4.1 Stroke unit care

Stroke units – which should provide coordinated, multidisciplinary care by personnel specialised in stroke care (European Stroke Organisation) – save lives and improve  outcomes. “Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke”[226]. The 2nd Helsingborg Declaration stated that “all patients in Europe with stroke will have access to… stroke units in the acute phase…by 2015”[227].

Using data from recent publications as well as information gathered through the questionnaire sent to European stroke experts[9] we found significant differences between countries in the number of stroke units and percentage of patients treated in stroke units (Figure 9) ranging from <10% in Malta, Iceland, Romania, and Ukraine to >85% in Sweden and Norway.

Lower rates of stroke unit care were generally found in Eastern Europe. However, two consecutive questionnaire-based surveys (CEESS Working Group, completed by stroke experts in the respective country) observed large variations between Central and Eastern European countries (included in Figure 9[229, 230]).

Overall, the number of stroke units and the percentage of stroke patients treated in stroke units have increased significantly since 2000. National audits in Germany, Poland, Sweden, and the UK showed a two-fold increase in the proportion of stroke patients treated in stroke units between 2004 and 2009[163]. In Spain, 39 stroke units existed in 2009 compared to 45 in 2011[231, 232], while 17% of stroke patients were treated in stroke units in 2005 compared to 23% in 2007[233].

In Finland this proportion increased by 18% between 1999 (11 stroke units) and 2007 (16 stroke units)[54, 234]. 2% of Irish stroke patients were cared for in a stroke unit in 2008 compared to 54% in 2015[129]. Also in most Eastern European countries, an increase in the percentage of patients treated in stroke units was seen in the two consecutive studies published in 2007 and 2015 (e.g. Czech Republic from 10% to 85%,[229, 230]). The number of stroke units in Poland increased from three in 1997 to 150 in 2012[235, 236].

Figure 9: Percentage of stroke patients receiving stroke unit care

References:  Norway:[9],  Sweden:[53],  Czech  Republic:[230],  UK  (excluding  Scotland):[237], Germany:[238], Poland:[230], Austria:[239], Finland:[54], Estonia:[230], Ireland:[129], Denmark:[240], Croatia:[230], Serbia:[230], Slovenia:[230], France:[241], Latvia:[230], Hungary:[230], Italy:[242], Spain:[233], Slovakia:[230], Bulgaria:[230], Romania:[230], Iceland:[9], Malta:[243]

Many european countries report variations in stroke unit care between different regions. Urban areas are usually better provided for than rural areas, e.g. Greece with variations between major cities, rural areas, and islands[9]. In Spain, stroke units are concentrated in Madrid and Barcelona[231], and the ratio of stroke unit beds to residents was found to range from 1/74,000 to 1/1,037,000[232]. Of 130 Italian stroke units, 67% are located in Northern, 22% in Central, and only 11% in Southern Regions, which, however, contains 34% of the Italian  population[244]. French data indicate that nationally 33% of stroke patients are treated in stroke units[241] compared to 51% in the Dijon Stroke Register area[162]). 73% of Finnish patients living within the catchment area of a stroke unit were treated in a stroke unit compared to 9% outside a catchment area[54]. In Austria, a stroke unit can usually be reached in less than 45 min, but some areas show travelling times of over 90min[245]. Therefore, within-country variations might be as large, or even larger than variations between national averages (if known).

However, comparing the published proportions of stroke unit care or number of stroke units across countries has to be done cautiously due to several limitations.

Firstly, due to the significant increase in stroke unit care over recent years, figures depend on when the data were collected.

Secondly, some studies only looked at subsets of stroke patients, e.g. those admitted to a stroke unit within a certain time of hospital arrival[240] or patients spending a certain proportion of their hospital stay in a stroke unit[162].

Thirdly, some studies use only hospitalised stroke patients as their denominator (national audits), while others give the proportion of all stroke patients in a certain area (e.g. populationbased registers). In this case, the proportion of stroke unit care is highly dependent on stroke hospitalisation rates, which again vary across Europe (estimated rates: Finland 95- 98%, Sweden 84-92%[54], Bulgaria 96%[189], Hungary 90%, Italy 87%, The Netherlands 60%, Scotland 62%[246]).

Some international studies have developed standardised datasets, in order to be able to compare between countries. The European Registers of Stroke (EROS) Investigators compared the proportion of stroke patients in population-based studies spending more than half of their hospital stay on a stroke unit in 2004-6 and found a proportion of  0% in Spain (Menorca), 16% in Italy (Sesto Fiorentino), 23% in Lithuania (Kaunas), 48% in Poland (Warsaw), 51% in France (Dijon), and 65% in England (London)[162]. The European Implementation Score (EIS) project, using national audit data of hospitalised stroke patients, reports stroke unit treatment rates of 91% for Poland, 84% for Sweden, 75% for Scotland, and 73% in England, Wales and Northern  Ireland  in  2008[163].  Again,  large differences between countries/studies could be seen.

