Neuropsychological input during hyper-acute stroke admission is associated with improved discharge outcomes

Background Discharge decisions in hyperacute stroke units (HASUs) are often made without a comprehensive understanding of a patient's cognitive functioning. Specialist neuropsychological assessment can provide valuable information to support these decisions, yet access to clinical neuropsychology remains limited across UK HASUs despite national recommendations. We examined whether neuropsychological input during HASU admission was independently associated with discharge destination, length of stay, and patient flow. Methods We analysed data from 2437 consecutive stroke patients admitted to a large inner city UK HASU between 2021 and 2026. Multivariable regression models examined associations between neuropsychological input, length of stay, and discharge destination (home vs repatriation), adjusting for demographic and clinical covariates. Subgroup analyses examined patients with prolonged admissions (≥14 days) and those referred but not assessed due to resource constraints. Results Neuropsychological input was not associated with a clinically meaningful increase in length of stay. However, it was independently associated with a higher likelihood of direct discharge to the community (OR 1.66; p = 0.007), particularly among patients with prolonged admissions (OR 2.64; p = 0.020). Patients referred but not seen due to a lack of neuropsychological provision were much less likely to be discharged to the community (17.6% vs 40.1%) and had substantially longer inpatient stays across the pathway (18.1 vs 5.7 days). Exploratory pathway modelling illustrate how consistent neuropsychological input may translate into meaningful bed-day savings. Conclusions Our findings suggest that specialist neuropsychology may play a decision-enabling role in discharge planning and may contribute to more efficient patient flow, reduced repatriation, and greater value across the stroke pathway.