.

In just a moment, I’m going to introduce two of the authors of these guidelines, but before doing that, I want to acknowledge the support of Kindred Hospital Rehabilitation Services in making today's webinar possible. Kindred is a national sponsor of the American Stroke Association’s Together to End Stroke initiative, which strives to educate stroke patients and caregivers, health professionals, and the public that stroke is preventable, treatable, and beatable. It is now my pleasure to introduce Dr. Sally Brooks, the Chief Medical Officer for Kindred Rehabilitation Services. Dr. Brooks joined Kindred Healthcare in 2009. Prior to her career as a physician-executive, she practiced in ambulatory and inpatient settings focusing on older adult care. Dr.

Stroke Rehab and Recovery Guidelines Webinar

Brooks, thank you for Kindred’s support and for joining us today. I'll turn the microphone over to you for brief remarks. Dr. Sally Brooks: Thank you very much and I thank all of you who are participating in this webinar today, very important subject. And we just wanted to point out the reason we're involved in this program is to ensure that patients with stroke are treated in the right setting, at the right time. We are seeing payers push back on access for appropriate patients to rehabilitation and certainly these guidelines reinforce that all patients with stroke deserve a referral and evaluation for acute inpatient rehabilitation.

The medical complexity of a patient with a stroke requires the daily physician oversight, rehabilitation nursing, and multidisciplinary team to provide the higher frequency and intensity needed to recover from a stroke. So we thank you very much for participating and now stay tuned for our speakers today. Stephanie Mohl: Thank you, Dr. Brooks. It is now my honor to briefly introduce today's distinguished speakers. Dr. Joel Stein is a physician who specializes in physical medicine and rehabilitation.

He currently serves as a sign-in Baruch professor and chair of the Department of Rehabilitation and Regenerative Medicine at the Columbia University College of Physicians and Surgeons, Professor and Chief of the Division of Rehabilitation Medicine at Weill Cornell Medical College, and Physiatrist-in-Chief at New York Presbyterian Hospital. He was the Vice Chair of the writing group for the guidelines. Our next speaker, Sue Pugh, has been a nurse for more than three decades. She is certified in rehabilitation and neuroscience nursing and is presently a Patient Care Manager at John Hopkins Bayview Medical Center, for their neuroscience unit, intermediate care unit, and intensive care unit. She was also a member of the writing group that authored the Stroke Rehabilitation and Recovery Guidelines. Dr. Stein and Ms. Pugh will now provide an overview of some of the most significant recommendations in the guidelines, with particular emphasis on the rehabilitation program recommendations.

Welcome, Dr. Stein. Dr.

Joel Stein: Thank you very much for that kind introduction and I’d like to thank the Heart Association for organizing this event, and Kindred, for sponsoring it. What I will be covering today will include a brief introduction to the guidelines, and then pursuing that I’ll go into the different categories of recommendations that are included in the guidelines, and then focusing in, in depth on the rehabilitation program in particular, and then of course, we'll hear from Sue Pugh about some of the practicalities of implementing these guidelines and finally, we'll have ample time for questions and answers. So I think most of the participants are probably familiar with the demographics of stroke in the U.S. But I think it's worth restating.

This is a huge problem. There are roughly 800,000 new strokes that occur in the U.S. Each year. While the age adjusted incidents of stroke and the mortality rate has gone down, the total number of strokes has remained relatively constant because the population at risk, that is to say the older population in the U.S., has continued to grow, resulting in roughly the same number of strokes over the last number of years.

As was noted earlier, the majority of stroke survivors do require some degree of rehabilitation after hospitalization. It’s estimated about two-thirds require some form of rehabilitation. This is the classification of the recommendations and level of evidence that was used for the guidelines, and really has two components to it. One is, the strength of the evidence which can be level A, B or C. Level A evidence being the strongest evidence, for example, from randomized controlled trials, level C the weakest level of evidence for example from consensus or expert opinion and level B being intermediate, perhaps from case series or less robust research design. The recommendations fall in four categories. Class l recommendations are the strongest recommendations. These are treatments or care that is highly recommended, and should be routine part of stroke care.

Class IIA are the suggested or worth considering. Class IIB are the reasonable, and Class III are the inadvisable or harmful. And those are important to reflect as we go through the guidelines that we’ll focus on today because some of these have greater or lesser degrees of evidence, and are stronger or less strongly recommended. In terms of the guidelines themselves, this is a substantial effort that was put into creating this, and it's quite a lengthy document, which is part of why I think you're fortunate to have hopefully a digest of it today.

