Measurement of Outcomes of Care
for Stroke Patients
BY CARL V. GRANGER, M.D.,* DAVID S. GREER, M.D.,t ELIZABETH LISET, R.N.,t
JOAN COULOMBE, R.N.,§ AND ELIZABETH O'BRIEN, R.N. II
Abstract:
Measurement
of Outcomes
of Care for
Stroke
Patients
• A coordinated system of care for stroke patients is established in the community of Fall
River, Massachusetts, involving the Stroke Unit of Union Hospital, the Rehabilitation Unit of
Earle E. Hussey Hospital, and the Fall River District Nurse Association. Long-Range Evaluation Summary (LRES) data collection forms developed at the Tufts University Medical
Rehabilitation Research and Training Center (RT-7) are being used to reflect the functional
status of the patient at any given point in time. Of 164 patients the Stroke Unit returned 49%
home and the Rehabilitation Unit returned another 9% home. This systematic approach to
functional assessment relates the disease-state and disability to outcomes of care. By taking into
account the several-fold nature of outcome determination it is possible to analyze program
effectiveness because such uniform descriptions, over time, permit us better to relate the population under care, its key characteristics for these purposes, and the comprehensiveness of
problem identification and planning all at the same time.
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Additional Key Words
long-range evaluation
D Stroke is a major cause of death and disability in
the elderly. A comprehensive care plan should begin
when the stroke begins. Strategies must be directed
first toward identification and stabilization of medical
factors that cause death or complicate care and
prolong morbidity. This phase constitutes the acute
hospital level of care. Secondly, management must be
directed toward restoring lost abilities and functions
and toward achieving the highest qualities of life possible. This phase constitutes the medical rehabilitation
level of care. All too often medical care for the stroke
patient is indifferent and rehabilitation is pessimistic
and perfunctory.
The degree to which a care program for stroke
patients meets the challenge of reducing morbidity
while enhancing dignity and independence of survivors
is measurable through adoption of a systematic approach that relates disease-state and disability to outcomes of care.
One important element of the Problem-Oriented
Record System of Weed is a complete and defined
'Professor and Chairman, Department of Physical and Rehabilitation Medicine, Tufts University School of Medicine, Boston,
Massachusetts. tProfessor of Community Health, and Associate
Dean for Medical Affairs, Brown University, Providence, Rhode
Island. ^Stroke Unit, Union Hospital of Fall River, Fall River,
Massachusetts. §RehabiIitation Unit, Earle E. Hussey Hospital,
Fall River, Massachusetts. |] Fall River District Nurse Association,
Fall River, Massachusetts.
Supported in part by Social and Rehabilitation Service Grant
Number 16-P-56800/1-10 (RT-7).
34
functional assessments
Barthel Index
coordinated care
PULSES Profile
follow-up
data base. In addition to usual history, physical examination, and laboratory and diagnostic data, a
standard assessment of functional abilities is important for directing emphasis in the care plan, for anticipating the next appropriate level of care in planning discharge, and for review and evaluation of the
stroke care program itself.
Methods
At Tufts University Medical Rehabilitation Research and
Training Center (RT-7), data collection forms were
developed, Long-Range Evaluation Summary (LRES), that
reflect the functional status of the patient at any given point
in time. The data are scaled according to Barthel and
PULSES indices1'2 (tables 1 and 2). Criteria for scaling
communication ability and intellectual and emotional
adaptability are shown in table 3. A coordinated system of
care and recording of data was established in the community
of Fall River, Massachusetts, involving the Stroke Unit of
the Union Hospital, the Rehabilitation Unit of the Earle E.
Hussey Hospital, and the Fall River District Nurse Association.
The Union Hospital Stroke Unit was organized in October, 1972. All patients admitted to the Stroke Unit receive
standardized functional assessments upon admission and
again upon discharge. Patients were discharged either to
their home, to the Hussey Rehabilitation Unit, or to a longterm care facility (nursing home or chronic hospital), or they
died while still in the Stroke Unit. Patients transferred to the
Hussey Rehabilitation Unit were also assessed upon admission and discharge. The District Nurse Association performed follow-up assessments upon patients after discharge
from Hussey either in the patient's home or in a long-term
care facility.
