Review
Care pathways for acute stroke care and stroke rehabilitation: From theory to evidence

https://doi.org/10.1016/j.jocn.2006.01.026Get rights and content

Abstract

Care pathways aim to promote evidence- and guideline-based care, improve the organisation and efficiency of care, and reduce cost. In the past decade, care pathways have been increasingly implemented as a tool in acute stroke care and stroke rehabilitation. In the most recent Cochrane systematic review, which included three randomised and 12 non-randomised studies, patient management with stroke care pathways was found to have no significant benefit on functional outcome, and patient satisfaction and quality of life might actually be worse. On the other hand, it was associated with a higher proportion of patients receiving investigations and a lower risk of developing certain complications such as infections and readmissions. Overall, the evidence supports the use of care pathways in acute stroke but not stroke rehabilitation. Future developments, including electronic care pathways, patient pathways, and pre-hospital care pathways for hyperacute stroke, will be discussed.

Section snippets

Care pathways: The theory

Care pathways are increasingly being implemented across many countries to improve the care of stroke patients, but there is relatively little debate about what they are and how they affect patient care and outcome.[1], [2] One reason could be that care pathways are generally regarded as harmless, and policy makers are keen to adopt new health service interventions that are intuitively beneficial, even though they have not yet been thoroughly tested. This paper describes the definition and

Different forms of stroke care pathways

Since care pathways were first introduced for stroke care in the mid-1980s,35 many different forms of ‘pathways’ have been developed, such as those used to aid the diagnosis of acute stroke and screening for thrombolytic therapy.[36], [37] Others have been developed to guide patient care in the community after hospital discharge.[38], [39] In general, stroke care pathways can be broadly divided into three categories: (i) those used for acute stroke management only; (ii) those used for stroke

Care pathways for stroke: The evidence

Compared with trials of pharmacological agents or surgical procedures, the evaluation of health service interventions such as care pathways is more complex. In practice, care pathways are highly variable in their nature and their operation depends greatly on the local circumstances. Consequently, the results generated by studies of care pathways may have questionable internal validity (that is, the extent to which differences between the study groups are real rather than a product of bias) and

Evidence from the Cochrane review

Using Cochrane methodology, a recent systematic review evaluated the effects of care pathways, as compared to standard medical care, among patients with acute stroke who had been admitted to hospital.81 The major databases were searched including the Cochrane Controlled Trials Register, MEDLINE, EMBASE, and CINAHL. The review considered randomised controlled trials and non-randomised studies, which included quasi-randomised trials, comparative studies, before-and-after studies, and interrupted

Interpretation of results

Non-randomised studies are particularly susceptible to biases, and all clinical studies of care pathways are susceptible to confounding. One obvious bias is selection bias, that is stroke patients may have been selected to be managed using a care pathway and may have differed from those who were managed using standard medical care. In one study, it was stated that patients were “selected for care pathway care using strict screening criteria”53 and we suspect that this was also the common

Effect of care pathways on major outcomes

Many experts think that care pathways must be beneficial and could not possibly do any harm, but this view is not wholly supported by this review. There is no conclusive evidence that care pathways provide additional benefit over standard care for the major clinical outcomes (death or discharge destination). In fact, there is some evidence from one randomised60 and one non-randomised study83 that patients in the care pathway group might be significantly less independent at discharge.

Care pathways and the basic structure of the stroke service

Care pathways are only likely to be effective in improving stroke care if the basic structure of the stroke service is already in place, such as the routine admission of patients to a stroke unit where patient care is provided by a coordinated multidisciplinary team made up of dedicated, motivated and skilled healthcare professionals.[89], [90] If the basic structure is not in place (for example, if patients managed by different medical teams in different general wards), then care pathways are

Care pathways for acute stroke management or stroke rehabilitation?

Although only a small number of studies were included in this systematic review, the results were consistently better for acute stroke pathways than stroke rehabilitation pathways. This can be explained by that fact that care pathways probably have the best potential to improve the process of care during the acute (or hyperacute) phase of stroke where the process of assessment, investigation, diagnosis can be highly complex (and often disorganised), and where speed is the essence when emergency

Electronic care pathways

Many hospital documents which have traditionally been paper-based (e.g. patient records) are increasingly becoming electronic. However, the introduction of any electronic patient record would be too expensive and time-consuming if it is only used as a tool to facilitate documentation and retrieve data faster; it must also add value in supporting clinical decision-making, improve quality of care, and possibly reduce hospitalisation costs.93 For this purpose, care pathways are increasingly being

Acknowledgement

Financial support: The author’s salary was supported by the Glaxo Wellcome Stroke Training Fellowship (2000–1) and Stroke Association Clinical Training Fellowship (2001–2).

References (96)

  • J. Suyama et al.

    Prehospital care of the stroke patient

    Emerg Med Clin North Am

    (2002)
  • K. de Luc

    Are different models of care pathways being developed?

    Int J Health Care Qual Assur

    (2000)
  • A.C. Norris

    Care pathways and the new NHS

    J Integrated Care

    (1998)
  • C. Hale

    Issues in the evaluation of multidisciplinary pathways of care

  • S. Overill

    A practical guide to care pathways

    J Integrated Care

    (1998)
  • M.J. Field et al.

    Guidelines for Clinical Practice: from Development to Use

    (1992)
  • D.J. Hunter et al.

