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

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

OBJECTIVE

Acute heart failure (AHF) is one of the most common conditions presenting to the ED and patients often require hospitalisation. Emerging evidence suggests early diagnosis and administration of diuretics are associated with improved patient outcomes. Currently, there is limited literature on the management of AHF in the Australian ED context.

METHODS

A retrospective review of consecutive AHF presentations to the ED in a metropolitan hospital. Patient demographics, clinical status and management were assessed including timeliness of diuretics administration and association with outcomes including ED length of stay (LOS) and inpatient mortality using linear regression.

RESULTS

One hundred and ninety-one presentations (median age 81 years, 50.8% male) were identified. Common cardiovascular comorbidities were prevalent. Fifty-four patients (28.3%) had ≥1 clinical high-risk feature at presentation. The median time from presentation to furosemide administration was 187 min (interquartile range 97-279 min); only 35 patients received diuretics within 60 min of presentation. Early diuretics was associated with shorter ED LOS (246 min vs 275 min, P = 0.03) and a lower but non-significant inpatient mortality (4.9% vs 6.3%, P = 0.21) and a non-significant increased rate of discharge home from ED (8.6% vs 4.7%, P = 0.15). The likelihood of discharge home was significantly more pronounced in patients receiving early diuretics without clinical high-risk features (16.7% vs 4.3%, P = 0.028).

CONCLUSION

Despite symptoms and signs being well recognised at presentation, time to diuretics was relatively long. Early diuretics administration was associated with improved patient outcomes, particularly in clinically more stable patients. Due to the limitations of the study design, results should be interpreted with caution and warrant further research to identify factors that delay timely administration of diuretics.

Application Analysis Based on Big Data Technology in Stroke Rehabilitation Nursing

According to the statistical analysis, the incidence of stroke disease has gradually increased, particularly in recent years, which poses a huge threat to the safety of human life. Due to the advancement in science and technology specifically big data and sensors, a new research dome known as data mining technology has been introduced, which has the potential value from the perspective of large amount of data analysis. Information has become a new trend of science and technology, and data mining has been used in various application areas to analyze and predict strokes at home and abroad. In this study, big data technology is utilized to collect potential information and explores clinical pathways of level-3 rehabilitation in certain regions of China. Moreover, application effects of data mining in the rehabilitation of patients with the first ischemic stroke have been evaluated and reported. For this purpose, fifty (50) first-time ischemic stroke patients have been screened through big data and were nonartificially assigned to level-3 clinical pathway and conventional rehabilitation groups, respectively, specifically through software. The first group of patients enters the clinical path of the corresponding level according to the way of three-level referral. These patients were analyzed based on the collected results of completing the unified rehabilitation treatment plan of the three-level rehabilitation medical institution in the patient record form. The second group was selected according to the routine rehabilitation model and method of the medical institution where the patients visited were divided into four stages: before treatment, three weeks after treatment, nine weeks after treatment, and seventeen weeks after treatment. For this purpose, a simplified Fugl-Meyer analysis (FMA), recording of various functions of limb movement, and modified Barthel index (MBI) scale were used to analyze and evaluate the ability of daily activities and compare their effects. The final results showed that FMA and MBI scores of the two groups were improved in the three stages after treatment. The FMA and MBI scores of the clinical pathway group on 3rd and 9th weekends were significantly different from those of the conventional rehabilitation group (which is p < 0.05). Moreover, difference in FMA and MBI scores between the two at the 17th weekend was not significant. The total cost of the clinical pathway group, particularly at the ninth weekend, was higher than that of the conventional rehabilitation group, but the cost-benefit ratio was better and the incidence of complications was lower than that of the other group.

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

When acute stroke care is organised using a "drip-and-ship" model, patients receive immediate treatment at the nearest primary stroke centre followed by transfer to a comprehensive stroke centre (CSC). When stroke care is further centralised into the "direct-to-mothership" model, patients with stroke symptoms are immediately brought to a CSC to further reduce treatment times and enhance stroke outcomes. We investigated the effects of the ongoing centralization in a Dutch urban setting on treatment times of patients with confirmed ischemic stroke in a 4-year period. Next, in a non-randomized controlled trial, we assessed treatment times of patients with suspected ischemic stroke, and treatment times of patients with neurologic disorders other than suspected ischemic stroke, before and after the intervention in the CSC and the decentralized hospitals, the intervention being the change from "drip and ship" into "direct-to-mothership". Our findings provide support for the ongoing centralization of acute stroke care in urban areas. Treatment times for patients with ischemic stroke decreased significantly, potentially improving functional outcomes. Improvements in treatment times for patients with suspected ischemic stroke were achieved without negative side effects for self-referrals with stroke symptoms and patients with other neurological disorders.