These were published in May of 2016. They are 72 pages long in published manuscript form and they contain 227 specific recommendations. Thankfully I will not be reading through each of those recommendations today but I encourage you all to do so at some point. They are all important but obviously we don't have time to go through them in detail. There were 18 authors on this document. And it's almost a thousand references. And when last I checked last month, this document had been downloaded about 78,000 times.

So this really has very quickly become disseminated and used by many people in not just in the U.S. But abroad, as an important source document for recommendations as well as the evidence supporting those. In terms of the categories of recommendations, I’m just going to run through these briefly. Each of these contain multiple detailed recommendations that we don't have enough time today to go into.

But I do encourage you to look through guidelines to delve in more deeply. The first section is the Rehabilitation Program, and that is the section actually we will be focusing on the most today. So I will skip that for the moment as we'll return to it shortly. Another important parse of the guidelines related to the Prevention and Medical Management of Comorbidities. There are many aspects of stroke that stroke survivors contend with beyond the direct effects of the stroke.

Those include issues such as deep venous thrombosis, skin breakdown, pain, depression just to mention a few of them. Those are very much a part of the rehabilitation program and care that stroke survivors need and therefore there are a substantial number of guidelines that specifically address these. Another very important area that is addressed in the guidelines is the assessment of stroke. Stroke survivors have difficulties often in multiple domains.

They may have difficulty with their motor abilities, their ability to move, they may have difficulty with their ability to feel things, their sensation, they may have difficulty performing activities of daily living, and difficulties with communication and cognitive issues to name a few and that's not a comprehensive list. So it's very important that the first step of any effective treatment and rehabilitation program is that these individuals be fully assessed and for that reason, assessment is an important part of the guidelines, with a number of very specific recommendations about when various aspects of a stroke survivor should be assessed and what types of assessments are appropriate. Then there are the sensorimotor impairments and activities. And these are the sorts of limitations that we often think of as being kind of the essence of stroke rehabilitation. For example, individuals who have weakness after stroke, difficulty walking, inability to use their upper limbs, difficulty with aphasia, or dysarthria, or swallowing difficulties. These are the very specific deficits and there are quite a substantial amount of literature that address what the appropriate exercise therapies are for example, what sorts of treatment would be appropriate for people who have difficulty communicating or with swallowing, and these are a very important part of the guidelines with numerous detailed recommendations.

Lastly, is the issue of transitions and community rehabilitation. This is an often neglected part of stroke rehabilitation and return to the community. What we find often is that as medical caregivers, we're very focused on the immediate medical issues and the return to home, making sure people are able to manage safely in their home environment.

But what happens after that often does not receive sufficient attention. Issues such as recreation and leisure activities are often given insufficient attention. Return to driving. Return to sexual activity. And the issues of family and caregiver impact to stroke are all addressed in this section of the guideline. This is a section with relatively limited evidence and I think that reflects that there hasn't been sufficient research in that, but important guidelines often based on consensus and best practice and I encourage everyone to review these guidelines as well. Now I’m going to focus more in detail on the issue of the rehabilitation program itself and this is really about the organization of care, how do we provide rehabilitation for people, in what setting, with what resources. The first stage of rehabilitation begins in the acute care hospital.

Patients may be in the ICU initially and then perhaps in a hospital floor bed. And the question of what rehabilitation people should receive and at what stage is very important, but as yet, still somewhat unclear in some ways and controversial. There is a general statement that patients should receive rehabilitation at the intensity commensurate with their anticipated benefit and tolerance.

That's a fairly general statement. It's means that when someone's able to and capable of receiving and benefiting from rehabilitation we should give them those services but it doesn't provide a lot of detail about what those are because, frankly, there is not yet enough scientific literature on that. The other issue which is much more specific and an important Class 3 recommendation comes out of a large, randomized trial called the AVERT trial, which is contained in the references for the guidelines. I encourage you to look at the original paper. This was a study looking at the very early mobilization of stroke survivors within the first 24 hours after stroke. And to many people’s, including my own, surprise, it turned out that aggressive mobilization within the very early, the first 24 hours, was actually associated with an unfavorable outcome relative to patients who received more typical care. This does not mean that all patients need to be at bed rest for 24 hours, but it does mean that aggressive efforts to ambulate patients in that first 24 hours, for example, are not recommended.

