Introduction
A care pathway is a goal-oriented, high-quality plan of care based on evidence/best practice guidelines. Care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
were introduced in an attempt to improve the quality and consistency of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation.
Care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
should, intuitively, improve the quality of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. care; however, surprisingly, evidence does not support this conclusion. It is not clear why this occurs. Care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
may simply reinforce rather than change practice. This suggests that imposing a blueprint of care, rather than individualizing treatment, does not improve outcomes. Therefore, although organized interdisciplinary strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation units have been shown to improve outcomes, care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
do not appear to be contributing to this success.
Patient/Family Information
Author: Marc-André Roy, MSc
What is a critical care pathway?
Critical care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
are designed to offer organized and efficient care based on research. The goal is to make sure each person with a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. receives important tests and treatments.
Spoiler title
Critical care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
differ from “normal” strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. care by following a written care plan. This plan is designed especially for persons with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. In most cases, checklists are created for each healthcare professional (doctors, nurses and therapists). These checklists are used to improve communication between these professionals and to make sure specific tests and treatments are done. They also help the healthcare professionals make decisions about the best treatment for an individual.
Is it better to receive treatment from a critical care pathway?
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Clinician Information
Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.
Seven studies were included in this review of critical care pathway for strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Of the seven studies, one was a Cochrane Systematic ReviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
, three were fair quality RCTs and one was a cohort study.
Care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
are often investigated using a comparison to a conventional, multidisciplinary mode of care. Outcomes compared and results are summarized below.
Results Table
View results table
Outcomes
Frequency of stroke-related assessment
Effective
1b
One high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. (Sulch et al. 2002b) and one non-randomized study (Kwan et al. 2004b) investigated the effect of care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
on the frequency of stroke-related assessments (i.e. nutritional assessments, tests of inattention and CT brain scans). An increased frequency of assessment was reported for those who had received care pathway interventions post-stroke.
Conclusion: There is moderate (Level 1b) evidence from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
increase the frequency of stroke-related assessments post-stroke.
Functional ability
Not effective
1B
One high quality randomized control trial (RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.) (Sulch et al. 2000), and one non-randomized study (Hamrin et al. 1990), have investigated the efficacy of care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
for improving functional ability post-stroke. No significant differences were found between groups.
Conclusion: There is moderate (Level 1b) evidence from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness., that care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
do not improve functional ability post-stroke.
Hospital costs
Not effective
2a
One fair quality RCT (Falconer et al. 1993) examined cost for usual care versus care in a care pathway. Care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
did not reduce hospital costs.
Conclusion: There is limited (Level 2a) evidence from one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
do not reduce hospital costs in comparison to conventional care for strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. patients.
Independence at discharge
Not effective
2A
One fair quality RCT (Falconer et al. 1993) investigated the use of care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
for improving functional independence at discharge compared to regular therapy. There was no significant difference between groups as measured using the FIM.
Conclusion: There is limited (Level 2a) evidence from one fair quality RCT that care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
do not increase patient independence at discharge.
Institutionalization
Not effective
1B
One high quality RCT (Sulch et al. 2000) and two non-randomized studies (Kwan et al. 2004b; Hamrin et al. 1990) investigated the use of care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
on frequency of institutionalization compared to regular therapy. There were no significant differences in institutionalization between groups in the three studies.
Conclusion: There is moderate (Level 1b) evidence from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
do not reduce frequency of institutionalization post-stroke.
Length of hospital stay (LOS)
Not effective
1B
Two RCTs, one of high quality (Sulch et al. 2000) and one of fair quality (Falconer et al. 1993), and one non-randomized study (Kwan et al. 2004b) have investigated the effectiveness of care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
in decreasing length of hospital stay (LOS) post-stroke. None of the three studies demonstrated shortened length of stay with the use of care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
.
Conclusion: There is moderate (Level 1b) evidence from one high quality RCT and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
do not decrease the length of stay in hospital post-stroke.
One high quality RCT (Sulch et al. 2000) and two non-randomized studies (Hamrin et al. 1990; Kwan et al. 2004b) investigated the relationship between care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
and mortality rates. No significant difference in mortality was observed between the group receiving care through a care pathway and the group receiving regular therapy.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
do not reduce mortality rates of stroke patients.
Patient satisfaction
No evidence
5
One fair quality RCT (Falconer et al. 1993) investigated the relationship between care pathway interventions and patient satisfaction. Significant differences were observed between groups for patient satisfaction on measures of general satisfaction in favor of the care pathway treatment group. No significant differences were noted on other satisfaction measures within the satisfaction questionnaire.
However, this study will not be included in the determination of the level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) for two reasons. First, the scale used to measure satisfaction was designed specifically for this study and has not been validated. Furthermore, in 46 of 80 cases (58%), family members completed the questionnaire (proxy respondent) because the patients had comprehension difficulties.
Conclusion: There is no evidence (level 5) that care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
affect patient satisfaction post-stroke.
Preventing urinary tract infection
Effective
2B
One systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
(Kwan and Sandercock, 2004) reported that patients managed with a care pathway were less likely to experience a urinary tract infection. However, the results were derived from non-randomized studies.
Conclusion: There is limited (Level 2b) evidence that care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
decrease the rate of urinary tract infection.
One systematic review (Kwan and Sandercock, 2004) reported that patients managed with a care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
were less likely to be readmitted to hospital. However, the results were derived from non-randomized studies.
Conclusion: There is limited (Level 2b) evidence that care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
decrease readmission after discharge.
Self-perceived health status/Quality of life
Not effective
1b
One high quality RCT (Sulch et al. 2000) has investigated the efficacy of care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
for improving self-perceived health status post-stroke. Patients treated using conventional care methods scored higher (better) on the Euro-QoL Visual Analogue Scale compared to patients treated within an Integrated Care Pathway (ICP) model of care.
Conclusion: There is moderate (Level 1b) evidence from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
reduce self-perceived health status/quality of life post-stroke.
References
Falconer J. A., Roth E. J., Sutin J. A., Strasser D. C., & Chang, R. W. (1993). The critical path method in stroke rehabilitation: lessons from an experiment in cost containment and outcome improvement. QRB Qual Rev Bull, 19(1), 8-16.
Hamrin E. K., & Lindmark, B. (1990). The effect of systematic care planningPlanning ability involves anticipating future events, formulating a goal or endpoint, and devising a sequence of steps or actions that will achieve the goal or endpoint" (Anderson, 2008, p. 17)
after acute stroke in general hospital medical wards. J Adv Nurs, 15(10), 1146-1153.
Kwan J., Hand P., Dennis M., & Sandercock, P. (2004). Effects of introducing an integrated care pathway in an acute stroke unitStroke units are designed to provide multidisciplinary specialized care for patients who have had a stroke. In the best units, the team consists of nurses, pharmacists, social workers, medical staff, and occupational, physical and speech therapists. Stroke units can be located in a special unit in a defined location, or can used as a roving stroke specialist team. (Hill, M. Stroke Units in Canada. CMAJ. 2002:167:649-50.). Age Ageing, 33(4), 362-367.
Sulch D., & Kalra, L. (2000). Integrated care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
in strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. management. Age Ageing, 29(4), 349-352.
Sulch D., Evans A., Melbourn A., & Kalra, L. (2002b). Does an integrated care pathway improve processes of care in strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation? A randomized controlled trial. Age Ageing, 31(3), 175-179.
Sulch D., Melbourn A., Perez I., & Kalra, L. (2002a). Integrated care pathwaysCare pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
and quality of life on a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation unit. StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., 33(6), 1600-1604.