Towards standardisation of evidence-based clinical care process specifications

There is a strong push towards standardisation of treatment approaches, care processes and documentation of clinical practice. However, confusion persists regarding terminology and description of many clinical care process specifications which this research seeks to resolve by developing a taxonomic characterisation of clinical care process specifications. Literature on clinical care process specifications was analysed, creating the starting point for identifying common characteristics and how each is constructed and used in the clinical setting. A taxonomy for clinical care process specifications is presented. The De Bleser approach to limited clinical care process specifications characterisation was extended and each clinical care process specification is successfully characterised in terms of purpose, core elements and relationship to the other clinical care process specification types. A case study on the diagnosis and treatment of Type 2 Diabetes in the United Kingdom was used to evaluate the taxonomy and demonstrate how the characterisation framework applies. Standardising clinical care process specifications ensures that the format and content are consistent with expectations, can be read more quickly and high-quality information can be recorded about the patient. Standardisation also enables computer interpretability, which is important in integrating Learning Health Systems into the modern clinical environment. The approach presented allows terminologies for clinical care process specifications that were widely used interchangeably to be easily distinguished, thus, eliminating the existing confusion.

CPDI: An Index for measuring deviations in Clinical Pathways

Clinical Pathways (CPs) are evidence-based recommendation for treating a diagnosis and an effective instrument to decrease undesired practice variability and improve clinician performance. Deviations from CPs might just as well reduce quality of care. Moreover they can be associated to possible adverse events. In this perspective, we developed and tested a system for comparing a patient trajectory (PT) with the corresponding CP in order to recognize significant variations. To measure adherence, a Clinical Pathway Deviation Index (CPDI) was constructed as the weighted-sum of five indicators. To build the indicators three different tools for CPs modeling have been tested. Only two of them proved suitable for our system. A preliminary analysis has been carried out using data of 24 real PTs. The aim of this paper is to present the system and to characterize CPDI performances.

The integrated care pathway for post stroke patients (iCaPPS): a shared care approach between stakeholders in areas with limited access to specialist stroke care services

BACKGROUND

Lack of intersectoral collaboration within public health sectors compound efforts to promote effective multidisciplinary post stroke care after discharge following acute phase. A coordinated, primary care-led care pathway to manage post stroke patients residing at home in the community was designed by an expert panel of specialist stroke care providers to help overcome fragmented post stroke care in areas where access is limited or lacking.

METHODS

Expert panel discussions comprising Family Medicine Specialists, Neurologists, Rehabilitation Physicians and Therapists, and Nurse Managers from Ministry of Health and acadaemia were conducted. In Phase One, experts chartered current care processes in public healthcare facilities, from acute stroke till discharge and also patients who presented late with stroke symptoms to public primary care health centres. In Phase Two, modified Delphi technique was employed to obtain consensus on recommendations, based on current evidence and best care practices. Care algorithms were designed around existing work schedules at public health centres.

RESULTS

Indication for patients eligible for monitoring by primary care at public health centres were identified. Gaps in transfer of care occurred either at post discharge from acute care or primary care patients diagnosed at or beyond subacute phase at health centres. Essential information required during transfer of care from tertiary care to primary care providers was identified. Care algorithms including appropriate tools were summarised to guide primary care teams to identify patients requiring further multidisciplinary interventions. Shared care approaches with Specialist Stroke care team were outlined. Components of the iCaPPS were developed simultaneously: (i) iCaPPS-Rehab© for rehabilitation of stroke patients at community level (ii) iCaPPS-Swallow© guided the primary care team to screen and manage stroke related swallowing problems.

CONCLUSION

Coordinated post stroke care monitoring service for patients at community level is achievable using the iCaPPS and its components as a guide. The iCaPPS may be used for post stroke care monitoring of patients in similar fragmented healthcare delivery systems or areas with limited access to specialist stroke care services.