So this is a somewhat counterintuitive finding because of the evidence in other disorders, for example, in patients with medical or surgical issues in the ICU where early mobilization has been found to be useful. In stroke it appears that at least the first 24 hours is a period of relative rest and that's an important recommendation from the guidelines. In terms of the organization of the stroke rehabilitation program and care, this is the slide that just details most of the typical members. I will say that no list of team members is always entirely complete and I apologize in advance to anyone omitted. I note that therapeutic recreation for example is omitted and I apologize for that. It is a team that is constituted based on the individual needs of the patient and certainly we expect that in individual cases, there will be additional members.

But generally speaking, physician leadership, with someone who is dedicated to stroke rehabilitation is important, typically a physiatrist or rehab physician, or a neurologist with a focus in this area, but occasionally geriatricians or internists with a focus on this, rehabilitation nursing, and we’ll be hearing from Sue Pugh shortly, PT, OT, and speech therapies, of course, social work, psychology, and the like. In terms of the types of rehabilitation care that are available. So some patients, of course, can go home directly after stroke with home care or sometimes directly going to outpatient rehabilitation services. When that is feasibility, that is preferred. I think we can all agree from our experience in healthcare that if you can be home safely, you should be home and the guidelines are consistent with that. But for those substantial number of individuals who are not able to return directly home, there are three or four levels of care that are most relevant.

The first of these is inpatient rehabilitation facilities or sometimes inpatient rehab hospitals, these are sometimes free standing facilities, sometimes they are hospital-based specialty units. These provide relatively intensive medical oversight with 24 hour nursing care, a daily physician visit, and at least three hours of therapy per today. I'll come back to what that three hours consists of in a few minutes. Skilled nursing facilities have -- provide a lower level of medical supervision and nursing support, typically a lot of variation, the regulations specifies the minimum but of course many facilities provide more than the minimum. There is not typically daily supervision by a physician, unless the patient is medically unstable and by and large patients tend to receive between a half hour and an hour and a half of therapy per day with obviously exceptions, including some facilities that will provide considerably more. Medicare typically covers up to 100 days for a qualifying patient in a skilled nursing facility and there's a lot of variation from facility to facility in terms of the resources and the organization of care. Nursing homes are long term care facilities, typically patients with stroke would require some period of time in skilled nursing facilities first, often these are co-located in different floors within the same facility and therefore patients would segue way from one to the other if they needed long term care. And long term acute care hospitals are a special type of hospital for patients with chronic, ongoing, substantial medical needs, often dealing with ventilator weaning or other complex medical issues.

They do care for some stroke patients and typically they are defined in part by an average length of stay of greater than 25 days. Some of the specific elements that we would like to highlight here, one is that some sort of formal assessment of patient’s rehabilitation need is advisable and important. It is critical that patients really receive a careful evaluation by trained personnel to make sure that they receive the appropriate rehabilitation services, since these different levels of care provide different levels of service and meet different patients' needs. Multiple transitions of care are typical for these patients and it is essential that we are attentive to that and make sure that there is a good continuity of care and communication among the different levels and that's really important. And then there have been significant changes within the Medicare program in particular, in the use of various types of post-acute care. In general the utilization for the Medicare population as a whole has been rising although there is not a lot of detailed information about how that's affected the stroke population in particular. At this point in terms of the first setting where patients go for their rehabilitation services, posthospitalization, nationally about 32% of patients go to skilled nursing facilities initially, about 22% go to inpatient rehabilitation facilities, and about 15% go directly to Home Health, relatively small numbers get outpatient rehabilitation services. And LPAC also is a relatively small number that is omitted from this.

These are some specific recommendations about the organization of post-stroke rehabilitation care. And the first of these is that stroke patients who require post-acute rehabilitation should receive organized, coordinated, inter-professional care. You can see that has a strong recommendation, Class l, Level of Evidence A. It sounds a little bit like motherhood and apple pie but the fact is that this level of organization and coordination is not present in all places.

It is important that the caregivers coordinate care among each other. So simply having a nurse caring for the patient, a physical therapist, an OT and a physician without coordination among them and communication is insufficient to really provide the type of care that is recommended by the guidelines. The next recommendation here is that patients, stroke survivors, who qualify for and have access to IRF care should receive treatment in an IRF in preference to a SNF. So this is saying and I think this is perhaps the most -- among the more controversial or novel anyway aspects of the guideline, is that if you meet the criteria for IRF care, and you’ve had a stroke, that really, if you can, you should have that. Now there are situations where there simply are no IRFs in the region. There are parts of this country where there are insufficient numbers of IRFs or they are very far away and a family may not be able to manage that. It may be too far to send them to a distant city.

