In the UK someone somewhere has a stroke every five minutes, and over one hundred and thirty thousand people have a stroke each year. These individuals, eighty percent of whom are over 65 years old, have roughly equal chances of death, dependency, or minimal or absent disability. There is, essentially, only one, time dependent, treatment for strokes associated with blocked blood vessels, and nothing for those associated with burst arteries in the brain, and an individual’s outcome is dependent upon a complex mix of starting points and professional and lay inputs that owes as much to chaos theory as it does to the planning of care and therapy. Stroke is the third biggest killer in the UK and the largest single cause of disability in the western world, but investment in research and development within the field has not reflected this prominence until recently, with new governmental priorities, investment in the pathway of care, and a national awareness campaign due to start in the Spring.

Now, in origami it is the first folds that matter. Whether you are working towards an object of pure beauty such as a crane, or something as utilitarian as a water bomb, it is the accuracy and precision with which you first touch the coloured square of paper which do most towards the outcome, be it beauty or function. Modern stroke care, likewise, recognises the importance of beginnings with the Government’s Stroke Strategy (Department of Health 2007) and the latest iteration of the Clinical Guidelines (Intercollegiate Stroke Working Party (Clinical Effectiveness & Evaluation Unit) of the Royal College of Physicians 2008) both emphasising the need for speedy recognition, admission, and intervention for individuals with stroke.

All origami creations, functional or decorative, rely on a simple set of folds and manipulations used in a variety of combinations, although most begin by folding the paper square in half. Likewise, at its simplest, modern stroke care relies on a simple set of principles and skills.

The first principle, the fold that underlies stroke care and opens up so many possibilities, is that ‘Time Is Brain’. In the early hours of a typical ischaemic stroke (which account for some eighty-five percent of all strokes) almost two million neurons, and seven and a half miles of myelinated fibres are lost every minute, literally time is brain. The only readily available treatment for ischaemic stroke, thrombolysis, is also time dependent, with a three hour window for its use (although the recently published results of the ECAS3 trial (Hacke et al. 2008) may open that window further), a window during which brain scans must be obtained and assessments of risk and benefit balanced. However, even with the availability of three, or even four and a half, hours in which to start treatment time is still brain, and the sooner the drug is administered, the greater the chance of a positive outcome, of re-opening the blocked vessel and returning blood flow to the portion of brain affected.

The second principle, the next basic fold, is that patients who are looked after in organised stroke care environments, stroke units, do better (Brainin and Tatschl 2007, Langhorne 2000, Silvestrelli et al. 2006, Stroke Unit Trialists’ Collaboration 1997a, 1997b, 1999). Stroke units are a bit of a black box, as no-one is quite sure how they work; only that they do. But stroke units have a set of prerequisites that together appear to make the difference including: nurses, therapists and medics who are specialists in stroke care, a stroke specific teaching programme, multi-disciplinary therapy and goal-setting, and links to external, non health service organisations with an interest in stroke.

The third principle, which has already been alluded to, and where the folds become complex, but in which the future shape of the creation is decided, is that there are actions that can be taken, and skills that can be brought to bear, at the outset of an individual’s stay in hospital after a stroke, that may make a difference to the eventual outcome for that individual. Immediate admission to the stroke unit, close monitoring for, and rapid response to, neurological or physiological change, and early multi-disciplinary intervention for the prevention of the complications of stroke all appear to make a difference to outcomes, whilst patients and those close to them appear to find comfort in knowledgeable staff and the specialist environment.

The fourth principle is that stroke care is, like origami, demanding, but unlike folding paper it is hard work, physically and emotionally, with no guarantees of success, and, like living with a stroke, only uncertainties as, rather cold, comfort. That said, and in my experience, stroke care nurses, therapists, and doctors are dedicated and committed professionals, whose interest in the complexities of the condition and in the individual patient may yet prove to be one of the most important factors in the success of stroke care.

The Stroke Unit at Oxford opened in a refurbished ex-trauma ward in January 2005, bringing together a small Acute Stroke Unit and a Care of the Elderly Ward that provided a rehabilitation environment for a cohort of patients with stroke. Originally twenty-three bedded, with a therapy gym (thanks to its previous use), adapted toilets and bathrooms, and a dedicated (in both senses of the word) multi-professional team of nurses, physiotherapists, occupational therapists, speech and language therapists, dieticians, pharmacist, ward clerk, and social worker, the Stroke Unit was designed as a combined, or comprehensive, unit offering both acute care and rehabilitation.

Now four years on, the times when the Stroke Unit has not been in a state of flux have been rare. The model of senior medical provision has been reviewed frequently, the basic skill base has been expanded, teams have been restructured, beds have been closed, the space made has been used, beds have been re-opened and the space lost, staff have come and gone, at one point five nurses were off on maternity leave at the same time, and what has been required of the unit has evolved as local and government priorities and policy have changed.

When the unit first opened, the challenge that we faced was to build a coherent team from the three groups of professionals brought together to provide Stroke Care in this new setting. There were a team of acute care nurses, a team of nurses from an elderly care rehabilitation environment, and a group of, mainly newly appointed, neuro-specialist therapists.