Stroke, Vol. 6, January-February 1975
MEASUREMENT OF OUTCOMES OF CARE FOR STROKE PATIENTS
TABLE 1
Ten Categories of Self-Care and Mobility Functions Are Rated by the Examiner Using the Batihel Index1
Independent
1.
2.
Feeding (if food needs to be cut = help)
Moving from wheelchair to bed and return (includes sitting
up in bed)
3. Personal toilet (wash face, comb hair, shave, clean teeth)
4. Getting on and off toilet (handling clothes, wipe, flush)
5. Bathing self
6. Walking on level surface (or if unable to walk, propel wheelchair)
*score only if unable to walk
7. Ascend and descend stairs
8. Dressing (includes tying shoes, fastening fasteners)
9. Controlling bowels
10. Controlling bladder
With help
5
10
15
10-5
5
10
5
15
*5
10
10
10
10
0
5
0
10
0
5
5
5
5
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Points are assigned to each category depending upon whether the patient performs the function alone or with help.
The worst score is 0 and the best score is 100. A patient scoring 100 Barthel Index is continent, feeds himself,
dresses himself, gets up out of bed and chairs, bathes himself, walks at least a block, and can ascend and descend
stairs. This does not mean that he is able to live alone; he may not be able to cook, keep house, and meet the
public, but he is able to get along without attendant care.
Results Beginning in October, 1972
One hundred and sixty-four patients with a diagnosis
of stroke were admitted to the Union Hospital Stroke
Unit and discharged by December 31, 1973. Approximately 85% of the patients were judged to have
atherothrombotic brain infarction with the remaining
having transient ischemic attacks, hemorrhage or embolism. Eighty-one (49%) were discharged home, 33
(20%) were transferred to Hussey Rehabilitation Unit,
29 (18%) were discharged to long-term care facilities
and 21 (13%) died (table 4). Of the 33 patients
transferred to Hussey Rehabilitation Unit, 28 were
discharged by December 31, 1973. Of these, 14 (50%)
were discharged home, four (13%) were discharged to
acute hospital care, and ten (37%) were discharged to
long-term care facilities. Follow-up data revealed that
5 of 28 patients had died following discharge from
Hussey (two who were discharged home, one who was
discharged to an acute hospital, and two who were discharged to long-term care). The District Nurse
Association assessed eight patients at home following
discharge and four in long-term care facilities (one of
whom had been discharged to acute hospital care from
Hussey) (table 5).
Comments on Union Hospital
Stroke Unit
The Union Hospital Stroke Unit has 13 beds arranged
in cubicle-fashion. This minimizes feelings of isolation
on the part of the patient. Toilets are adapted by
placement of support bars at suitable locations. There
is a dining room on the unit for patients to take their
meals: A set of parallel bars in the dining room permits ambulation training between mealtimes. The
emphasis of the Unit is short-term comprehensive care
rather than intensive care or long-term rehabilitation.
Stroke, Vol. 6, January-February
1975
However, rehabilitation philosophy and methods are
applied when the patient is admitted to the Unit.
Guiding principles have been described by others36 in
contrast to the purposes of the stroke intensive care
unit.7
Patients are admitted under the care of their
attending physicians. It is estimated that better than
95% of patients with the diagnosis of stroke are either
admitted directly or are subsequently transferred to
the Unit. Patients transferred off the Unit for reasons
of changed diagnosis or change in treatment plan are
not counted in the study group. Patients in coma as
well as those with good potential for recovery are admitted, including patients with transient ischemic attacks. It is well recognized that a patient's level of consciousness on admission after stroke correlates highly
with his chance of survival.3'8 If a patient requires intensive care because of complications in addition to
those of atherothrombotic brain infarction, then the
patient would be cared for in the intensive care unit of
the hospital. Problem cases are reviewed by a consulting neurologist. A consulting physiatrist reviews
almost all cases for determination of rehabilitation
potential, for direction of program and for discharge
planning. Physiatric rounds are conducted in a conference setting to provide maximum exchange of information between members of the care team. The
attending physician calls for consultation from other
specialists when needed. Supportive services include
physical therapy, social service, liaison with the district nurse, a speech therapy consultant and an
orthotist. A Stroke Unit Committee of the Hospital
formulates overall policy. It has been projected that
lengths of stay would average three weeks.