There may be situations where they lack coverage for this in their insurance, for whatever reason. And, of course, there are patients who don't meet the criteria. And those I’ll talk about a little bit more in a minute. But not everybody is able to participate adequately in an IRF care or requires IRF care.

And for that reason, this specifies that it’s patients who qualify for and have access to it. The organization of care in the outpatient setting and home based setting is also referenced. There's not a lot of evidence on this but there is a belief that this is an important component of receiving appropriate post-stroke care. And then early supported discharge which is really more relevant in some areas than others, is appropriate for patients who have relatively mildly disability. This is essentially intensive home care services often involving physician visits for example to the home environment. Unfortunately, this is not widely available in most parts of the U.S.

Let’s just focus a little bit more on the issue of IRF vs. SNF care. So we talked about three hours of therapy for IRF care but I think it's really important for those who don't work in IRFs and have less familiarity with that to understand what that means.

What this does not mean is three hours of aerobic exercise, sweating on the elliptical in the gym. And, unfortunately, I think patients are sometimes scared off from IRF care by well-meaning caregivers who feel that they are too frail or too elderly or not able to participate fully and will say, “Well, you have to participate in three hours.” And patients imagine literally three hours in the gym. In reality that three hours include things such as speech therapy, which may be dedicated to working on swallowing, maybe dealing with aphasia, if patients have those issues; it involves performing your tasks of daily living, under the supervision and training of an occupational therapist. That could include hygiene tasks, dressing tasks, daily tasks that are relatively low energy expenditure but very important for independence in the home environment. And in terms of the physical therapy it often means getting out of bed, practicing transfers, learning how to manage your wheelchair and it is not all intensive exercise in the gym. Nonetheless, there are patients who cannot tolerate that or are not medically ready for that. SNF care, skilled nursing facility is appropriate for patients who have limited rehabilitation potential, for example, due to substantial premorbid disability, premorbid dementia, patients who are very frail or medically fragile, for other reasons perhaps unrelated to their stroke, and are unable to tolerate the intensity of rehabilitation that’s given in the IRF. Patients who have very mild deficits, maybe they are just very slightly unsteady but for whatever reason they're not able to go directly home, maybe they have medical needs that require supervision, maybe they lack supports in the community and those patients may be appropriate for a skilled facility as well.

And then as I mentioned, patients who lack geographic access to an IRF. Lastly, there are patients who have completed care in an IRF but are unable to return directly home because of continued disability and because of perhaps family supports that are limited. So for those reasons, is not unusual, although it is certainly not the norm, for patients to complete a course of care in an IRF and then transition to a skilled nursing facility prior to return home. So I will stop there. And I will be happy to turn this over to Sue Pugh who will talk about reading between the lines and how we really can take these guidelines and turn them into practical change in patient care. Sue. Sue Pugh: Thank you, Dr.

Stein. And I too want to thank the American Heart and Stroke Association for their support of this. Rehab is such an important component to the recovery of stroke patients. And I really appreciate that they saw the value of this, and agreed to the creating of this guideline, and then for this webinar and all the many, many resources they have related to this. So, my part of the presentation is called “Reading Between the Lines” because part of what's frustrating about some of the recommendations that Dr. Stein mentioned is that they don't always have a lot of recommendations about things that we all know that we do, we think is the right thing to do, we consider it best practice, but there isn't a lot of research that actually supports that. So I saw this quote and thought it was really apropos for this part is the most important thing in communication is hearing what isn't being said.

The art of reading between the lines is a lifelong quest of the wise. Sometimes that’s what we have in healthcare is we have to read between the lines. So there are lots of recommendations in the guidelines.

And being a nurse, I’m bringing forward some of the ones that are certainly important from a nursing perspective as well as hitting on lots of different topics. But I thought we’d get bowel and bladder management out of the way first. This is a huge driver of some patients actually going into different type settings because of their inability to manage this. So when we looked at bladder management and bowel management, there wasn't an enormous amount of literature out there. From bladder perspective, you know, assess pre-stroke, urological issues and remove the Foley catheter within three hours. Again, Class I left level of evidence B, that’s probably one of the strongest recommendations that we have and really the piece that kind of took it to the next cart was, so we know we need to do an assessment and we know we need to take out the catheter, but then what do we do to help them become continent? And this is where you kind of have to read between the lines because there really wasn't any research or literature out there regarding stroke specifically.