There was a choice to be made, we could create something that was purely functional, like a water bomb, a unit where the skills of each individual would be used to ‘get the job done’, or we could shape it into something more aesthetically meaningful, like the paper crane, a unit where each individual could work to provide more comprehensive care and therapy for their patients.

We chose the second option, working to integrate the skills and ideals of rehabilitation and the care of the older person with acute care principles. Before the unit opened nursing staff moved between acute and rehabilitation environments to gain, develop, or strengthen specific skills, and to highlight issues that we were then able to address whilst the unit prepared to open. This process was supported by teaching / learning sessions, which have continued since the Stroke Unit opened and now includes all the members of the multi-disciplinary team, including the medical staff. These educational sessions have evolved over the course of time, and now revolve around specific cases that illustrate or illuminate areas of stroke care where multi-professional care can best serve the individual with stroke, linking diagnostics, medicine, nursing and therapy with the individual’s progress and outcomes.

We were largely successful in our initial aims (which is not to say that there were not plenty of problems along the way), but the shape of the unit was destined to change again when a thrombolysis service began to be planned, and with the Stroke Unit playing a central role in its provision.

The skills involved in caring for a patient who has undergone thrombolysis for ischaemic stroke are not that different from those used in usual stroke care, but they are certainly more intense, and, to accommodate immediate post-thrombolysis care, the Stroke Unit needed to adapt to a new way of working, faster and more responsive to change, both for the patient, and in the need to rapidly adapt the environment to facilitate their care.

The lessons learnt from this change influenced the hyper-acute care of all stroke patients, changes which have served, and will continue to serve, the Stroke Unit well as it has moved into a new era of responding to an increasing body of evidence supporting the importance of expert and knowledgeable care in the hours and days following an acute event – those first folds that shape the outcome.

The Stroke Unit is now facing a third period of major reshaping, but the initial work undertaken to embed rehabilitation, both as a principle and a skills base, remain valid first folds.

For a variety of reasons, the Stroke Unit has always faced problems in maintaining the through flow of stroke patients, not least amongst which have been the unpredictable admission pattern and the availability of ongoing specialist rehabilitation facilities. However, the government’s Stroke Strategy (Department of Health 2007) has made clear that there is a need to provide primary stroke prevention, a thrombolysis service, rapid admission to organised stroke care, ongoing rehabilitation and re-enablement (including supporting individuals in their own homes), and lifelong support. The acute trust (responsible for the Oxford Stroke Unit and its sister ward in Banbury) is working with the local community trust, social services, ambulance trust, and voluntary organisations such as the Stroke Association (http://www.Stroke.org.uk) to shape a pathway for all individuals with stroke and transient ischaemic cerebral events that is responsive, in both time and its respect of the individual, equitable, evidence based, and which ensures that all those with stroke are in the right place at the right time.

Compared to the paper crane this pathway is likely to have a shape and complexity to rival the famed origami roses, or the creations of artists such as Brian Chan (http://chosetec.darkclan.net/origami) but, just like the Stroke Unit, the pathway will best serve those at risk of stroke or suffering from one if it gets the first folds right, both in terms of developing the pathway, and in providing care at each milestone on that road.

This new pathway should also serve the Stroke Unit by providing on-going care and rehabilitation in a timely and seamless manner so that the unit and its skilled nursing, therapy and medical staff can provide those important first folds – so that whatever the final shape, the outcome for the individual who has had a stroke, it is as beneficial as it can be.

References

Brainin, M. and Tatschl, C. (2007) Acute stroke units are effective, also in eastern Europe. European Journal of Neurology,14, 595-596.

Department of Health (2007) National Stroke Strategy. Department of Health, London.

Hacke, W., Kaste, M., Bluhmki, E., Brozman, M., Dávalos, A., Guidetti, D., Larrue, V., Lees, K., Medeghri, Z., Machnig, T., Schneider, D., von Kummer, R., Wahlgren, N., Toni, D. and the ECASS Investigators (2008) Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. The New England Journal of Medicine,359(13), 1317-1329.

Intercollegiate Stroke Working Party (Clinical Effectiveness & Evaluation Unit) of the Royal College of Physicians (2008) National clinical guidelines for stroke, third edition, Royal College of Physicians, London.

Langhorne, P. (2000) Organisation of acute stroke care. British Medical Bulletin,56(2), 436-433.

Silvestrelli, G., Parnetti, L., Paciaroni, M., Caso, V., Corea, F., Vitali, R., Capocchi, G. and Agnelli, G. (2006) Early admission to stroke unit influences clinical outcome. European Journal of Neurology,13, 250-255.

Stroke Unit Trialists’ Collaboration (1997a) Collaborative systematic review of the randomised trials of inpatient (stroke unit) care after stroke. British Medical Journal,314(7088), 1151-1159.

Stroke Unit Trialists’ Collaboration (1997b) How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke,28(11), 2139-2144.

Stroke Unit Trialists’ Collaboration (1999) Organised in-patient (stroke unit) care for stroke, Cochrane Library, Oxford.

End of Policy and Practice section