Many problems are anticipated and managed by
the nursing staff primarily. Those patients able to
35
GRANGER, GREEK, LISET, COULOMBE, O'BRIEN
TABLE 1
PULSES Profile.2 (Adapted by C. Granger)
P
1.
2.
3.
4.
U
1.
2.
3.
4.
L
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1.
2.
3.
4.
S
1.
2.
3.
4.
E
1.
2.
3.
4.
S
1.
2.
3.
4.
Physical condition including diseases of the viscera (cardiovascular, gastrointestinal, urological, and endocrine) and neurological disorders:
Medical problems sufficiently stable that medical or nursing monitoring is not required more often than
three-month intervals.
Medical or nurse monitoring is needed more often than three-month intervals but not each week.
Medical problems are sufficiently unstable as to require regular medical and/or nursing attention at least
weekly.
Medical problems require intensive medical and/or nursing attention at least daily (excluding personal core
assistance only).
Self-care activities dependent mainly upon upper limb function:
Independent in self care without impairment of upper limbs.
Independent in self care with some impairment of upper limbs.
Dependent upon assistance or supervision in self care with or without impairment of upper limbs.
Dependent totally in self care with marked impairment of upper limbs.
Mobility activities dependent mainly upon lower limb function:
Independent in mobility without impairment of lower limbs.
Independent in mobility with some impairment of lower limbs, such as needing ambulatory aids, a brace or
prosthesis, or else fully independent in a wheelchair without significant architectural or environmental barriers.
Dependent upon assistance or supervision in mobility with or without impairment of lower limbs, or else
partly independent in a wheelchair or else there are significant architectural or environmental barriers.
Dependent totally in mobility with marked impairment of lower limbs.
Sensory components relating to communication (speech and hearing) and vision:
Independent in communication and vision without impairment.
Independent in communication and vision with some impairment such as mild dysarthria, mild aphasia, or
need for eyeglasses or hearing aid, or needing regular medication.
Dependent upon assistance, an interpreter or supervision in communication or vision.
Dependent totally in communication or vision.
Excretory functions (bladder and bowel):
Complete voluntary control of bladder and bowel sphincters.
Control of sphincters allows normal social activities despite urgency or need for catheter, appliance, suppositors, etc. Able to care for needs without assistance.
Dependent upon assistance in sphincter management or else has accidents occasionally.
Frequent soiling from incontinence of bladder or bowel sphincters.
Consider intellectual and emotional adaptability, support from family unit, and financial ability:
Able to fulfill usual role(s) and perform customary tasks.
Must make some modification in usual role(s) or performance of customary tasks.
Dependent upon assistance, supervision or encouragement due to any of the above.
Dependent upon long-term institutional care (chronic hospital, nursing home, etc.) excluding time-limited
hospitalization for specific evaluation, treatment or active rehabilitation.
The published PULSES definitions have been adapted. A global assessment of functional abilities is obtained by rating the patient
in each of six categories: P reflects need for assistance due to illness; U reflects need for assistance in self-care activities; L reflects
need for assistance in mobility activities; S reflects need for assistance due to speech or visual impairment; E reflects need for assistance
in managing bladder and bowel functions; S reflects need for assistance due to psychological or social problems. A total PULSES
score is obtained by adding the component numbers. The best score possible is 6 and the worst score is 24.
tolerate it begin mobilization, reintegration and
retraining in the activities of daily living within a day
or two of admission. The admission assessments are
performed by the nurse 24 to 48 hours after admission.