What was out there was studies about how to deal with incontinence in, you know, adults. So, cognition for spin stroke does play a part in prompted voiding and public floor muscle training can be reasonable to try. Those would be great things to try but again you’ve got to understand if your patient has the cognition to be able to actually manage that. Once you realize that they don't have the cognition, well, then we're in a whole different area of how do we manage the bladder situation.

So what I put as between the lines is that we really need to do research. This is something that we have a call or a need to do. Lots of different people do lots of different things but there really isn't a whole lot out there, really there is nothing out there that says what to do. From a bowel management perspective, the only real thing that we could really find from an evidence perspective was to assess prior bowel patterns. That we look at what the patient had before. And what they were doing before to kind of help drive forward what you do. And again, really what would be the things to do between the lines is, you know, look at the recommendations are to help people with bowel continence for adults. What do you do to try to manage someone? But again, cognition is going to play another piece into it.

Stool consistency is clearly important, so looking at patients' nutritional status. You know, because if they have loose stools, that’s obviously more difficult to control than if their stools are more firm, how much food are they taking in. Again, looking at best practices, but unfortunately don't have a lot of data to support that. From the perspective of follow-up care, we do know that it’s really important that the patients have follow-up care once they leave the organized support systems of the healthcare environment. We know that the family and the patient need training and education. We all know that this is something that's so important.

We also all know that when a patient, you know, we have recommendations and education of the things that they're supposed to do that we provide in the acute care hospital, that gets reinforced in the rehabilitation environment, which gets reinforced in the home healthcare environment. There’s all these places of reinforcement and when they come back in for that follow-up appointment with hopefully a rehabilitation provider, someone who actually knows to ask about specifically about stroke, the needs of the stroke patient, the family support, and what we know that they need is that kind of follow-up. But so often, the things that we've been teaching them all along they come in and they’re just like I don't remember anybody telling me that. And sometimes that means that the patient hasn't really followed up on the important aspects of what they needed to be following up on and making sure happen.

They’ve stopped taking their aspirin and they’ll say well, nobody told me to take it. And we all know that we all told them to take it but for whatever reason they just didn't get that piece followed up. So at that follow-up appointment, again, you know, we recommend that we follow up on the things that we know should have been discussed during their different settings. We need to evaluate these patients for social isolation, we have issues related to returning to work.

There are recommendations in the guidelines about the returning to work, because of lots of reasons that it's good for them to get back into that type environment from an isolation perspective. And, of course, we need to do an assessment of their cognitive, their perception, physical and motor abilities in order to really determine if they are going to be able to return to work. We also should evaluate proposed stroke depression. We should also evaluate for anxiety. There are lots of different inventories to use to actually evaluate the PHQ-2 is actually recommended for screening for post-stroke depression. That's a Class I level of evidence B. So that is a good tool to use and that does seem to work well in stroke. But then, of course, the next question is, so then we do this, and what do we do once we find out the patient is depressed? There are recommendations in the guidelines related to medications that might be of benefit to the stroke patient.

You know, looking at whether they need counseling. Again, I think one of the things that we all know is that someone who understands the specific needs of the stroke patient and the family would be important. But again, are all those resources always available and in their community? From a sexuality standpoint, one of the things that I thought was particularly interesting about sexuality is that it really is recommended, it was Class IIb Level of Evidence B which obviously isn't super-strong evidence but it is a limited amount of evidence that's out there, this is what it indicates is that we really should discuss prior to discharge from the hospital, you know, their -- ask questions about sex and their sexuality related to that transitioning to home. What was out there is that things we should ask them about are if they have any safety concerns, have they had any changes in their libido, and questions about physical limitations, the emotional consequences of stroke.

All of those things are things to ask them about that can relate back to sexuality. And then, again, what we recommend is that after they are home and maybe have had an opportunity now to actually do something with this, from a sexual perspective, and then what kind of issues have they encountered? And then once again, we now ask these questions. So who are we going to make referrals to? Sometimes it could be to an actual physical therapist or occupational therapist related to positioning. It could be related to their having -- they need to be reassured that no one's going to get hurt. Or other things like, you know, actual emotional counseling for them related to this.

Another thing is we should be evaluating and paying very close attention to the patient and family caregiver and really the support system of the patient. We know that these individuals do need support. And they do need to be followed up on. There have been some studies out there indicating that, you know, once a patient has a stroke that, you know, the support system also has some concerns that develop as a result of this. And in order to really help these individuals with transition, support should likely include the minimum of providing education, providing them with training, counseling and really a support structure for the patient and the caregiver. For the caregiver to possibly need respite care, or knowing that, you know, yes, they are out there struggling and there are issues with living with someone with a stroke and that they have the support that they need to help them deal with the issues that they are encountering.

