Clinical Guidelines for Acute Stroke Management - Living on the EDge

CONSUMER
1.3 ORGANISATION OF CARE FOR RURAL CENTRES GRADE LEVEL RATING
a) All health services caring <strong>for</strong> people with stroke should use D Level IV –
networks which link large stroke specialist centres with smaller
36, 37, 39, 42
regional and rural centres.
b) These networks should assist to establish appropriate stroke units D Level IV –
along with protocols governing rapid assessment, pathways <strong>for</strong>
36, 37, 39, 42
direct communication with stroke specialist centres
(“telestroke” services), and rapid transfers.
1.4 Care pathways
<strong>Clinical</strong> pathways (also known as care pathways or
critical pathways) are defined as a plan of care that
aims to promote organised and efficient
multidisciplinary stroke care based on the best
available evidence and guidelines. 44 Care pathways are
one way of promoting organised and efficient patient
care and hence improve outcomes. The definition,
structure and detail contained within the pathway may
vary from setting to setting. 45
A robust systematic review on the use of care
pathways found that such interventions can have both
positive and negative effects and concluded that there
was insufficient evidence to justify routine use of care
pathways. 44 However, of the three RCTs and 12 non
RCTs included only one RCT and 7 non RCTs were
initiated in the acute phase (three of the non RCTs
were initiated in the hyper acute phase in the
emergency department). When the acute trials were
considered separately no negative effects were found
while benefits of some patient outcomes (reduced
length of stay, fewer readmissions and fewer urinary
tract infections) as well as improved process
outcomes (access to neuroimaging) were found.
Of the other outcomes reported a large proportion
demonstrated non significant trends in favour of care
pathway intervention. 44
Several subsequent Level III-3 & IV studies have found
improved efficiency in acute processes primarily
focused on increasing the number of people eligible <strong>for</strong>
thrombolysis (e.g. door to CT and door to IV
thrombolysis times). 46-48 One other Level III-3 study
failed to find benefits of an acute pathway when
implemented on a general medical ward. 49
Overall there is a small body of generally consistent
evidence that suggests care pathways can improve
the process of care in acute stroke management
where a number of investigations are needed in a
short period of time, particularly when thrombolysis is
considered. In the clinical setting, care pathways can
provide a useful resource to optimise early stroke care,
especially in settings without organised stroke care or
where staff are frequently changing.
Section 1 Organisation of Services
CONSUMER
1.4 CARE PATHWAYS GRADE LEVEL RATING
All stroke patients admitted to hospital may be managed using an acute C Level II 44 –
care pathway.
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