TRIAL REGISTRATION

No.: ACTRN12616001322426 (Registration Date: 21st September 2016).

Effect of a 72 Hour Stroke Care Bundle on Early Outcomes after Acute Stroke: A Non Randomised Controlled Study

Background

Integrated care pathways (ICP) in stroke management are increasingly being implemented to improve outcomes of acute stroke patients. We evaluated the effect of implementing a 72 hour stroke care bundle on early outcomes among patients admitted within seven days post stroke to the national referral hospital in Uganda.

Methods

In a one year non-randomised controlled study, 127 stroke patients who had ‘usual care’ (control group) were compared to 127 stroke patients who received selected elements from an ICP (intervention group). Patients were consecutively enrolled (controls first, intervention group second) into each group over 5 month periods and followed to 30-days post stroke. Incidence outcomes (mortality and functional ability) were compared using chi square test and adjusted for potential confounders. Kaplan Meier survival estimates and log rank test for comparison were used for time to death analysis for all strokes and by stroke severity categories. Secondary outcomes were in-hospital mortality, median survival time and median length of hospital stay.

Results

Mortality within 7 days was higher in the intervention group compared to controls (RR 13.1, 95% CI 3.3–52.9). There was no difference in 30-day mortality between the two groups (RR 1.2, 95% CI 0.5–2.6). There was better 30-day survival in patients with severe stroke in the intervention group compared to controls (P = 0.018). The median survival time was 30 days (IQR 29–30 days) in the control group and 30 days (IQR 7–30 days) in the intervention group. In the intervention group, 41patients (32.3%) died in hospital compared to 23 (18.1%) in controls (P < 0.001). The median length of hospital stay was 8 days (IQR 5–12 days) in the controls and 4 days (IQR 2–7 days) in the intervention group. There was no difference in functional outcomes between the groups (RR 0.9, 95% CI 0.4–2.2).

Conclusions

While implementing elements of a stroke-focused ICP in a Ugandan national referral hospital appeared to have little overall benefit in mortality and functioning, patients with severe stroke may benefit on selected outcomes. More research is needed to better understand how and when stroke protocols should be implemented in sub-Saharan African settings.

Trial Registration

Pan African Clinical Trials Registry PACTR201510001272347

Retrospective assessment of the implementation of critical pathway in stroke patients in a single university hospital

Objective

To evaluate the effects of the implementation of critical pathway (CP) in stroke patients treated at a single university hospital.

Methods

A retrospective medical review collected data from 497 patients who had suffered acute stroke in the rehabilitation center. Stroke outcomes were compared between before and after the implementation of CP based on factors including demographic factors, stroke characteristics, pre-existing medical conditions, medical complications, functional states, and length of stay (LOS).

Results

After the implementation of CP, the patients showed significantly higher stage for upper proximal (p=0.008) and lower extremity (p=0.001) on Brunnstrom stage and significantly lower scores for modified Rankin Scale (p=0.003) at transfer. For those with pre-existing medical conditions, there were significantly increased osteoarthritis (p=0.002) and valvular heart disease (p=0.011). Regarding medical complications during acute inpatient rehabilitation, there were significantly decreased shoulder pain (p=0.001) and dysphagia (p=0.017), and significantly increased gastrointestinal symptoms (p=0.001). Functional gain and efficiency of stroke patients during rehabilitation center hospitalization did not significantly change after implementation of CP. But, shorter LOS of total hospitalization, pre-rehabilitation center hospitalization, and rehabilitation center hospitalization were evident.

Conclusion

After the implementation of CP, patients less often developed complications and displayed no changes in functional gain and efficiency. They had shorter LOS of total hospitalization, pre-rehabilitation center hospitalization and rehabilitation center hospitalization.

Main barriers to effective implementation of stroke care pathways in France: a qualitative study

Background

Stroke Care Pathways (SCPs) aim to improve quality of care by providing better access to stroke units, rehabilitation centres, and home care for dependent patients. The objective of this study was to identify the main barriers to effective implementation of SCPs in France.

Methods

We selected 4 types of SCPs currently implemented in France that differed in terms of geographical location, population size, socio-economic conditions, and available health care facilities. We carried out 51 semi-structured interviews of 44 key health professionals involved in these SCPs and used the interview data to (i) create a typology of the organisational barriers to effective SCP implementation by axial coding, (ii) define barrier contents by vertical coding. The typology was validated by a panel of 15 stroke care professionals.