And, of course, another very important component is financial assistance. People once they get home need different things done. They need ramps built, they need sometimes home modifications, they need some minor home modifications, and some of these people don't have funding to be able to do that. And so helping them being able to figure some of those things out as well as financial support, if the stroke patient was the primary caretaker and the primary source of financial stability in the household, then how do they survive after this? And again, all of these recommendations were -- they were of such minor research out there and evidence to support, again, these are all things that we all face and encounter but knowing what it is that we should do and what really works best is really left to still be decided. Another thing is the follow-up to the rehabilitation care.

One of the things that I know the families encounter and the support systems encounter is how do you make a decision about where your loved one should go? Dr. Stein has very much elaborated on the evidence indicating that if someone qualifies for in-patient rehab that they should go to in-patient rehab. But there are lots of questions that need to be answered, again, as far as distance, people if they have the opportunity should go and visit a facility or setting prior to making a decision. Understanding what their insurance will cover and what it won't cover. The question of being close to home versus going to an environment where they can receive better services but are so far away from the family that they won't be able to visit often and provide support. American Heart and Stroke Association have “Making Rehabilitation Decisions.” It’s a pamphlet that helps families be able to make the decision of where should we take our loved ones, you know, that would be best for them. So this is an excellent resource out there to use.

There are also other tools available for you. We have lots of quick sheets, an activation kit, patient planning list, patient decision-making guides. All of these are out there and it's right there -- if you go to the, these are out there and can be downloaded and printed for patients as resources. And actually, one of the recommendations is that as different providers we should all have resources available and handy for our patients and families to help them not only hear the words that we tell them and try the educate them with, but actually hand them something that they can take with them. So now we're going to go over the conclusion. Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers, and everyone involved. It's important to have the full team weigh in on what are the best things for the patient, what direction should they go in.

Communication and coordination among these team members is paramount so that we're all on the same page. Certainly I’ve sat through team conferences where one department is saying we think this person needs to have this kind of support, another person says no, we think they need minimum assistance. And they think they just need more rest and then once they have more rest they're able to do more. We've got to be communicating with each other so that we're all on the same page and giving the same message. It really creates effective and efficient rehab and it really is what underlines the entire guideline of how all of us play a part in the recovery and success of the patient and families. There are so many other recommendations but we don't really have time to go over all the rest of them. So I think what we're going to do now is turn this over to Kayla and Kristina to discuss and take some of your questions, and we'll go from there. Kristina Wait: Thank you, Sue.

This is Kristina Wait, everyone, from the American Stroke Association. And I’ll be reading your questions that you have posted online so that Sue and Dr. Stein can have an opportunity to provide you with some further information. Ginneen, do you mind reviewing one more time for everyone the instructions for asking Q&A? Operator: Thank you. As a reminder, if you’d like to ask a question, please click on the green “Q&A” button in the lower left-hand corner of your screen, type your question in the open area, and click “Submit.” And I’ll turn it back for your Q&A session. Kristina Wait: Thank you, Ginneen, appreciate that. We have a tremendous number of questions that have come through so I’m hopeful we can get through all of them.

If we’re not able to, we will certainly find a way to provide answers to everyone post-call so that you have the information you need. So the first question that has been asked from the audience is: What is the percentage of people who get back to level prior to stroke? Comparing an IRF to a SNF? Sue or Dr. Stein, which one of you would like to take that question? Dr. Joel Stein: Sure, I can take that. It’s not an easy question to answer. The reality is that most of the patients who go to these levels of care have significant disability as a result of their stroke.

And as a result, I would say relatively few achieve full recovery during the time they spend in the facility. I often tell the patients who are being referred for either of these levels of care, I emphasize that the goal of inpatient rehabilitation is not to complete their recovery and rehabilitation process, but to get to the point where they can be home safely and managed in a home environment with the expectation that they’ll be ongoing rehabilitation there. Most patients actually are pleased to realize they’re going to get home as soon as they can and continue on an outpatient basis rather than trying and stay until they’ve really maximized their full recovery.

But I would say it's a minority of patients who achieve their premorbid level by the time of discharge. Kristina Wait: Thank you, Dr. Stein. I think another question you can probably weigh in on is: The role of dementia in prescribing post-acute care. What role does dementia play in choosing a care setting and does it exclude someone from inpatient rehabilitation? Dr. Joel Stein: Sure.