If a patient should show a decline in function from the
initial assessment, then a repeat assessment is made to
reflect his lowest level. In general the nursing staff
have observed the following:
1. No treatment has been needed for superimposed pneumonia. One patient required anticoagulant
therapy for pulmonary embolism. Intermittent
positive pressure breathing is not used unless required
36
because of pre-existing chronic lung disease.
2. No new pressure sores developed in patients
during their care on the Unit.
3. Belt restraints are used minimally because
wants of the patients are anticipated, eliminating his
need to reach for objects beyond a safe range.
4. No enemas have been given past the initial few
weeks of opening the Unit. Rather, a bowel check is
performed daily. If no evacuation has occurred by the
second day, two ducolax suppositories are used, with
results obtained within one hour even in unconscious
patients.
Stroke, Vol. 6, January-February 1975
MEASUREMENT OF OUTCOMES OF CARE FOR STROKE PATIENTS
f ABLE 1
Criteria for Scaling Communication Ability and Intellectual and Emotional Adaptability
Communication Ability — Verbal and Hearing
Independent—No more than slight to moderate limitation in communication due to language barrier or verbal
or hearing disorder.
Dependent—Either no communication is possible or else a structured setting or interpreter is needed to facilitate
communication due to a verbal or hearing disorder or language barrier.
Intellectual and Emotional Adaptability
Independent—Patient functions independently without impairment or only mild impairment in problem-solving,
regard for others, perceptual-motor skills, judgment, reliability or self-esteem.
Dependent—Patient is observed to function appreciably better with assistance, supervision, cuing, coaxing or
structured environment due to above impairments or else impairments are too severe to be
benefited by assistance.
These criteria were used to assess communication ability and intellectual and emotional adaptability at the time of hospital discharge.
Table 5 only shows the rating given at the time of discharge from the Hussey Rehabilitation Unit.
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5. Catheters are not used except in comatose
patients. Attempts are made to determine and follow
the patient's normal voiding pattern.
6. The toilet is used rather than bedpans except
at night or following the afternoon nap.
7. Having a predictable routine on the Unit
appears to have diminished the need to control disruptive behavior or to administer a great deal of medication for sedation, tranquilization or sleep. No narcotics have been used.
TABLE 4
Patients Discharged From Union Hospital Stroke Unit From October 1972 Through December 1973, Total = 164
Home
(81) 49%
Median age
Age range
Male
Female
Median stay in weeks
Range of stay
Right hemiplegia
Left hemiplegia
Bilateral weakness
Not weak
Admission
Barthel—median
Barthel—range
Discharge
Barthel—median
Barthel—range
Admission Barthel
>20
>20
<20
<20
Discharge Barthel
>60
<60
<60
Huuey
(JJ) 20%
Outcovne«
LTCF
(M) 1»%
68
70
78
48-85
49-87
52-89
44
37
2
1-6
26
36
10
9
15
18
4
2-7
13
14
6
0
12
17
4
1-9
8
12
7
2
59
0-100
25
10
0-76
0-73
95
47
35
0-100
7-95
0-94
Died
(«)1J%
75
61-83
10 = 81
11 = 83
2
1 day-6 weeks
4-51
6 = 68
11 = 34
0=11
0
0-42
69 of 81 (85%)
18 of 33 (54%)
21 of 29 (73%)
19 of 21 (90%)
68 of 81 (84%)
25 of 33 (76%)
26 of 29 (90%)
Characteristics of patients are arranged according to discharge outcomes. Eighty-five percent of patients discharged home had admission Barthel scores of greater than 20. Fifty-four percent of patients discharged to Hussey Rehabilitation Unit had admission Barthel
scores of greater than 20. Seventy-three percent of patients discharged to long-term care facilities (nursing home or chronic hospital)
had admission Barthel scores of 20 or less. Ninety percent of patients who died had admission Barthel scores of 20 or less.
Eighty-four percent of patients discharged home had discharge Barthel scores of greater than 60. Seventy-six percent of patients
discharged to Hussey Rehabilitation Unit had discharge Barthel scores of 60 or less. Ninety percent of patients discharged to long-term
care facilities had discharge Barthel scores of 60 or less.