    Disease management

    BMJ

    (1997)
  • National electronic Library for Health. About Integrated Care Pathways (ICPs). NeLH 2004 Available from: URL:...
  • M.E. Modell

    A Professional’s Guide to Systems Analysis

    (1996)
  • J.A. Landry

    Project Management: Comparing PERT/CPM, Gantt Charts, Function Points, Metrics

    (2001)
  • M.B. Crummer et al.

    Critical pathways - the pivotal tool

    J Cardiovasc Nurs

    (1993)
  • S. Nelson

    Following pathways in pursuit of excellence

    Int J Health Care Qual Assur

    (1995)
  • D. Kitchiner et al.

    Clinical pathways. A practical tool for specifying, evaluating and improving the quality of clinical practice

    Med J Aust

    (1999)
  • H. Campbell et al.

    Integrated care pathways

    BMJ

    (1998)
  • K. Riley

    Paving the way. Care pathways are a tool to standardise care

    Health Serv J

    (1998)
  • P.A. Quigley et al.

    Successful experience with clinical pathways in rehabilitation

    J Rehabil

    (1998)
  • B. Yandell

    Critical paths at Alliant Health System

    Qual Manag Health Care

    (1995)
  • S.W. Brown et al.

    Developing a variance reporting system to facilitate quality improvement

    Outcomes Manag Nurs Pract

    (1998)
  • J. Schriefer

    Managing critical pathway variances

    Qual Manag Health Care

    (1995)
  • P.C. Dykes

    Designing and implementing critical pathways: an overview

  • H.C. Roberts et al.

    The effectiveness of implementing a care pathway for femoral neck fracture in older people: a prospective controlled before and after study

    Age Ageing

    (2004)
  • K. Zander

    Integrated care pathways: eleven international trends

    J Integr Care Pathways

    (2002)
  • S.D. Pearson et al.

    Critical pathways as a strategy for improving care: problems and potential

    Ann Intern Med

    (1995)
  • R. Thomson et al.

    How to ensure that guidelines are effective

    BMJ

    (1995)
  • A.J. Sutton et al.

    Empirical assessment of effect of publication bias on meta-analyses

    BMJ

    (2000)
  • D.A. Bertram et al.

    Implementation of an inpatient case management program in rural hospitals

    J Rural Health

    (1996)
  • J. Harding

    Practice guidelines. Cookbook medicine

    Physician Exec

    (1994)
  • J. Wilson

    Best practice guidelines

    Br J Nurs

    (1999)
  • S. O’Malley

    Pathways: improving outcomes, not just ‘cookbook medicine’

    Qual Lett Healthc Lead

    (1997)
  • A. Wigfield et al.

    Critical care pathway development: the way forward

    Br J Nurs

    (1996)
  • L.M. Miller et al.

    Surgical integrated care pathway development: compliance and staff satisfaction

    J Integr Care Pathways

    (2003)
  • A.S. Wee et al.

    The development of a stroke clinical pathway: an experience in a medium-sized community hospital

    J Miss State Med Assoc

    (2000)
  • K. Zander

    Nursing case management: strategic management of cost and quality outcomes

    J Nurs Adm

    (1988)
  • J.P. Broderick

    Practical considerations in the early treatment of ischemic stroke

    Am Fam Physician

    (1998)
  • S.M. Schmidt et al.

    Epidemiologic determination of community-based nursing case management for stroke

    J Nurs Adm

    (1999)
  • M.B. Dignan et al.

    Evaluation of the North Carolina stroke care program

    Stroke

    (1986)
  • H.P. Adams et al.

    Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association

    Stroke

    (1996)
  • P. Langhorne et al.

    Stroke Units: an Evidence Based Approach

    (1998)

    • Cited by (31)

    • Impact of ongoing centralization of acute stroke care from “drip and ship” into “direct-to-mothership” model in a Dutch urban area

      2021, Health Policy
      Citation Excerpt :

      Also, non-urgent self-referrals had shorter ED LOS than urgent self-referrals, regardless in which hospital they presented (Table 4, Supplements 7 and 8). The effects of stroke care units and centralized care on the health outcomes of stroke patients are extensively explored in several countries and different health care systems [5,7,8,16–24]. Comprehensive stroke centres are associated with improved functional outcomes and a more frequent use of reperfusion therapy [25].

    • Evaluation of clinical pathway in acute ischemic stroke: A comparative study

      2016, European Journal of Integrative Medicine
      Citation Excerpt :

      The Australian National Stroke Foundation suggests that all patients with stroke who are admitted to the hospital should be managed using CP [5]. This recommendation was based on the evidence from the Cochrane Collaboration [5,6]. Results of several studies showed that CP can significantly improve the outcomes of patients with ischemic stroke and elevate the adherence of evidence-based processes [7].

    • Treatment taxonomy for rehabilitation: Past, present, and prospects

      2014, Archives of Physical Medicine and Rehabilitation

    • Contemporary management of acute heart failure in the emergency department and the potential impact of early diuretic therapy on outcomes

      2024, EMA - Emergency Medicine Australasia

    • Does implementation of a standardized pathway of stroke care affect functional outcome after stroke?

      2023, International Journal of Stroke

    • Acute perioperative neurological emergencies

      2023, International Anesthesiology Clinics
    View all citing articles on Scopus
    View full text
    Copyright © 2006 Elsevier Ltd. All rights reserved.