The Ontario Stroke Network has recently set a benchmark of 39%, indicating the percentage of all patients who should be admitted for in-patient rehabilitation following discharge from an acute care facility in Ontario (Hall et al. 2010
). This figure was calculated retrospectively using a paired-mean approach (Kiefe et al. 1998
) based on in-patient rehabilitation admissions from the 11 Regional Stroke Centres in Ontario over seven quarters (from 2006 to 2008). In this study of 396 unselected patients admitted to eight acute care institutions, 37.1% were identified as appropriate candidates for in-patient rehabilitation using a standardized screening method. This figure, derived using a prospective process, is quite similar to the proposed benchmark. However, the estimates of either 37% or 39% of individuals who require in-patient rehabilitation services following stroke diverge sharply from historical estimates of those who have received it. From the years 2003 to 2008, between 21% and 23% of all stroke patients in Ontario were admitted for in-patient rehabilitation (Hall et al. 2010
). Moreover, the percentage of patients who were admitted to in-patient rehabilitation programs ranged from 9% to 45% across regions, suggesting variations in admitting practices. Previously, there has been no reference point from which to assess whether the level of service provided was a reflection of actual need or the limits of capacity; the results of this study may suggest the latter.
Among patients deemed to be appropriate candidates for in-patient rehabilitation in this study, 75% were discharged to a location where they would receive this service. The main reason that an appropriate rehabilitation candidate was not discharged to a rehabilitation bed was availability. Whether bed shortages were chronic or cyclical is unknown; however, patients in this study spent a substantial number of days in ALC status awaiting a rehabilitation bed. In addition, seven patients were screened and deemed not to be suitable candidates but were nevertheless discharged to an in-patient rehabilitation facility, suggesting that factors other than suitability for rehabilitation sometimes determine discharge destination. One of these patients was unable to follow commands, had no rehabilitation goals and was unwilling to participate in an in-patient program. In this particular case, pressure to vacate the acute care bed at a time when a rehabilitation bed was available may have been the deciding factor.
The screening tool was designed to be patient-focused. It de-emphasized initial stroke severity as the primary criterion and minimized the use of prognostic and external factors such as age and caregiver availability among the candidacy criteria, factors that are often used in clinical decision-making. As a result, patients from across the severity spectrum were identified as in-patient rehabilitation candidates, including those with severely disabling strokes. Although within the limits of a constrained healthcare system these patients have not traditionally been considered good candidates for in-patient rehabilitation, evidence suggests that they do benefit. Using the definition of “non-ambulatory” to classify stroke as severe, patients admitted to a specialized rehabilitation program demonstrated significant improvements in FIM® scores from admission to discharge and 43% returned home (Teasell et al. 2005
). Almost certainly, without that opportunity a large number of these patients would otherwise have been admitted directly to a long-term care institution.
The use of the SRCST had been adopted voluntarily within the preceding year by the participating institutions; its use was not mandatory. The tool had not been completed prospectively on a substantial number of patients. In some cases, this may have been due to early discharge, because 24% of patients were discharged on or before day 5 following admission. Alternatively, it may also suggest that busy clinicians saved themselves additional work, anticipating that these patients would not be considered appropriate candidates and would be discharged imminently, or they engaged in their own informal pre-screening. Regardless of the reason, of the 166 patients who were not screened during their hospital stay and discharged, 19 were later identified as rehabilitation candidates when the SRCST tool was scored by chart audit. It is of concern that a large percentage of patients were discharged from acute care within the first five days of stroke without their need for rehabilitation services having been assessed.
The results of this study may be used to estimate the number of patients who require in-patient rehabilitation on a provincial level. Using the most updated data from the Ontario Stroke Evaluation Report (Hall et al. 2010
: 39), a total of 13,219 patients were discharged alive from an acute care facility following stroke in a single year (2007/08). In that same year, 2,998 (22.7%) patients were discharged to a rehabilitation facility. If we use the estimate of 37% from the present study, then 4,891 patients should have had access to a rehabilitation bed but did not, leaving 1,893, or 14.3% of all admissions, with an unmet need. The gap between the need for care and current levels of service availability is notable.
One of the strengths of this study was that candidacy criteria were applied in a standardized fashion. We did not use a statistical modelling approach that included an array of prognostic factors to predict admission to a rehabilitation program as a surrogate marker for the patients who require in-patient rehabilitation, as others have (Treger et al. 2008
; Ilett et al. 2010
; Schlegel et al. 2003
; Rundek et al. 2000
). These studies, which included patients already admitted for in-patient rehabilitation, have assumed that all patients who were admitted were suitable candidates and excludes the unknown number of patients who were not admitted but who might have been appropriate candidates had they been assessed.
There are several limitations to this study. For a large number of patients (41%), candidacy assessment was completed using a retrospective process. Because patients were not followed to their final destination, some may have been admitted for in-patient rehabilitation following discharge to an intermediate destination, such as CCC or home. Another limitation is that pre-stroke living arrangements were unknown. Given that it is unlikely that a patient admitted to acute care from a LTC facility would be considered a rehabilitation candidate, this may have slightly inflated our reported estimate of the percentage of patients requiring in-patient rehabilitation. Patients who presented with stroke requiring neurosurgical services were not included in this study and may have led to an underestimate. These patients were transferred to the regional tertiary care centre for treatment. Although the standardized tool we developed and used may require modifications and adaptations for broader use, we have demonstrated that it is feasible to screen patients for in-patient rehabilitation eligibility in the early days following stroke.