A model for management of patients with stroke during the acute phase. Outcome and economic implications

Tailoring therapy to a stroke patient's potential

Stroke survivors can be plagued by numerous medical complications, including aspiration pneumonia, heart disease, depression, and venous thromboembolism. Given the impairment already caused by stroke itself, these patients require careful management by a comprehensive rehabilitation team. Dr Harvey discusses common stroke syndromes, possible complications, and appropriate rehabilitation options covering a variety of circumstances.

The effects of clinical pathways for renal transplant on patient outcomes and length of stay

OBJECTIVES

Clinical pathways have been implemented nationwide but little is understood about their effects on efficiency of care and patient outcomes. The present study examined the effects of both development and implementation of two renal transplant pathways.

METHODS

Cohorts of patients at a university hospital were compared before, during, and after the development and implementation of two renal transplant clinical pathways: isolated renal transplant from cadaveric donors (n = 170) or from living donors (n = 178). Clinical pathways for cadaveric and living related donor renal transplants were developed and implemented. Hospital length of stay and complications and infections after renal transplant were determined.

RESULTS

Mean length of hospital stay decreased after development and implementation of the cadaveric donor pathway (11.8 days after implementation versus 17.5 days before development). Cadaveric kidney recipients also had statistically fewer complications and infections after both guideline development and guideline implementation (57.1% before, 24.5% during, 18.5% after), but the greatest effect occurred during development. All of these findings persisted after control for demographic and comorbid factors. There were no changes in hospital stay, complications, or infections in the patients who received kidneys from living donors.

CONCLUSIONS

The development and use of a clinical pathway for cadaveric donor renal transplant patients was associated with a significant decline in length of stay, complications, and infections, but much of the effect was seen during development rather than during implementation, and a closely related pathway for living related donor patients had no effect. Further understanding of what factors predict an effective pathway and what elements (ie, development or implementation) have an effect should be undertaken.

The uptake and costs of guidelines for stroke in a district of southern England

STUDY OBJECTIVE

To assess the impact of guidelines for stroke management on the utilisation of services by patients and the cost consequences of implementation.

DESIGN

Prospective audit.

SETTING

District health authority in southern England.

PATIENTS

A total of 468 live non-comatose stroke patients registered between November 1991 and May 1993.

MAIN OUTCOME MEASURES

A comparison between the three, six month periods for investigations performed and rehabilitation received and their associated costs.

RESULTS

The appropriateness of the use of investigations improved over time to between 88 and 92% except for computed tomography (CT) (24%). Younger, more severely impaired patients in a medical bed were more likely to have CT. Overall levels of rehabilitation were low. There was no change in use of physiotherapy (61% to 63%), a significant increase in occupational therapy (26% to 39%) and a non significant change in speech therapy (34% to 25%) over time. Guideline introduction caused a modest 23 Pounds increase in costs per patient in the 2nd six months and 41 Pounds in the 3rd six months but this sum could rise to 430 Pounds per patient if full implementation of the guidelines occurred which is still only around 13% of the costs of nursing care while in hospital.

CONCLUSIONS

This 18 month aduit shows only modest changes in practice compared with guidelines, and overall levels of rehabilitation were low. The costs of full implementation seem considerable, but in fact constitute only a small proportion of nursing care costs.

Utility of clinical pathway and prospective case management to achieve cost and hospital stay reduction for aortic aneurysm surgery at a tertiary care hospital

PURPOSE

We reviewed our experience with a clinical pathway instituted in December 1993 for all nonurgent abdominal aortic aneurysm (AAA) surgery.

METHODS

We analyzed a reference group of 49 consecutive pre-pathway AAA patients (group I) and the 44 patients enrolled in the first year of the pathway (group II). On the basis of the interim review of data collected during the first year, pathway modifications were made, and 34 patients enrolled after these modifications (group III) were also analyzed.

