Hospitalists commonly provide acute care for stroke, but they may be less certain about recommending care after discharge, when many patients need ongoing rehab in addition to other therapies. With the aim of improving and standardizing practice, the American Heart Association (AHA) and the American Stroke Association in May published their first comprehensive set of guidelines focused on rehabilitation and recovery after stroke.
Physiatrist Joel Stein, MD, vice chair of the AHA Stroke Rehabilitation Guideline Committee and coauthor of the guidelines, spoke with ACP Hospitalist about the main takeaways. Dr. Stein is professor and chair of the department of rehabilitation and regenerative medicine at Columbia University College of Physicians and Surgeons in New York.
Q: What are some key recommendations from the guidelines that hospitalists should know?
A: From a hospitalist's perspective, I think that one of the important recommendations is the formal assessment of patients' ability to perform activities of daily living, as well as their communication abilities and their functional mobility, before they leave the hospital. Stroke can affect all these areas, but it's easy to miss things in a hospital setting, and this ensures that there's a good understanding of what the patient's needs are so that appropriate aftercare and rehabilitation services can be set up prior to discharge.
There is a recommendation in the guidelines that patients who have access to and qualify for inpatient rehab care should receive that type of care in preference to a SNF [skilled nursing facility]. To be clear, that doesn't mean that no one should go to a SNF; in fact, many patients are not appropriate for various reasons for IRF [inpatient rehab facility] care, and a SNF is the best option for them.
Another very important issue that's highlighted in the guidelines is depression after stroke. Some estimates have as many as 40% of stroke survivors having significant levels of depression. There's a concern that it's not screened for consistently, and there is a recommendation specifically about screening for it and that it be treated when identified. Thankfully, people with poststroke depression respond very well to standard treatments for it [e.g., selective serotonin reuptake inhibitors].
Q: What factors indicate who should receive inpatient or subacute rehab?
A: First of all, the criteria are not as well established as they should be, and our guidelines don't directly address those criteria. But CMS, for Medicare, has established certain levels of criteria, and those are widely followed by other insurers. That includes the need for and the likelihood of benefit from a relatively intensive rehabilitation in an IRF. That's defined as 3 or more hours of therapy per day. . . It's important not to overstate that 3-hour requirement because it's not 3 hours of intensive workout in the gym; it includes activities such as brushing your teeth or feeding yourself in a therapeutic context.
Generally speaking, patients who have intermediate levels of disability are the more typical patients for an IRF, so not the [patients with] very mild [disability] who can hopefully go home, and not some of the most severe who maybe have premorbid dementia or have a very poor likelihood of a good outcome. Particularly, I think people who are of younger age deserve special consideration.
Q: What role do hospitalists play in referring patients to stroke rehab?
A: Typically, the referrals to these facilities are managed by the social worker, care coordinator, or discharge planner, depending on the institution, not typically by the physician. But certainly, the physician, the hospitalist, has an oversight role in terms of making sure that patients are receiving appropriate levels of care. Families are often unaware of the differences between different levels of rehabilitation and may be inclined to make these decisions based largely on geography. I think it's important for the hospitalists to be aware that these different levels of care exist and that patients may require advocacy. Sometimes, there's also the need to advocate [on their behalf] with insurance companies.
Q: How soon after the stroke should an assessment happen?
A: There's no specific recommendation about the exact timing, but it should occur prior to discharge. You don't want to do it the moment before discharge either because that doesn't give enough time to prepare and make plans around it. I would say sometime in the period between 24 and 72 hours would be typical.
Q: How can hospitalists make sure the assessment takes place?
A: One way is to develop practices within their institution to make sure that there is a system in place so that this is done systematically. In many institutions, there may be order sets that are involved, particularly if you're having physical and occupational therapy evaluate the patients while they're in the hospital. I think that physicians and hospitalists play a key role in setting up systems so that there is consistency of care and a reliable way of making sure these things are done.
Q: How does current practice fall short of these recommendations?
A: Anecdotally, it is not uncommon to see people with significant depression after stroke where the patient themselves, the family, and their physicians all ascribe it to a normal reaction to a bad event, and I think that is clearly an educational opportunity to make sure people understand that's not the case. In terms of the utilization of postacute rehabilitation and selecting the right level, there is data showing substantial variation in the utilization of SNFs and IRFs around the country, and some states have much higher utilization rates than other states. It's not clear which are the correct rates, but it's clear that there's not consistency in practice. This is a large population who needs a lot of services and benefits from them, and it's really important that we help people determine what treatment is necessary.