Critical Care Pathways

Evidence Reviewed as of before: 22-11-2011
Author(s): Robert Teasell, MD; Norine Foley, BASc; Sanjit Bhogal, MSc; Mark Speechley, MD; Chelsea Hellings
Patient/Family Information Table of contents

Introduction

A care pathway is a goal-oriented, high-quality plan of care based on evidence/best practice guidelines. Care pathways were introduced in an attempt to improve the quality and consistency of stroke rehabilitation.

Care pathways should, intuitively, improve the quality of stroke care; however, surprisingly, evidence does not support this conclusion. It is not clear why this occurs. Care pathways 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 stroke rehabilitation units have been shown to improve outcomes, care pathways 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 pathways are designed to offer organized and efficient care based on research. The goal is to make sure each person with a stroke receives important tests and treatments.

Spoiler title

Critical care pathways differ from “normal” stroke care by following a written care plan. This plan is designed especially for persons with stroke. 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?

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) 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 stroke. Of the seven studies, one was a Cochrane Systematic Review, three were fair quality RCTs and one was a cohort study.

Care pathways 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 RCT (Sulch et al. 2002b) and one non-randomized study (Kwan et al. 2004b) investigated the effect of care pathways 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 RCT that care pathways increase the frequency of stroke-related assessments post-stroke.

Functional ability
Not effective
1B

One high quality randomized control trial (RCT) (Sulch et al. 2000), and one non-randomized study (Hamrin et al. 1990), have investigated the efficacy of care pathways for improving functional ability post-stroke. No significant differences were found between groups.

Conclusion: There is moderate (Level 1b) evidence from one high quality RCT, that care pathways 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 pathways did not reduce hospital costs.

Conclusion: There is limited (Level 2a) evidence from one fair quality RCT that care pathways do not reduce hospital costs in comparison to conventional care for stroke patients.

Independence at discharge
Not effective
2A

One fair quality RCT (Falconer et al. 1993) investigated the use of care pathways 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 pathways 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 pathways 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 RCT that care pathways 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 pathways in decreasing length of hospital stay (LOS) post-stroke. None of the three studies demonstrated shortened length of stay with the use of care pathways.

Conclusion: There is moderate (Level 1b) evidence from one high quality RCT and one fair quality RCT that care pathways do not decrease the length of stay in hospital post-stroke.

Mortality
Not effective
1B

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 pathways 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 pathways 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 evidence 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 pathways affect patient satisfaction post-stroke.

Preventing urinary tract infection
Effective
2B

One systematic review (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 pathways decrease the rate of urinary tract infection.

Readmission
Effective
2B

One systematic review (Kwan and Sandercock, 2004) reported that patients managed with a care pathways 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 pathways 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 pathways 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 RCT that care pathways 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 planning 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 unit. Age Ageing, 33(4), 362-367.

Sulch D., & Kalra, L. (2000). Integrated care pathways in stroke 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 stroke rehabilitation? A randomized controlled trial. Age Ageing, 31(3), 175-179.

Sulch D., Melbourn A., Perez I., & Kalra, L. (2002a). Integrated care pathways and quality of life on a stroke rehabilitation unit. Stroke, 33(6), 1600-1604.

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