However, definitions of what is called a “stroke unit” are not always the same and significant differences in standards of care can be found. The European Stroke Initiative (EUSI), based on expert opinion, stratified “Stroke Units” into “comprehensive stroke centres” (CSCs, equipped with interventional neuroradiology, advanced neurosurgery, 24/7 MRI) and “primary stroke centres” (PSCs, multidisciplinary team, stroke-trained nurses,  24/7  CT)  and  any  hospital ward (AHW) admitting stroke patients routinely[247]. The European Stroke Facilities Survey, 2005, looked at the number of hospitals fulfilling CSC-, PSC-, and AHW-standards. It found large disparities between countries, with only few European hospitals providing an  optimal  level  of  care[248].  In  Estonia, France, Greece, and Portugal more than three quarters of participating hospitals did not provide the minimum level of care. Countries with a large number of small hospitals treating only few stroke patients, e.g. France and Germany, performed badly in this survey.

Overall, 51% of participating European hospitals caring for 42% of stroke patients did not meet minimum standards. Only 5% of hospitals had facilities meeting the standards of comprehensive stroke centres[248].

Much has improved over the last decade  in terms of the availability and standard of stroke unit treatment, but also the quality of stroke units. Poland had no CSCs in 2003, while by 2010 nine stroke units fulfilled the CSC  criteria.  In  2003,  most  “stroke  units” failed to provide care at PSC level, but by 2010 all of them did[236]. In Catalonia, a stroke network has been operating since May 2006 with 6 CSCs, 8 PSCs, and 35 Community hospitals, and those providing thrombolysis (6) are linked to their PSCs via   telestroke[244].   The   Czech   Republic introduced a system with 11 comprehensive and 34 primary stroke centres in 2010/11[249].

The Central Denmark Region carried out   a stroke care reform in 2012 involving centralisation of stroke care into two specialised centres and found increasing thrombolysis rates and reduced 30-day mortality[250].

In two UK urban areas (London and Manchester), stroke services were centralised in 2010 into a small number of hyperacute stroke units for the acute phase and general stroke units.

Example from the Czech Republic[249]: before 2001 there was no central accreditation of stroke units; 2001-9: stroke units were accredited by scientific society; 2011: new system of 34 PSC/11 CSC, accredited by Ministry of Health and scientific societies; 2013: 12 Quality of care indicators reviewed in 6-monthly audit (compulsory); stroke unit care of stroke patients increased from 10%[229] to 85%[230];
Example from Bulgaria: St. Marina University Hospital in Varna: 2005 course of stroke care for nurses – 2007 introduction of thrombolysis – 2011 enrolled in the SITS programme – 2015 part of QUICK program, ESO and part of ESOEast – 2016 registered for Angels Initiative, thrombolysis rate 5.8%, nationally under 1%.[9]


Patients admitted to hyperacute stroke units were shown to be significantly more likely to receive evidence-based interventions and experience better outcomes[251, 252]. Despite this, the 2014 UK national stroke audit (using a gold standard of seven stroke unit criteria) reported that the majority of UK stroke unit beds  did  not  meet  this  standard[253].  So improvements made in some areas, in this case two large metropolitan areas, might not be representative of a country as a whole.

The large inequalities in quantity and quality of stroke  unit  care  between and within European countries led to several international (Stroke Unit Trialists’ Organisation, ESO) and national stroke organisations,     e.g.     Belgian     Stroke Council, German Stroke Society, Spanish Neurological Society, issuing guidelines for the creation of stroke units using widely agreed standards based on evidence  or experts consensus.

A system of official accreditation has been introduced on a European- and national level  (e.g.  ESO  Stroke  Unit  and  Stroke Centre Certification Platform launched in   2016).   Hospitals   are   encouraged   to apply[244, 254]. Certification is now mandatory in some countries/areas (e.g.  France)  and financed  and  organised  by  governmental agencies.  In  other  countries,  it  remains voluntary   (e.g.   Germany, organised  by the  German Stroke Society, the German Stroke Foundation  and an  accredited certification institution, and paid for by the hospital).    Some European countries have no system of official accreditation,  e.g. Belgium, Lithuania[244], Sweden (where the national audit is a driver of care quality), or Macedonia[178]. In many European countries (Latvia, Croatia, Slovakia, Lithuania, Bulgaria, Hungary, Poland, Greece, Czech Republic, Romania, Austria, France), some hospitals have become members of the ESO Registry, setting standards of stroke unit care, but figures vary from less than 5 in Latvia and Croatia, to over 50 in France[228].

Comparisons of stroke unit care across Europe have many caveats because there is no Europe-wide standardised system of assessment. However, it is clear that stroke unit care differs widely between, and within countries in terms of both quantity and quality.

The 2015 Helsingborg goals of universal availability for every stroke patients have not been reached, in most countries by a very wide margin.

Example from the UK: Until 2010 acute stroke care in London was provided in 32 acute hospitals of very variable quality, even though each hospital had a stroke unit. From July 2010, all acute stroke patients were taken to one of 8 accredited hyperacute stroke units for the initial 2-3 days. Several hospitals were not accredited and ceased providing any stroke care at all. Length of stay has fallen by about 4 days and thrombolysis rates have risen from about 3% to about 12%.[244]