Results

Four main barriers to effective SCP implementation were identified: lack of resources (31/44 interviewees), coordination problems among staff (14/44) and among facilities (27/44), suboptimal professional and organisational practices (16/44), and inadequate public education about stroke (13/44). Transposition of the findings onto a generic SCP highlighted alternative care options and identified 10 to 17 barriers that could disrupt continuity of care.

Conclusion

Lack of resources was considered to be the chief obstacle to effective SCP implementation. However, the main weakness of existing SCPs was poor communication and cooperation among health professionals and among facilities. We intend to use this knowledge to construct a robust set of quality indicators for use in SCP quality improvement initiatives, in comparisons between SCPs, and in the assessment of the effective implementation of clinical practice guidelines.

Treatment taxonomy for rehabilitation: past, present, and prospects

The idea of constructing a taxonomy of rehabilitation interventions has been around for quite some time, but other than small and mostly ad hoc efforts, not much progress has been made, in spite of articulate pleas by some well-respected clinician scholars. In this article, treatment taxonomies used in health care, and in rehabilitation specifically, are selectively reviewed, with a focus on the need to base a rehabilitation treatment taxonomy (RTT) on the "active ingredients" of treatments and their link to patient/client deficits/problems that are targeted in therapy. This is followed by a description of what we see as a fruitful approach to the development of an RTT that crosses disciplines, settings, and patient diagnoses, and a discussion of the potential uses in and benefits of a well-developed RTT for clinical service, research, education, and service administration.

Monitoring adherence to evidence-based practices: a method to utilize HL7 messages from hospital information systems

BACKGROUND

Clinical pathways are evidence-based recommendations for treating a diagnosis. Although implementations of clinical pathways have reduced medical errors, lowered costs, and improved patient outcomes, monitoring whether a patient is following the intended pathway is problematic. Implementing a variance reporting program is impeded by the lack of a reliable source of electronic data and automatic retrieval methods.

OBJECTIVES

Our objective is to develop an automated method of measuring and reporting patient variance from a clinical pathway.

METHODS

We identify a viable and ubiquitous data source for establishing the realized patient's path- Health Level Seven (HL7) formatted message exchanges between Hospital Information Systems. This is in contrast to current practices in most hospitals where data for clinical pathway variance reporting is obtained from multiple data sources, often retrospectively. This paper develops a method to use message exchanges to automatically establish and compare a patient's path against a clinical pathway. Our method not only considers pathway activities as is common practice, but also extracts patient outcomes from HL7 messages and reports this in addition to the variance.

RESULTS

Using data from our partner hospital, we illustrate our clinical pathway variance analysis tool using major joint replacement patients. We validate our method by comparing audit results for a random sample of HL7 constructed pathways with data extracted from patient charts. We report several variances such as omitted laboratory tests or additional activities such as blood transfusions. Our method successfully identifies variances and reports them in a quantified way to support decisions related to quality control.

CONCLUSIONS

OUR APPROACH DIFFERS FROM PREVIOUS STUDIES IN THAT A QUANTITATIVE MEASURE IS ESTABLISHED OVER THREE DIMENSIONS: (1) omissions from the pathway, (2) additions to the pathway, and (3) patient outcomes. By examining variances providers can evaluate clinical decisions, and support quality feedback and training mechanisms.

Systematic review of the effectiveness of integrated care pathways: what works, for whom, in which circumstances?

Aim  Integrated care pathways (ICP) are management technologies which formalise multidisciplinary team-working and enable professionals to examine their roles and responsibilities. ICPs are now being implemented across international healthcare arena, but evidence to support their use is equivocal. The aim of this study was to identify the circumstances in which ICPs are effective, for whom and in what contexts. Methods  A systematic review of high-quality randomised controlled trials published between 1980 and 2008 (March) evaluating ICP use in child and adult populations in the full range of healthcare settings.