Stroke, Vol. 6, JanuoryFebruory 1975
37
GRANGER, GREER, LISET, COULOMBE, O'BRIEN
TABLE 5
Patients Transferred From Union Stroke Unit to Hussey Rehabilitation Unit and Discharged From October
1972 Through December 1973, Total = 28
Outcomes
Home
14(30%)
Age
Sex
Hemiplegia
median
range
male
female
right
left
66
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Stroke Unit
Stay in weeks
Barthel admission
Barthel discharge
PULSES
median
range
median
range
median
range
median
range
Hussey Rehabilitation Unit
Communication ability
Patients
Intellectual/emotional ability
Patients
Follow-up by District Nurse Association
Number
Months from onset
median
range
mode
disposition
median
Barthel
range
median
PULSES
range
Died
Patients
81
49-83
6
8
7
6
1
Bilateral weakness
Hussey Rehabilitation Unit
median
Stay in weeks
range
Barthel admission
median
range
Barthel discharge
median
range
PULSES
median
range
Acute hospital
«(tJ%>
75-87
LTCF
10(37%)
70
60-85
2
2
0
4
0
5
4
6
3
4
3
4
2-15
45
0-92
2-11
38
32-45
5
2-12
42
25-63
80
32
47
47-100
0-42
22-64
12
20
9-17
19-24
14-23
4
2-7
27
3
2-3
16
4
3-4
4
7-48
10-54
0-53
55
37
52
20-95
23-62
7-64
16
19
12-22
17-20
18
17
14-22
8*
6f
3* It
6*
9*
5f
1* 3t
1* 9f
1
3
8
5
2-6
2 Readm, 6 Home
8 Home
96
47-100
11
8-16
2
3
LTCF
1 LTCF
10
23
1
4f
6
5-7
LTCF
3 LTCF
30
15-32
20
20-23
2
•Independent.
fDependent.
Characteristics of patients are arranged according to discharge outcomes. Comparison is made between length of
stay in weeks, Barthel admission and discharge scores and discharge PULSES scores for the same patients in the
Hussey Rehabilitation Unit and the Union Stroke Unit. Patients who were eventually discharged home were
less impaired in the Stroke Unit than patients who required continued hospitalization or institutionalization.
Communication ability and intellectual and emotional adaptability are shown as rated at the time of discharge
from Hussey according to criteria shown in table 3. District Nurse Association follow-up shows that except for
two patients who died, eight patients discharged home improved further (even though two of them had been
readmitted to the hospital for reasons other than stroke).
38
Stroke, Vol. 6, January-February 1975
MEASUREMENT OF OUTCOMES OF CARE FOR STROKE PATIENTS
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8. Painful shoulder-hand syndromes have not
occurred. Prevention includes absolute avoidance of
assisting the helpless patient by pulling on his affected
upper limb. Subluxation of the shoulder occurred in
five patients during the period of time when use of
shoulder slings was temporarily abandoned. Use of
shoulder slings has been resumed. Physical support to
the patient is usually given through a waist belt.
9. Good appetites appear related to the fact that
meals are taken in the dining room. If for some reason
patients are required to eat at bedside or overbed
tables, they appear to become more discouraged or
disturbed.
10. The fact that admission and discharge functional assessments are filled out by the nurses, according to scales that are comprehensive and according to
definitions with precise meanings, has served to increase their confidence in their own observations of
patients' behaviors and abilities. Thus, at the
behavioral level the nursing staff is better prepared to
recognize differences between stroke and conditions
that may mimic it, such as brain tumor, subdural
hematoma, etc. Consequently, the diagnosis of such
conditions becomes suspected early by the nurse when
a patient is mistakenly admitted to the Unit.
11. Family contact, proper discharge planning
and after-discharge contacts are viewed by the nursing
staff as normal components of the continuum of care.
Consequently, the attending physician is freed of being
confronted frequently with issues that might otherwise
arise if the care plan was managed in a fragmentary
fashion.