So, dementia obviously has varying degrees. And there are patients who are diagnosed with early dementia who have some mild memory difficulties. They have trouble with short-term memory, remembering what they did yesterday or what they had for breakfast but are still able to learn new material or still able to manage independently in the community but carry this diagnosis. And I think we need to be careful to understand that dementia is a process as much as it is a diagnosis.

Patients who are severely demented, those who are unable to communicate, unable to learn new things, unable to manage their own care are obviously not candidates for attempted rehabilitation. Patients with mild early dementia who are experiencing some cognitive struggles but are still able to manage in a home environment with minimal support, those are certainty appropriate and frequent recipients. And I’ll point out, there are many patients who are simply never formally diagnosed but is not uncommon when you probe a little bit to realize that grandma was having a few memory issues prior to this and an assessment might in fact make a diagnosis but they were mild enough that it really wasn't affecting her function very much. So, I think it's important that that not be a label used categorically to exclude patients from any particular type of care. Kristina Wait: Thank you Dr. Stein.

We have a question from an acute care therapist who asks: Are there are any objective measures that show where the patient should go for rehab after discharge? She shares that often they use their clinical judgment in having worked in different settings they may have a more qualitative perspective on who should go to an IRF versus a SNF. But are there any objective measures out there that can help make that decision? Dr. Joel Stein: Oh dear, someone asks the most -- question that I could come up with. So this is something I’m personally very interested in trying to define. These do not exist, simply stated at this point.

And frankly, this definition that was used for the guidelines was sort of an operational definition that if you meet the criteria you should go. That means that patients who meet IRF criteria should not generally be sent to SNFs unless there is no alternative. But it doesn't really help the clinician at the bedside very much in saying, well, does this patient truly meet criteria? Because those criteria are somewhat subjective.

And I would say we should give the benefit of the doubt would be my general thinking. I think it's distressing to think of some individuals who could benefit who were not offered this more intensive level of care. But we do need to define more specific formal criteria. I will say that I've been involved in some research looking at things such as ABL scales, like Barthel Index or the FIM, which is very similar. And those at least don't seem to be sufficiently predictive to say who's going to go to IRF versus SNF by themselves nor is the NIH stroke scale sufficient to make that determination. It’s one component but it’s not the only component. Very astute question. Kristina Wait: Great.

So, you know, we saw on one of the early slides in the presentation, the chart that shows how we define at the American Heart Association, American Stroke Association our levels of classification for our guidelines. And when you have a question wanting more information about those levels of classification, the question is, can we explain the grading system used for Class I Level of Evidence, what is the A, B or C mean? Dr. Joel Stein: I’m happy to answer that one as well. Generally speaking, Level A evidence would be from large, randomized trials, often more than one or at least one large one.

So these are the highest level of evidence. They’re hard to find in rehabilitation, to be honest. But these are the sort of evidence, for example, that are used to determine that tPA is appropriate for acute stroke management and more recently the clinical trials that were used to establish that clot retrieval interventions are appropriate. That's Level I evidence. But that's hard to find.

Level A evidence, excuse me. Level B evidence would be more typical of what we see in rehabilitation. Smaller studies, perhaps several of them, they may be observational in nature. A lot of the IRF vs. SNF literature, for example, is not randomized but is based on observational research where data sets that are obtained in the course of routine care are examined and analyzed to determine what the various contributors to care were.

And then Level C evidence is the least strong evidence which includes, for example, case reports, expert opinion, consensus statements, is not based on as formal evidence but may be very evident to everybody that it's important. A good example of Level C evidence would be the use of parachutes for people jumping out of airplanes. That's a joke but I know it's hard to laugh. Kristina Wait: I chuckled on this end, Dr.

Stein. [Laughing] Sue Pugh: One other thing that I just want to mention about that is if folks go and download the actual guidelines, like two to three pages in, the actual -- there’s like a graph that indicates the difference between Class I and all the different classes and the different levels and it’s actually very detailed and it’s there as a reference. So when you are reading some of the recommendations you can go back and refer to what they each mean. Kristina Wait: Thank you, Sue, I appreciate you advising that as a reference for everybody and noting that those details are provided for future reference.