RESULTS

1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner. This can lead to improvements in service quality and service efficiency without adverse consequences for patients. 2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocols thereby reducing variation in practice. 3 ICPs can be effective in improving documentation of treatment goals, documentation of communication with patients, carers and health professionals. 4 ICPs can be effective in improving physician agreement about treatment options. 5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide. 6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction, where there is scope for improvement or where roles are new. 7 Even in contexts in which health professionals are already experienced with a particular pathway, ICP use brings additional beneficial effects in directing professional practice in the desired direction. 8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories. 9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established. 10 Depending on their purpose, the benefits of ICPs may be greater for certain patient subgroups than others. 11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits. 12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice, particularly in circumstances in which ICP use is a significant change in organisational culture. 13 ICP documentation can introduce scope for new kinds of error. Conclusions  ICPs are most effective in contexts where patient care trajectories are predictable. Their value in settings in which recovery pathways are more variable is less clear. ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services; their value in contexts where inter-professional working is well established is less certain. None of the studies reviewed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation.

A cluster randomized trial to assess the effect of clinical pathways for patients with stroke: results of the clinical pathways for effective and appropriate care study

BACKGROUND

Clinical pathways (CPs) are used to improve the outcomes of acute stroke, but their use in stroke care is questionable, because the evidence on their effectiveness is still inconclusive. The objective of this study was to evaluate whether CPs improve the outcomes and the quality of care provided to patients after acute ischemic stroke.

METHODS

This was a multicentre cluster-randomized trial, in which 14 hospitals were randomized to the CP arm or to the non intervention/usual care (UC) arm. Healthcare workers in the CP arm received 3 days of training in quality improvement of CPs and in use of a standardized package including information on evidence-based key interventions and indicators. Healthcare workers in the usual-care arm followed their standard procedures. The teams in the CP arm developed their CPs over a 6-month period. The primary end point was mortality. Secondary end points were: use of diagnostic and therapeutic procedures, implementation of organized care, length of stay, re-admission and institutionalization rates after discharge, dependency levels, and complication rates.

RESULTS

Compared with the patients in the UC arm, the patients in the CP arm had a significantly lower risk of mortality at 7 days (OR = 0.10; 95% CI 0.01 to 0.95) and significantly lower rates of adverse functional outcomes, expressed as the odds of not returning to pre-stroke functioning in their daily life (OR = 0.42; 95 CI 0.18 to 0.98). There was no significant effect on 30-day mortality. Compared with the UC arm, the hospital diagnostic and therapeutic procedures were performed more appropriately in the CP arm, and the evidence-based key interventions and organized care were more applied in the CP arm.

CONCLUSIONS

CPs can significantly improve the outcomes of patients with ischemic patients with stroke, indicating better application of evidence-based key interventions and of diagnostic and therapeutic procedures. This study tested a new hypothesis and provided evidence on how CPs can work.

TRIAL REGISTRATION

ClinicalTrials.gov ID: [NCT00673491].

Processes of Care and Medical Complications in Patients With Stroke

Background and Purpose—

The relationship between processes of care and the risk of medical complications in patients with stroke remains unclear. We therefore examined the association in a population-based follow-up study.

Methods—

We identified 11 757 patients admitted for stroke to stroke units in 2 Danish counties in 2003 to 2008. The examined processes of care included early admission to a stroke unit, early initiation of antiplatelet or oral anticoagulant therapy, early CT/MRI scan, and early assessment by a physiotherapist and an occupational therapist of nutritional risk and of swallowing function and early mobilization.

Results—

Overall, 25.3% (n=2969) of the patients experienced ≥1 medical complications during hospitalization. The most common medical complications were urinary tract infection (15.5%), pneumonia (8.8%), and constipation (7.0%). We found indications of an inverse dose–response relationship between the number of processes of care that the patients received and the risk of medical complications. The lowest risk of complications was found among patients who received all relevant processes of care compared with patients who failed to receive any of the processes (ie, adjusted ORs ranged from 0.42 [95% CI, 0.24 to 0.74] for pressure ulcer to 0.64 [95% CI, 0.44 to 0.93] for pneumonia). Of the individual processes of care, early mobilization was associated with the lowest risk of complications.

Conclusions—

Higher quality of acute stroke care was associated with a lower risk of medical complications.

Variations and determinants of hospital costs for acute stroke in China

Background

The burden of stroke is high and increasing in China. We modelled variations in, and predictors of, the costs of hospital care for patients with acute stroke in China.

