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Pathway

Pathway

This section provides information on the step-by-step actions taken by healthcare professionals in caring for stroke patients once a diagnosis has been made. Pathways (also called care tracks and care maps) include a range of documents such as internal hospital forms, triage and protocol guidelines, intervention guidelines, as well as stroke care systems development and stroke team/center development.

Cleveland Clinic Foundation Coordinated Care Tracks

  • Blood Pressure Management for Acute Stroke Thrombolysis Candidate
  • Cleveland Clinic IV rt-PA Faxable Protocol Checklist
  • Department of Radiology
  • Discharge Planning Record (DPR)
  • DPR Continuation
  • Emergency Department
  • Hospital Day 1
  • Hospital Day 2
  • Hospital Day 3
  • Hospital Day 4
  • Triaging Acute Stroke

Froedtert & Medical College: Stroke, Neurovascular History, Physical Kit, and Discharge Day Management

  • Discharge Day Management Summary For Neurovascular Patients
  • Stroke & Neurovascular History & Physical Kit

Greater Cincinnati – Northern Kentucky Stroke Team: Ischemic Stroke Management at the University of Cincinnati

University Hospital, Inc. 234 Goodman Street Cincinnati, Ohio 45267

Ischemic Stroke Management at The University Hospital Cincinnati, OH

Program Overview

In 1994, a CQI group was established to focus on management of stroke patients. Physicians and department representatives met to discuss causes of delays in patient care and opportunities for improvement. They identified rate-limiting steps in the clinical process and found opportunities for reducing costs and length of stay, increasing admissions, and achieving uniform practice standards among physicians. Stroke care is managed by neurology physicians who are stroke specialists. Orders are designed to conform with the clinical pathway.

Process of Care – Patient Management

All potential stroke patients are evaluated immediately. Patients are triaged and admitted to the “resuscitation” room in the ED, which is dedicated to critically ill patients. A packet of all necessary stroke documents is available in the ED. This packet includes the stroke clinical pathway, standing orders, the NIH Stroke Scale, and educational material for the patient and family.

Evaluation using the NIH Stroke Scale is performed in the ED and repeated on every subsequent shift. Heparin is administered according to a weight-based protocol.

Family education begins as soon as the patient arrives. Family support is evaluated immediately, and a discharge plan is determined within the first day. The nursing staff uses a swallowing screening tool to identify patients at risk for aspiration and in need of speech therapy. The speech therapist evaluates patients and works with nurses, respiratory therapists, and the dietitian to implement appropriate patient care. The physical therapists maintain close contact with the attending physicians. Discharge Planning Rounds occur twice a week, at which time each patient’s discharge needs can be evaluated.

A strong relationship with rehabilitation facility has contributed to early patient transfers. Patients on heparin can be transferred to the rehabilitation facility.

Community Outreach

An educational program targets the lay public. As part of this program, a stroke risk assessment form was inserted in the newspaper. Upon completion, the form could be mailed to the hospital, where a neurologist specializing in stroke management would review the information. The neurologist’s recommendations would then be mailed back to the person wishing to be assessed.

The acute Stroke Team, which includes attending physicians, is responsible to the care of stroke patients in 15 area hospitals.

Overview of the University Hospital

StructureEnvironment
Not for Profit (as of 1/1/97)
418 Beds
Occupancy: 70.4%
30% Medicare patients
37% Medicaid patients
1995 discharges: 21,641
Market stage 3
(consolidation) in the
Market Evolution Model

Rationale and Background of Stroke Clinical Pathway

I. Goals

  • Highest quality care.
  • Consistent and efficient management.
  • Appropriate utilization of resources.
  • Identify rate-limiting steps in prolonging patient’s stay.

II. Reality – Pre-Pathway

  • To expensive and too long relative to National average.
  • Inconsistency of care delivery and poor knowledge about underlying costs.
  • Level of expertise for acute stroke care among the highest in the world.

III. Rate-limiting steps identified in critical pathway process

  • Disposition of patients – delay in consultation to rehab (Drake) setting, delay in getting patients transferred to Drake, no consultation of transfer on weekends, delay of stroke patients with minor medical problems, delay in social work to identify payor source and family supports to facilitate discharge to nursing home or home.
  • Certain tests not done on weekends. Delay in echo reports.
  • Delay in decision to begin warfarin if indicated.
  • Actions to address these issues:
  • Process of Drake referral and transfer greatly facilitated. Early standard orders to consult PMR and Drake within the first 2 days of admission. Increased medical presence of Drake has facilitated earlier transfer to Drake (e.g. switching from heparin to warfarin treatment).
  • Tests can be obtained on weekends.
  • Standard order of tests, as indicated within first day.

IV. Appropriate utilization of resources

  • The issue of stroke units – what is needed is often not an intensive-care unit setting but a monitored-bed setting with more intensive care for the first 1-2 days.
  • We are addressing the use and overuse of echo as well as other diagnostic tests.
  • Review charges and use of respiratory therapy.

V. Consistent and efficient management

A packet for each patient form entry with preprinted and standardized orders on each day.

VI. Highest quality care

  • High degree of neurologic input from stroke neurologists and neurosurgeons.
  • Accuracy of coding (TIA vs. stroke) – already being done by Drs. Brott and Broderick.
  • Develop criteria for doing tests.
  • Close monitoring of stroke patients to insure things work well and for neede changes.

VII. Suggested directions

Need for stroke monitoring unit, not intensive-care, for most patients – good care, reasonable cost.
Strong neurologic overseeing of process including patient care.

National Stroke Association: Stroke: The First Hours

North Carolina Baptist Hospital Stroke Center Clinical Practice Guidelines PDF File

Stanford Stroke Center: Ischemic Stroke Management at Stanford Health Services

Thomas Jefferson University Hospital: Acute Ischemic Stroke Critical Pathway Card

  • Acute Ischemic Stroke Critical Pathway Card Part 1
  • Acute Ischemic Stroke Critical Pathway Card Part 2

TPA Stroke Study Group: Algorithm for Management of Intracranial Hemorrhage Following Thrombolytic Therapy for Stroke PDF File