RESULTS

Comparison of groups I and II showed that institution of the pathway resulted in a marginally significant reduction in mean charges of 14.7% (p = 0.09), and a slight fall in mean length of stay (LOS) (13.8 vs 13.1 days, NS) and mortality rate (4.1% vs 2.3%, NS). For group II, a significant correlate (p < 0.05) of increased charges was fluid overload as diagnosed by chest radiograph. This recognition led to active efforts to reduce perioperative fluid administration. Comparison of groups II and III revealed that the practice modifications led to marked reduction in the incidence of fluid overload (73% vs 24%; p < 0.01), mean charges (30.4% reduction; p < 0.05), mean LOS (13.1 vs 10.2 days; p < 0.05), and median LOS (11 vs 8 days). Multiple regression analysis of all pathway patients showed that preoperative renal insufficiency is a significant predictor of both increased LOS (p < 0.01) and charges (p < 0.01), but that age, sex, and coronary disease were not predictive. Of the postoperative parameters analyzed, important correlates of increased charges were acute renal failure (p < 0.01) and fluid overload (p < 0.01).

CONCLUSIONS

Institution of a clinical pathway for AAA repair resulted in significant charge reduction and a slight reduction in stay. Practice modifications based on interim data analysis yielded further significant reductions in charges and LOS, with overall per-patient charge savings (group I vs III) of 40.6% (p < 0.05) and overall LOS reduction of 3.5 days (p < 0.05). The reduction in actual charges was seen despite an overall increase in the hospital rate structure. Comparing groups I, II, and III, we found no indication of increasing mortality rate. Ongoing analysis has identified correlates of increased charges, potentially permitting identification of high-cost subgroups and more focused cost-control efforts. Rather than restricting management, clinical pathways with periodic data analysis may improve quality of care.

Stroke is an emergency

Stroke is an emergency. Ischemic stroke is similar to myocardial infarction in that the pathogenesis is loss of blood supply to the tissue, which can result in irreversible damage if blood flow is not restored quickly. Public education is needed to emphasize the warning signs of stroke. Patients should seek medical help immediately, using emergency transport systems. Therapy geared toward minimizing the damage from an acute stroke should be started without delay in the emergency room. This includes measures to protect brain tissue, support perfusion pressure, and minimize cerebral edema. Strategies for improving recovery should also begin immediately. All major medical centers need stroke teams and stroke units. Stroke prevention should be given high priority as a public health strategy. Risk factor management should be part of general health care and should begin in childhood, with emphasis on nutrition, exercise, weight control, and avoidance of tobacco. Health screening and early treatment of hypertension and hypercholesterolemia has decreased the incidence of stroke and heart disease, but these efforts need to be expanded to reach all segments of the population. Basic research has opened the door to new therapies aimed at re-establishing blood flow and limiting tissue damage. Clinical trials have already led to changes in stroke prevention, including studies of carotid endarterectomy and ticlopidine and warfarin therapy (for patients with atrial fibrillation). Trials in progress are testing the usefulness of ancrod, neuroprotective agents, antioxidant agents, anti-inflammatory agents, low-molecular-weight heparin, thrombolytic drugs, and angioplasty. Any delay starting therapy after an acute stroke will result in progressive, irreversible loss of brain tissue. Clinicians should remember that for a stroke patient, time is brain tissue.

Acute stroke

Disruption of cerebral blood flow may influence brain energy metabolism to produce reversible or irreversible neurologic deficits. The emergency physician is in a unique position to provide timely treatment during the first few hours of an acute stroke. He or she must be facile with unique pharmacologic and non-pharmacologic treatment designed for the stroke patient concerning ventilation, blood pressure, and circulation.

Geriatric patients with depression. Improving outcomes using a multidisciplinary clinical path model

Clinical pathways define multidisciplinary staff members' responsibilities, time lines, and patient outcomes. Although medical and surgical care settings frequently use them to improve quality, clinical, and fiscal outcomes for specific patient populations, staff members of psychiatric care settings have been hesitant to use clinical pathways because psychiatry emphasizes patient individuality. The authors describe the development and implementation of a psychiatric clinical pathway for geriatric patients with depression and identify common multidisciplinary interventions and a pattern of outcomes over the course of treatment for these patients. They also delineate quality and fiscal outcomes and future directions. Implementation of the pathway has been successful, and the development and implementation processes have applicability to other patient populations and care settings.

