The Main Components of Stroke Unit Care: What Is the Question?

teams (which probably do not improve patient outcomes) was emphasised. We should acknowledge that there is surprisingly little evidence to demonstrate that comprehensive stroke centres improve patient outcomes [5] and at present their role must be justified by their ability to deliver specific services. In contrast, primary stroke centres appear to be evidence-based stroke units while the third level of care (any hospital ward) would now be considered to fall below national standards of acceptable care in many countries. Despite these concerns we must recognise the need to move stroke services onto a higher level. In many countries this will include improvements in hyperacute care, and this consensus document will be useful to help argue for better resources. However, in striving to improve hyperacute care we must ensure that all patients continue to enjoy the benefits of ‘routine’ comprehensive stroke unit care that are both significant and widely applicable [5, 6] . The article ‘The main components of stroke unit care’ [1] describes a survey of European stroke experts who were asked to identify what they believed to be the main components of organised stroke unit care. This form of consensus gathering can have a useful role where there is a need to summarise clinician opinion with the aim of driving up standards of care, particularly where reliable clinical evidence is not available. What then is the value in doing such an exercise around stroke unit care, which has been relatively well researched and described [2–4] ? The authors’ justification is that there is little evidence about the relative merits of different types of stroke unit. What this really means is that we lack evidence about different services that are often linked to a stroke unit, in particular hyperacute assessment and management. In fact, the evidence base for the basic pathway of ‘routine’ multidisciplinary stroke unit care appears strong and uncontroversial and has been remarkably consistent across the different randomised trials [4] . It is reassuring that the consensus process has given top priority to a number of features of this pathway; for example staffing with a co-ordinated multidisciplinary team including specialist stroke nurses and early physiotherapy. Why should we have any concerns about combining the different (but presumably complementary) objectives of improving ‘routine’ stroke unit care and hyperacute management? Firstly, the survey was based on a North American model of stroke care (centred on comprehensive stroke centres) that may be applicable for that type of healthcare system. However, it may not be easily applied in places like the UK and Scandinavia where stroke outcomes are being improved by providing stroke units in all hospitals [5, 6] . Secondly, where there is a lack of evidence, opinions tend to reflect the orthodox views and interests of those consulted. A low priority is often given to alternative options such as the use of telemedicine networks to provide expert neurological input across a wide area. The final concern is that focussing recommendations on hyperacute management may remove emphasis from the importance of providing comprehensive stroke unit care. For example, the recent North American consensus statement on the criteria for primary stroke centres [7] has been criticised [8] because the role of multidisciplinary stroke units (for which there is a lot of evidence) was downplayed and the role of mobile stroke Published online: April 13, 2007