Early Scandinavian Stroke Scale Scores as a Predictive Tool for Rehabilitation and Discharge Planning Brett Jones1, Ronak Patel2,3, Christian Lueck1,3 1Department of Neurology, Canberra Hospital and Health Services 2Stroke Service, Calvary Public Hospital Bruce 3Australian National University Thank you to the CHARM committee for the opportunity to present today. My name is Brett Jones, and I am currently the Stroke Liaison Nurse here at the Canberra Hospital. I would like to thank my co-authors for their involvement in this project and their assistance to me in getting this idea off the ground. Today I will be speaking about the use of a stroke severity score, the Scandinavian Stroke Scale, in a novel way as a tool to predict the discharge destination of acute stroke patients.

The Scandinavian Stroke Scale Initially developed by Scandinavian Stroke Study Group in 1985 as no other scale was available for use by non neurologists2 Elements include: Consciousness Eye movement Arm, motor power Hand, motor power Leg, motor power Facial palsy Gait One such score that passes all five of these tests is the Scandinavian Stroke Scale or SSS Initially the score was developed in the 80s by a Scandinavian research group conducting a trial on haemodilution in stroke. They required a scale to rate severity, when none existed they proposed the first variation of this new scale. Elements included level of consciousness, motor power in the arm, hand and leg, facial weakness and gait. 2Scandinavian Stroke Study Group. Stroke. 1985;16:885-890

This the current scale in use at the Canberra Hospital. While the National Institutes of Health Stroke Score is by far more widely used it needs specific certification to be valid. The SSS however requires relatively little training and can be used by nursing staff quite quickly to rate the severity of stroke. One of the elements of the SSS which is heavily weighted and easily scored is gait. This is very useful in telling us what a patient’s likely level of function will be.

Background Pressure to minimise LOS Early prognostication to guide discharge planning vs rehab would be helpful Stroke severity tools have been shown to correlate with outcomes of death or disability1 Unknown if these tools are able to predict discharge destination In acute hospitals there is always pressure to ensure we minimise length of stay and maximise efficiency. The best way to do this when caring for stroke patients is by knowing very early in the admission where the patient will end up. If we know early that they will need rehabilitation or if they can be discharged directly home, we know where to focus our planning efforts. Stroke severity scores have been shown to be helpful at telling us about outcomes, but its not known if they can also tell us what the discharge destination will be. 3Christensen et al. Cerebrovascular Diseases 2005; 20:46-48

Background The Canberra Hospital Stroke Unit uses the Scandinavian Stroke Scale Scores range from 0 (worst) to 58 (best) We hypothesised that the SSS could predict early discharge and the need for rehabilitation Currently the Scandinavian stroke scale is used in the Canberra Hospital Stroke unit. The Score ranges from 0 at worst to 58 at best. We wanted to test our hypothesis that the score within the first 24 hours of admission to the stroke unit would be able to predict if a patient would be discharged home or need rehabilitation.

Methods Prospective data collected of 162 patients May, 2015 – Jan, 2016 Admitted to acute stroke unit at the Canberra Hospital Clinical and/or radiological diagnosis of stroke: Both ischaemic and haemorrhagic We had available prospective data in the Canberra Hospital Stroke Registry from May 2015 to Jan 2016 From here we only looked at patients admitted to the stroke unit who had complete data of which there were 162 patients. We included both ischaemic and haemorrhagic stroke patients in our study.

Methods SSS Scores within first 24 hours of admission divided into three groups: Good (>50) Intermediate (30-49) Poor (<30) Discharge destination from acute care analysed to see how well admission SSS scores predicted discharge destination We divided the SSS categories into three groups : Scores of 50 or more as good Scores between 30-49 as intermediate And scores bellow 30 as poor Discharge destination from acute care was matched to the patient’s score to see how well it predicted discharge destination.

Results Of our results when the SSS scores were allocated into these categories 47% scored 50 and over, 35% scored 30-49 and 18% recorded a score of less than 30. This actually gave us good information about our patient’s symptoms initially being quite mild.

Results Of discharge destination we could see that over half of our patients went home direct from acute care, 28% were transferred for ongoing inpatient rehab 11% were transferred direct to a nursing home and 8% died in hospital

Results When we combined the discharge destinations with the SSS categories we obtained the following results. We could see that over 90% of patients who scored over 50 went directly to home. Over half of the patient’s who scored between 30-49 needed rehab and over a quarter went directly home from acute care. In the scores less than 30 we could see that none went directly home, and that nearly all our patients who died in hospital were in this group.

Conclusions SSS of >50 was highly predictive of discharge home SSS of <30 was highly predictive of lack of early independence or death 90% of patients who died in hospital scored <30 A score of 30-49 was not predictive of discharge destination Further study needed to validate the predictive potential of the SSS In conclusion: A score of greater than 50 was highly predictive of discharge home directly from acute care. An SSS of less than 30 was highly predictive of lack of early independence or death. 90% of patients who died had a poor score of less than 30. An intermediate score was not clearly predictive of discharge destination, but rehabilitation patients were highly represented in this category. Further study is needed to validate the predictive potential of the score. Thank you.

References 1Hanson et al. Stroke 1994 25:2215-2219 2Christensen et al. Cerebrovascular Diseases 2005; 20:46-48 3Scandinavian Stroke Study Group. Stroke 1985;16:885-890