INFLUENCIA DEL TRATAMIENTO CON DOPAMINA EN LOS VALORES DE T4L.

The rehabilitation standards identified within the current study identified two inter-dependent issues of the proportion of inpatient stay spent in specialist stroke services and timeliness of interventions. The two resulting standards of patients spending '90% of their inpatient stay on a stroke unit' and 'accessing rehabilitation as soon as the patient is medically stable' have therefore been considered together. These two standards achieved a high compliance within the current study with a mean of 93% and 96% respectively, with a small range. This suggests minimal variation in the compliance to these standards. A mean compliance rate of 93% within the current study to the standard of '90% of their inpatient stay on a stroke unit' is higher than the national picture of 62.2% (Sentinel Audit, RCP, 2010).

A robust body of evidence from systematic reviews of controlled trials (Stroke Unit Trialists' Collaboration, 1997; 2007), with strong external validity, supports improved survival and functional outcomes from treatment in a stroke unit resulting in ‘access stroke specialist care as soon as medically stable’ being invariably recommended in national guidance (National Stroke Strategy, 2007; Healthcare for London, 2009; Stroke Service Specification, BASP, 2007). With such a strong evidence base and focus on a national level, teams within this study have been striving to offer specialist stroke rehabilitation for many years, which may account for the high compliance to this standard. Additionally, the treatment of strokes has historically been viewed utilising a medical model. It is only following the more recent publication of the ICF (2001) that a paradigm shift

occurred resulting in the combination of the medical model and social model towards a biopsychosocial model. As a result the principles underlying the medially based recommendation of ‘access stroke specialist care as soon as medically stable’ may have been utilised within stroke care for a longer time than other recommendations. A further factor accounting for the high compliance in the current study and the higher compliance than the national picture may be the local financial incentive of Commissioning for Quality and Innovation (CQUIN) (Department of Health, 2008). CQUIN is a national initiative to reward service providers for attaining certain recommendations. The providers are paid a percentage of the total contract value if they have achieved the standard. In August 2010, one of the five ‘CQUIN recommendations’ applied across the North-West included ‘direct admission to a stroke unit within four hours of hospital admission’. In addition a national database of stroke care quality indicators (Vital Signs, Department of Health), reports to the Department of Health quarterly and includes, ‘the percentage of people who were admitted to hospital following a stroke, who then spent 90% of their time on a stroke unit’ as a standard. In order to attain a 90% of hospital inpatient stay on a stroke ward the patient must be transferred to a stroke specialist ward with minimal delay.

Research into what is the optimal timing for onset of rehabilitation remains inconclusive (Cifu and Stewart, 1999). It is an important question to answer as it is potentially modifiable, unlike other predictors of functional recovery after stroke such as age or severity of stroke. In a systematic review of the literature, the definition of 'early intervention’ used in the primary studies varied from three to 30 days after stroke (Cifu and Stewart, 1999). However, since the publication of this research in 1999, pressures to reduce length of stay in inpatient rehabilitation settings has increased (http://www.reducinglengthofstay.org.uk/ ). Currently the money paid to the acute team for each stroke patient admitted to hospital covers 56 days of care therefore delaying accessing rehabilitation until day 30 of the 56 days of care is 53.5% of the overall time. 30 days, as cited as

'early' by Cifu and Stewart (1999) may no longer be considered as 'early' within the length of time patients receive care. In a cohort study Musicco et al (2003) defined 'early' initiation of therapy as seven days from onset of stroke symptoms, concluding that initiation of therapy within seven days has a positive relationship with functional outcome. This study had a large sample of 1716 subjects but was observational in nature. The conclusions drawn from their study can not, therefore, be solely attributed to timing of onset of rehabilitation as more factors than timing of the initiation of therapy were involved in the patients care. More research is required to investigate this more fully with a randomised control trial comparing initiation of therapy prior and post 7days. The standards developed in the current study did not specify a time scale between admission to hospital and commencement of rehabilitation and neither do the national recommendations (National Stroke Strategy, 2007; Stroke Rehabilitation Guide: Supporting London commissioners to Commission Quality services in 2010/2011, Healthcare for London, 2009). The standard given within the current study is that rehabilitation should start 'as soon as the patient is medically stable', which implies a clinical judgement. Further research evaluating whether objective indicators can be identified to specify when a patient is suitable to enter rehabilitation may be beneficial. This could then inform future national recommendations and assist clinicians in deciding whether patients are ready to enter rehabilitation. However, the distinction between acute care and rehabilitation is perhaps becoming less defined as services managing different stages of the care pathway merge to offer a ‘seamless service’.