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Stroke and Vascular Units

Mixed stroke unit

The mixed stroke unit (MSU) is the adequate hospital area to specialized care for patients with stroke, with defined physical area and hospital beds used in the treatment of patients with stroke with clinical status already stabilized but still in the acute phase, starting rehabilitation early (is not intended for thrombolysis). The service is provided by an interdisciplinary team, coordinating the use of medical procedures, rehabilitation, educational and social procedures aiming to achieve the best functional outcome.

The mixed stroke unit should have a technical manager characterized by a physician with the specialist degree provided by the Brazilian Academy of Neurology or a certificate of a residency program in Neurology, supported by the Medical Residency Program, recognized by the MEC. The chief Neurologist responsible for the MSU should do at least a weekly visit to all hospitalized patients, recorded at the medical charts and report, and train the entire team that will care for the patients. He will also be legally responsible for the MSU. The MSU should have sufficient staff able to attend for clinical complications at the ward must have a weekly outpatient clinic. The unit must have their own guidelines and routines, written, updated annually and signed by the Chief Neurolosgist.

1.Equipe Basic Health:
a.Neurologist: physician with the specialist degree provided by the Brazilian Academy of Neurology or a certificate of a residency program in Neurology, supported by the Medical Residency Program, recognized by the MEC, which is allowed to be the MSU chief.
b.Clinician: physician with the specialist degree provided by the relevant specialist medical society recognized by the Brazilian Medical Association - BMA or a certificate of a residency program in Neurology, supported by the Medical Residency Program, recognized by the MEC c.Nurse: the team must have a nurse coordinator with stroke care trainning. Also must have nurses, nursing technicians and nursing assistants in sufficient quantity to meet the ward, all trained for stroke treatment.
d.Physioterapist: 
e. Occupational Therapist
f.Phonoaudiologist: capable of swallowing and language rehabilitation.
g.Nutricionist
h. Social Assistent
i. Psychologist


2. Complementary Health Team (multidisciplinary team):
 The unit should have a permanent or reachable team characterized by:
a.Neurosurgeon
b.Cardiologist
c. Vascular surgeon
d. Interventional Neuroradiologist: radiologits, neurosurgeon or neurologist with the certificate of interventional neurology residency program recognized by the MEC.

3. Specific physical installations:
 The MSU should have rooms suitable for patients with disabilities (adaptations in bathrooms, carpet grip, lifted toilet seat and safety bars), caged beds, chair for early withdrawal of the patient"s bed. At least 40% of the beds should be monitored. Sufficient staff to care for outpatient clinic.

4. Complementary installations:
a. Local physiotherapy service or outpatient referenced center;
b. Speech rehabilitation service or outpatient referenced center.


Vascular Units
The Vascular Unit (VU) is a unit with defined physical area and its own medical staff within the Emergency Department with specific beds for the care of patients with acute vascular diseases: stroke, acute coronary disease, pulmonary embolism and acute aortic syndromes. It combines in one physical space the benefits of a chest pain unit and stroke unit. The primary objective of the Vascular Unit is to make faster, easier and safer the treatment of acute vascular diseases in emergency departments constantly overcrowded.

The VU must have high turnover and treatment guidelines similar to an intensive care unit. Mostly concerning the adoption of routines employed in critical care and not for the sophisticated equipment required. Caged beds, one multiparameter patient monitor, oxygen support and 2 infusion pumps per bed are the highest required sophistication. The most important is the coordinated set of actions leading to the best care, especially the integration of multidisciplinary team. What makes the difference is well a trained staff. Rapid laboratory tests, hemodynamic and radiology services and acute care for the clinical complications is essential. Recognize and treat the patient with hemodynamic instability, severe hypertension, respiratory arrest or change in the sensory level are skills that the VU team must possess. The implementation of a VU routine has a positive impact on the quality of patient care.

The VU, unlike the rest of the emergency, should have a limited number of beds, ideally 3-5 beds. The VU should be  connected by telephone with the reception, collecting, laboratory, radiology and hemodynamics. Specialists teams (cardiology, neurology, neurosurgery, hemodynamics, vascular surgery, pulmonology) should provide technical support 24 hours per day at least on demand to guide the specific treatment. Emergency physicians, intensivists or physicians with emergency medicine should be trained to manage patients with acute stroke and its complications. In addition, nurses and nursing technicians should also be trained for routine stroke care. All these actions are justified to reduce the time between the beginning of symptoms and thrombolysis initiation. Stroke patients usually stay 24-48 hours at the VU. The quality indicators should be measured considering the time between the beginning of symptoms and thrombolysis initiation (if applicable), hospitalization need, ICU need, mortality, rate of symptomatic cerebral bleeding and the proportion of patients with minimal or no disability at 3 months .



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