Swallow management in patients on an acute stroke pathway: quality is cost effective

OBJECTIVE

To assess the effects of swallowing management in patients with acute nonhemorrhagic stroke placed on a clinical pathway, and to evaluate whether swallow function on admission can be used as a predictor of length of stay (LOS) and outcome disposition.

DESIGN

Intervention study to reduce complications of dysphagia in patients with acute stroke.

SETTING

Urban community hospital.

PATIENTS

Data were collected on 124 patients with acute nonhemorrhagic stroke admitted from January to December 1993.

INTERVENTIONS

A swallow screen was completed within one day of admission and before any oral intake.

MAIN OUTCOME MEASURES

Dysphagia and functional independence measure (FIM) scores on admission, occurrence of aspiration pneumonia, LOS, outcome disposition and cost effectiveness analysis.

RESULTS

Thirty-nine percent of all patients (p < .05) failed the initial swallow screen and required altered dietary texture and intervention. No patients developed aspiration pneumonia. Of those with dysphagia, 21% recovered intact swallowing by discharge; 19% required gastrostomy tube placement. Patients with dysphagia had lower admission FIM scores than nondysphagia patients. The LOS was longer for the dysphagia group (8.4 +/- 0.9 days) compared with patients without dysphagia (6.4 +/- 0.6 days, p < .05). Patients with dysphagia were less likely to be discharged to home (27%) than were nondysphagia patients (55%), and twice as likely to be discharged to a nursing home (p < .05).

CONCLUSIONS

This study demonstrates that early swallow screening and dysphagia management in patients with acute stroke reduces the risk of aspiration pneumonia, is cost effective, and assures quality care with optimal outcome.

Critical path analysis for the management of fractured neck of femur

The aim of this study was to determine the effect of a critical path analysis, used as a management tool, on the efficiency of clinical service delivery for patients with a fractured neck of femur. It is a before-and-after study of the medical records of all patients admitted between October 1992 and October 1993 with a primary diagnosis of fractured neck of femur, but excluding patients under 50 years old and those with multiple fractures or metastatic disease. Patients fell into two groups: those admitted in the six months before the introduction of a clinical management program based on a critical path analysis, and those admitted after the introduction of the program in April 1993 (88 program cases and 90 nonprogram cases). A medical records administrator blinded to the program category of the patients independently coded diagnostic data, while other data were abstracted from the clinical notes. The length of stay for a fractured neck of femur declined from a mean of 19.3 days to a mean of 11.0 days (P < 0.0001). The outcome measures were: the distance walked just before discharge from hospital, the discharge destination, and unplanned readmission. These did not change significantly, and the wound infection rate declined during the period of the intervention. The implementation of a clinical management pathway based on a critical path analysis dramatically reduced the length of stay for patients admitted with a fractured neck of femur while maintaining quality of outcomes. Critical path analysis is a useful management tool to improve the efficiency of certain clinical services.

Paradoxical embolism after cardiac catheterization

Paradoxical embolism is seen in fewer than 2% of all arterial emboli. It occurs most often through a patent foramen ovale (PFO), which is present in up to one-third of patients with strokes of unknown etiology. We report a 69-year-old woman in whom a thrombus traveled from the lower extremity venous system to her right middle cerebral artery through an unsuspected atrial septal defect. Following right femoral artery catheterization for coronary angiography, she developed a femoral artery pseudoaneurysm and groin hematoma causing compression of the right femoral vein and venous thrombosis. Before she could undergo surgical evacuation and repair, she developed a right brain stroke with cognitive deficits, left field cut, left hemiparesis, and sensory loss. Transthoracic echocardiography with bubble contrast showed a small PFO with right-to-left interatrial shunting. A Greenfield filter was placed in the inferior vena cava, and the patient was anticoagulated before she underwent inpatient rehabilitation. This case illustrates the importance of considering paradoxical emboli in unexplained strokes. The literature is reviewed, and treatment and prevention of paradoxical emboli are discussed.