Methods and Findings

Baseline characteristics and hospital costs for 5,255 patients were collected using the prospective register-based ChinaQUEST study, conducted in 48 Level 3 and 14 Level 2 hospitals in China during 2006–2007. Ordinary least squares estimation was used to determine factors associated with hospital costs. Overall mean cost of hospitalisation was 11,216 Chinese Yuan Renminbi (CNY) (≈US$1,602) per patient, which equates to more than half the average annual wage in China. Variations in cost were largely attributable to stroke severity and length of hospital stay (LOS). Model forecasts showed that reducing LOS from the mean of 20 days for Level 3 and 18 days for Level 2 hospitals to a duration of 1 week, which is common among Western countries, afforded cost reductions of 49% and 19%, respectively. Other lesser determinants varied by hospital level: in Level 3 hospitals, health insurance and the occurrence of in-hospital complications were each associated with 10% and 18% increases in cost, respectively, whilst treatment in a teaching hospital was associated with approximately 39% decrease in cost on average. For Level 2 hospitals, stroke due to intracerebral haemorrhage was associated with a 19% greater cost than for ischaemic stroke.

Conclusions

Changes to hospital policies to standardise resource use and reduce the variation in LOS could attenuate costs and improve efficiencies for acute stroke management in China. The success of these strategies will be enhanced by broader policy initiatives currently underway to reform hospital reimbursement systems.

Stroke Units: Many Questions, Some Answers

Background The development of specialized stroke units has been a landmark innovation in acute stroke care. However, the high scientific evidence level for the recommendation for stroke units to provide clinical attention for acute stroke patients does not correspond to the level of stroke unit implementation. A narrative, nonsystematic review on published studies on stroke units was conducted, with special emphasis on those demonstrating their efficacy and effectiveness. We also attempt to provide some answers to several open questions regarding practical issues of stroke units.

The Effectiveness of Integrated Care Pathways for Adults and Children in Health Care Settings: A Systematic Review

BACKGROUND

Integrated Care Pathways (ICPs) are management technologies which formalise multi-disciplinary team-working and enable professionals to examine and address how they articulate their respective roles, responsibilities and activities. They map out a patient's journey and aim to have: 'the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome'. Initially introduced into the health care context in the 1980s in the US, enthusiasm for ICPs now extends across the world. They have been promoted as a means to realise: evidence based practice, clinical governance, continuity of care, patient empowerment, efficiency gains, service re-engineering, role realignment and staff education.While ICPs are now being developed and implemented across international health care arena, evidence to support their use is equivocal and understanding of their 'active ingredients' is poor. Reviews of evidence of ICP effectiveness have focused on their use in specific patient populations. However, ICPs are 'complex interventions' and are increasingly being implemented for a variety of purposes in a range of organisational contexts. Identification of the circumstances in which ICPs are effective is the first step towards developing hypotheses about their active ingredients and the generative mechanisms by which they have their effects.This review was designed to address a slightly different set of questions to those that typify systematic reviews of ICP effectiveness. Rather than simply asking: 'Are ICPs effective?', our concern was to identify the circumstances in which ICPs are effective, for whom and in what contexts. In addition to identifying evidence of ICP effectiveness, the review therefore required attention to the contexts in which ICPs are utilised, the purposes to which they are put and the factors critical to their success. In framing the review in this way we are drawing on the insights afforded by Pawson and Tilley's realistic evaluation methodology. The underlying rationale for this approach is that if we know and understand how different interventions produce varying effects in different circumstances, we are better able to decide what policies/services to implement in what conditions.

OBJECTIVES

To identify the purposes for which ICPs are effective, for whom and in what contexts;To identify the purposes for which ICPs are not effective, for whom and in what contexts;To produce recommendations on how ICPs should be used in the full range of health care settings.