Comments on Hussey Hospital
Rehabilitation Unit
The Hussey Hospital Rehabilitation Unit has 35 beds
divided between two floors. Single-bed rooms are used
for more seriously ill patients. Each floor has a dining
room used by all patients for all three meals. Toilets
are adapted by use of grab bars, removable elevated
toilet seats and high-hung toilets. Weekly tub baths
are given using either the hydraulic chair lift or a
regular tub in order to simulate the home situation.
Parallel bars are used for walking patients between
therapy sessions. The main corridor is equipped with
hand rails.
Patients are usually referred from community
hospitals by their private physicians. Applications are
screened by members of the rehabilitation team for estimation of potential to benefit from rehabilitation.
Patients admitted have a variety of major handicapping conditions usually related to neurological,
musculoskeletal, circulatory or respiratory impairment. The usual goal for these patients is discharge
home with improved capacity for self-sufficiency. The
treatment approach is individualized for each patient
and is multidisciplinary. The total care is supervised
by the medical director. Upon completion of the inStroke, Vol. 6, January-February 1975
patient program the patient is returned to the care of
his private physician. Surgical and medical specialists
from the community are available for consultation. A
consulting physiatrist conducts weekly conferences to
evaluate each patient, determine potential, set goals,
follow progress and plan for discharge. Daily rounds
on the nursing unit are conducted with the medical
director, nurse, physical therapist, occupational
therapist and medical students.
Belt restraints are used on all wheelchairs because
the patients take responsibility for their own mobility.
The patient is taken to the toilet after each meal.
Prune juice and milk of magnesia are used in the
bowel training program. Indwelling bladder catheters
are used only as a last resort. Bedpans are used only
after patients have been bedded down for the night.
A routine of appointments and nursing
procedures is established to diminish patients' anxieties. Patients are frequently reminded to maintain
promptness in meeting their therapy appointments.
This helps to encourage time-orientation and gives
patients increasing responsibility for their own activities, and therefore, more of a sense of independence. The usual analgesics are used for pain. Narcotics are very seldom required. Slings are used to
support paralyzed arms and waist belts are used to
assist getting up and down from a chair and for helping ambulation. Various assistive devices are used to
encourage even minimal use of the affected limb.
Social service keeps close contact with family
members and they are encouraged to participate in activities of daily living training. They are also enlisted
to give support and help plan for discharge.
Independence is fostered by encouraging patients to
do for themselves and to take passes for weekend visits
home prior to actual discharge. A guiding motto is
"Never say I can't, say I'll try."
Discussion
STROKE UNIT
Patients discharged to long-term care facilities tended
to be older than patients discharged home. The intermediate group included patients who died or went
to Hussey. Patients admitted from nursing homes
were returned to nursing homes. Patients discharged
home who were not weak (nine) included those with
transient ischemic attacks.
A Barthel score gradient was evident on admission and on discharge favoring patients discharged
home; those transferred to Hussey ranked second,
followed by those discharged to long-term care. Those
patients who died had the lowest aggregate score on
admission (including those in coma or semicomatose).
It is useful to consider that patients with admission Barthel scores of less than 20 points had less
favorable prognoses than those with scores higher
than 20. Patients with scores over 60 are more likely
39
GRANGER, GREER, LISET, COULOMBE, O'BRIEN
to be discharged home than those who do not attain a
level of 60.
REHABILITATION UNIT
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Patients discharged to acute hospital level of care
tended to be older than patients discharged home, and
those discharged to long-term care were in the middle
age range.
Admission Barthel scores were similar in
aggregate for patients admitted. However, discharge
scores were greater for patients discharged home than
for patients discharged to acute care or long-term care
facilities. On review of the Barthel scores of those
same patients when they were admitted to the Stroke
Unit, the aggregate scores were less than 20 for
patients who were eventually discharged from Hussey
to acute care and to long-term care. In contrast, those
who were discharged home from the Hussey
Rehabilitation Unit had admission Barthel scores on
the Stroke Unit of over 20. In other words, patients
who eventually made it back home were less severely
impaired at the onset as measured by the Barthel
Index than those who required continued hospitalization or institutionalization.