The next question we have then is: What is your take on TIA or stroke cases which do not necessarily end up with disability? Should those stroke cases still have an evaluation by a rehab team? Dr. Joel Stein: That issue was not specifically addressed in the guidelines as far as I can recall but I think my clinical recommendation would be if someone is truly at baseline, if all their symptoms have resolved and they’re functioning well in the baseline in the community, then no it's not needed. But I think you have to make sure both of those are met because there are people who are struggling in the first place and now show up for medical attention and it would be a shame not to address their baseline needs while they are in the hospital.

Kristina Wait: Thanks. Sue, you talked about in your presentation bowel and bladder management and other post-stroke conditions. We have a question asking: Do you have recommendations for depression, anxiety, medications, bowel, bladder management programs to support post-stroke recovery? Sue Pugh: So in the guidelines, there actually is a section that actually addresses medications following depression.

And the recommendations are Class IIa, Level A, which says that a trial of an SSRI is reasonable to consider for these patients. So when you're talking about the depression and anxiety you could use -- you could try an SSRI. Of course if that is something that is medically something they can take that would be something to consider. As far as the bowel and bladder goes, there are so many different things to really consider. In my own personal practice, because certainly there was not a lot in the literature, one of the things that I find is always, always, always overlooked is literally what is the patient taking in and putting out.

And that people don't always understand that when they drink five cups of coffee, that coffee is a diuretic, how much fluid they’re taking in, and then what are the ramifications about what comes out? And I always work with people just understanding, you know, that what goes in has an effect on what comes outs. And then, you know, actually as they talked about looking at from a cognitive perspective, if the patient is capable of being trained and learning something, literally the sensation of the full bladder, getting them to the restroom on a frequent basis, you know, sometimes people talk about toileting someone every two hours. If they eat a meal, the toileting should be sooner after the meal versus, you know, you wouldn't necessarily make them wait two hours afterwards when by the sheer fact that they have had a meal they would need to require toileting. There are lots of things to consider. But I don't want to take up the rest trying to answer this question because there are just so many different recommendations that you can look at and I really recommend going out there and looking at treatment for incontinence for adults and then look at what those recommendations are because at this point there is no literature that says what specifically we should do for strokes. So we really have to go on what you would do for just adults in general. Kristina Wait: Thanks, Sue.

And take a short breath but not too long because I’m going to ask you another question that’s directed for you. Somebody asked: As an in-patient stroke coordinator, what advice do you have for assisting the bedside nurse with discharge education if someone is going to rehab? The observation is the bedside nurse might not do as much in depth education prior to the patient going home, and knowing that for this particular person, they have 25% of their population going to an IRH. They are curious to know from your perspective how a stroke coordinator can facilitate that process. Sue Pugh: Well, I think that it's really different everywhere.

Because it depends on how many stroke coordinators you have, what's their availability to be able to do any sort of help and assistance to the bedside nurse. I think that at the very least, something that a stroke coordinator could do is provide educational materials, you know, actually something in writing for the staff nurses to be able to grab and reference and use. I think that a lot of times, you know, the bedside nurse wants to provide good education, may not always have all the time but may understand some of the detail of the case but doesn't have something to be able to hand someone and give it to them. Because, as I mentioned before, the number of patients who actually follow all the recommendations really through and thoroughly, is just that there's so much that they're learning and they're so overwhelmed with so much information, that actually giving the something is something to really hold on to and take in.

So that's really an excellent thing to have as a resource for the bedside nurse. And then if the stroke coordinator can actually make themselves available to, you know, actually help with the discharge instruction, I certainly think that -- I don't think there's a staff nurse that would say no, I don't want you to do that. I think they would love the help. It's just usually a matter of who has the time to do it.

Kristina Wait: Thank you, Sue, very appreciative. And we have many, many, many, many more questions that are being asked. Which I think speaks to the quality of information Sue and Dr. Stein, you have provided to our attendees today. We will do our best to try to gather answers to some of these questions and provide back to our participants in some way post-call. Before everybody hangs up, I’d like to give Ginneen, our web specialist, an opportunity to close this out.

We will be having a survey go out after this call, and if you could take a few moments to answer the survey we’d be very appreciative. The American Stroke Association is happy that we were able to provide with you this learning opportunity. And thank you for supporting our mission and providing patients with better outcomes. Ginneen? Operator: Again, thank you all for joining us today. We hope you found this presentation informative. This concludes our program and you may all disconnect.

Krista Evans, MD, General Surgeon - Burlington, VT, The UVM Medical Center

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Operator: It is now my pleasure to turn today’s program over to Stephanie Mohl, vice president of the American Stroke Association. The floor is yours. Stephanie Mohl: Thank you, Ginneen.On…

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