INCLUSION CRITERIA

Types of participants - The review focused on adults and children that accessed health care settings in which ICPs are used.Types of intervention(s)/phenomena of interest - For the purposes of the review, the ICP had to meet the defining characteristics set by the European Pathway Association (EPA):An explicit statement of the goals and key elements of care based on evidence, best practice and patient expectations;Facilitation of communication, coordination of roles, and sequencing of activities of the multidisciplinary care team, patients and their relatives;The documentation, monitoring, and evaluation of variances and outcomes;The identification of the appropriate resources.Here multidisciplinary is taken to refer to the involvement of two or more disciplines.Types of outcomes - Outcome measures were determined by the purposes of the studies selected for review and the type of study participant. Specific clinical outcomes were determined by the group of patients for which the ICP was developed.Types of studies - To address the aims of the review it was necessary to examine evidence of ICP effectiveness across the full spectrum of contexts in which they are in use. In order to keep the study to a manageable scale we limited its scope to randomised controlled trials (RCTs). All RCTs reported between 1980 and 2008 (March) were included in the review. The search was restricted to publications after 1980 coinciding with the emergence of ICPs in the health care context. Non-English language studies were considered for inclusion based on the English language abstract where this was available. Papers were included if an English, German or French translation was available.

EXCLUSION CRITERIA

The review excluded studies that: SEARCH STRATEGY: The strategy consisted of high precision MeSH and non-MeSH index terms and keywords to ensure that all relevant material was captured (). To avoid any potential replication, initial searches of the Joanna Briggs Institute for Evidence Based Nursing and Midwifery and Cochrane Library databases were conducted to establish that no other systematic reviews existed or were currently in progress. Following these initial enquiries a three step search strategy was designed to identify both published and unpublished studies. Stage one involved searching online databases using preliminary keywords, stage two involved using additional search words identified in the title or abstracts found in stage one and stage three involved hand searches of reference lists, bibliographies and key journals including the Journal of Integrated Care Pathways and International Journal of Integrated Care.

DATA COLLECTION

Our search strategy located 4055 papers, of which 31 were retrieved for further evaluation. We critically appraised 9 papers, representing 7 studies. These studies were appraised for methodological quality using the JBI Critical Appraisal Checklist for Experimental Studies (See ). This appraisal focused specifically upon the reliability and validity of the study method and findings. Two reviewers independently assessed all of the included studies. In cases where reviewers could not reach an agreement a third reviewer was consulted. If disagreement was due to a lack of information then the study authors were contacted for clarification. Following the process of critical appraisal, 9 papers which represents 7 studies, were considered to be of a high enough quality to proceed to data extraction.

DATA EXTRACTION

As the aim of the review was to capture information on context as well as effectiveness, a bespoke data extraction tool was developed. The tool drew on the information included in the JBI extraction sheet for experimental studies and also incorporated specific information and issues relevant to the purpose of the review including aspects of ICP purpose, information on context and critical success factors ().

DATA SYNTHESIS

Given the heterogeneity of the included studies meta-analysis and/or qualitative synthesis was not possible. A narrative summary of the study findings is therefore presented.

RESULTS

Based on the evidence considered in this review, we conclude that:Based on the evidence considered in this review we conclude that:Active Ingredients - We have argued that ICPs are a classic example of a complex intervention. That is they comprise 'a number of separate elements which seem essential to the proper functioning of the intervention although the "active ingredient" of the intervention that is effective is difficult to specify'. None of the studies included in the review were underpinned by explicit theories of ICPs' active ingredients or their generative effects. Moreover, the information provided on ICP development and implementation processes was varied and in no case was any evidence provided to enable the role of these components of the intervention to be assessed. The interventions described by the studies in the review varied in terms of their key components ().Generative Mechanisms - Although none of the studies explicitly address the question of generative mechanisms, in several cases it was possible to make inferences about authors' implicit assumptions, based on the discussion sections of the papers (). On the basis of the evidence considered in the review we suggest that ICPs can be considered as having a multiple role as directing, coordinating, organising, decision-making, and accumulating devices. In addition, because ICPs accumulate information, it seems reasonable to infer that they also function as 'distributing devices' by circulating information to users of the pathway, although no definitive evidence is provided in the studies reviewed to support this assertion.

CONCLUSIONS

Our review indicates that ICPs can have positive effects on service quality and efficiency as a result of their functions. They are effective in supporting the timely implementation of clinical interventions and the mobilisation of resources around the patient without incurring additional increases in length of stay. They also have value in supporting implementation of best practice guidelines and protocols by translating these into a format which is suitable for daily use by busy health professionals, thereby improving inter and intra-professional consensus and reducing unacceptable variations in clinical practice. Because they function as accumulating and distributing devices ICPs may also bring about improvements in documentation, which in turn augments their coordinating effects. They provide a focal point of reference - a common resource - to which various members can refer in order to understand where their role fits into the larger whole and determine what actions are necessary and when.

