The process of stroke rehabilitation: what happens and why

To assess the process of hospital-based stroke rehabilitation.

A criterion-based process audit, combined with surveys of patient and staff opinions and basic outcome measures.

All wards and units treating stroke patients in a health care district, including an acute and a community National Health Service (NHS) trust.

Process audit: documented notes of 115 stroke patients admitted over a four-month period. Patient satisfaction survey: 93 surviving stroke patients. Staff opinion survey: Hospital doctors, therapists and nurses treating stroke patients throughout the district.

A disappointingly poor level of service. The main shortcomings were poor assessment of impairment (pass rate, 46%), inadequate communication between staff and with patients and carers (pass rate, 43%), and an absence of rehabilitation beyond the basic of activities of daily living and indoor mobility (pass rate for assessment of disability and emotional need, 50%). Thirty-three per cent of patients were dissatisfied with the hospital-based service they received, particularly lack of therapy, information and recovery. The main reasons for these shortcomings were low priority given to stroke patients, lack of time, shortage of staff, and lack of knowledge and awareness of stroke amongst the staff. Rehabilitation units and elderly care tended to perform better than general medical units in areas of assessment of impairment, self-care skills and mobility, and wheelchair provision.

Evidence from previous publications suggests that this service was no worse than in other districts, but this audit methodology, by comprehensively examining many aspects of a service together, is better able to reveal inadequacies.