Communication problems, such as aphasia, a
foreign language spoken, or hearing deficit, were evident in all three discharged groups. Problems in intellectual or emotional adaptability (confusion, short
attention span, learning problems, etc.) were present
in all three groups but were more severe in those discharged to long-term care. Criteria for communication ability and intellectual and emotional ability are
explained in table 3.
Surviving patients who were assessed by the
District Nurse Association at home had a higher
aggregate score than the comparable score at the time
the patients had been discharged from Hussey.
Donaldson et al.9 described a unified activities of
daily living (ADL) evaluation form which incorporates all self care and mobility factors commonly
used by previous authors plus a few additional
variables. From this they developed scores for the
Katz,10 Kenny11 and Barthel1 scales. In a follow-up
study of 100 patients with a variety of disability conditions who underwent medical rehabilitation they
concluded that the Katz scale was least sensitive, the
Barthel was intermediate and the Kenny was most
sensitive to functional changes in the patient.
Wylie12 used the Barthel Index to follow patients
admitted and discharged from a chronic disease and
rehabilitation hospital over a nine-year period. He
noted that mortality was higher in patients with lower
initial scores. Thirty-six percent of patients who
scored 0 to 15 points on admission improved compared with 77% of those with scores of 60 to 100
points. Patients scoring 75 or more points were more
likely to be discharged home than those with lower
scores.
Carroll13 used the Barthel Index to evaluate
40
stroke patients within one week of onset of stroke and
with follow-up of up to two years. Mortality was
related to increased age and correlated with the lowest
scores on admission of 0 to 10 points. Patients most
independent on admission were most likely to attain
full independence. Complete independence was
achieved in 21% of the group of 98 cases.
Moskowitz et al.14 demonstrated PULSES
profile to be a suitable vehicle for recording the level
of function of post-stroke patients. Variations in the
profile should alert attending personnel to the need for
re-evaluation of the patient.
In a study by Isaacs and Marks15 of 87 severely
disabled stroke patients admitted to a rehabilitation
ward, approximately one month after onset half were
discharged home, a quarter died and a quarter were
transferred to long-stay accommodation. The factors
associated with a favorable outcome were age under
65 and the absence of severe cognitive disturbance.
Conclusion
The objectives of a stroke care program should
include maintenance of a low mortality rate and
rehabilitation of surviving patients to the highest functional outcomes possible. One expression of achievement of rehabilitation goals is to discharge patients
home rather than to long-term care facilities. If a full
rehabilitation program is not available in the acute
hospital, rather than discharge to a long-term care
facility, it is preferable to transfer patients to a
medical rehabilitation unit. From the rehabilitation
unit it should be possible to return additional patients
home.
To an extent the outcomes for some patients are
predetermined by factors of age, co-morbid factors
(such as heart disease, pulmonary disease, vascular
disease, etc.), level of functional abilities at admission
and discharge, availability of competent family support and the patient's mental and psychological
abilities. The degree to which such factors determine
outcomes can be shown by using a system of standardized functional assessments which allows uniform
description of patients over time. By taking into account the several-fold nature of outcome determination it is possible to analyze program effectiveness
because such uniform descriptions, over time, permit
us better to relate the population under care, its key
characteristics for these purposes, and the comprehensiveness of problem identification and planning all at
the same time.
References
1. Mahoney Fl, Barthel DW: Functional evaluation: The Barthel
index. Md State Med J 14:61-65, 1965
2. Moskowitz E, McCann C: Classification of disability in the
chronically ill and aging. J Chron Dis 5:342-346, 1957
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Stroke, Vol. 6, Jonuary-Fabruary 1975
41
Measurement of Outcomes of Care for Stroke Patients
CARL V. GRANGER, DAVID S. GREER, ELIZABETH LISET, JOAN COULOMBE and
ELIZABETH O'BRIEN
Stroke. 1975;6:34-41
doi: 10.1161/01.STR.6.1.34
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