IMPLICATIONS FOR PRACTICE

Recommendation 1: Given the costs of their development, service providers should restrict ICP use to those areas of service provision where there are clearly identified deficiencies in existing care provision and/or where change is required.Recommendation 2: Prior to ICP development, developers should seek to specify how they wish to change practice, and which of the potential active ingredients of ICPs are necessary for this purpose.Recommendation 3: The evidence suggests that the ICP will change practice. It is imperative therefore, that the directions for action embedded in the tool are based on best practice or evidence.Recommendation 4: ICPs can be usefully deployed to make best practice guidelines available to staff in a form that is useable in daily practice.Recommendation 5: In cases where trajectories of care are more variable ICPs need to have greater degrees of in-built flexibility. Moreover, it is important that staff are supported in exercising professional judgement in those cases when adherence to the pathway is not in the individual patient's interest.Recommendation 6: ICP developers should consider carefully the patient population to whom the ICP applies and identify any sub-groups for whom its use may not be appropriate.

IMPLICATIONS FOR RESEARCH

Recommendation 1: Primary research is necessary in order to provide stronger evidence of the active ingredients of ICPs, their generative mechanisms and inter-relationships.Recommendation 2: Evaluations of ICPs should specify the ingredients of the intervention, including processes to support development, implementation and sustainability as well as the detail of the ICP artefact itself.Recommendation 3: Evaluations of ICPs need to be underpinned by clarity as to the purposes of the intervention.Recommendation 4: Evaluations of ICPs must include theoretically informed outcome and process measures which take into account the perspective of all relevant stakeholders and the wider system effects of the intervention.Recommendation 5: Evaluations of ICPs should include theoretically informed process outcomes in order to develop understanding of ICP use in practice so that the reasons for behavioural change or its absence are understood.Recommendation 6: Evaluations of ICPs should provide adequate information on the 'control'.Recommendation 7: Evaluations of ICPs should provide adequate information on the local context, taking care to identify critical success factors.Recommendation 8: It is unlikely that ICPs will work for all purposes and in all contexts. Researchers should aim to produce realistic evaluations of ICPs which seek to develop an explanation (and therefore a theory) about how the intervention in question works in particular situations/contexts, by exploring the relationship between context, mechanism and outcome.

A cluster randomized trial to assess the impact of clinical pathways for patients with stroke: rationale and design of the Clinical Pathways for Effective and Appropriate Care Study [NCT00673491]

BACKGROUND

Patients with stroke should have access to a continuum of care from organized stroke units in the acute phase, to appropriate rehabilitation and secondary prevention measures. Moreover to improve the outcomes for acute stroke patients from an organizational perspective, the use of multidisciplinary teams and the delivery of continuous stroke education both to the professionals and to the public, and the implementation of evidence-based stroke care are recommended. Clinical pathways are complex interventions that can be used for this purpose. However in stroke care the use of clinical pathways remains questionable because little prospective controlled data has demonstrated their effectiveness. The purpose of this study is to determine whether clinical pathways could improve the quality of the care provided to the patients affected by stroke in hospital and through the continuum of the care.

METHODS

Two-arm, cluster-randomized trial with hospitals and rehabilitation long-term care facilities as randomization units. 14 units will be randomized either to arm 1 (clinical pathway) or to arm 2 (no intervention, usual care). The sample will include 238 in each group, this gives a power of 80%, at 5% significance level. The primary outcome measure is 30-days mortality. The impact of the clinical pathways along the continuum of care will also be analyzed by comparing the length of hospital stay, the hospital re-admissions rates, the institutionalization rates after hospital discharge, the patients' dependency levels, and complication rates. The quality of the care provided to the patients will be assessed by monitoring the use of diagnostic and therapeutic procedures during hospital stay and rehabilitation, and by the use of key quality indicators at discharge. The implementation of organized care will be also evaluated.

CONCLUSION

The management of patients affected by stroke involves the expertise of several professionals, which can result in poor coordination or inefficiencies in patient treatment, and clinical pathways can significantly improve the outcomes of these patients. It is proposed that this study will test a new hypothesis and provide evidence of how clinical pathways can work.

TRIAL REGISTRATION

ClinicalTrials.gov ID [NCT00673491].