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Protocols and Pathways:Ischemic and Hemorrhagic StrokeAbby Doerr, APN, FNP-BC, ANVP, SCRNProcedural APN: Neurointerventional SurgeryNorthwestern Medicine Central DuPage Hospital

Disclosures No disclosures related to this presentation

Objectives Discuss the definitions of clinical pathways and protocols. Identify and discuss the potential benefits ofimplementation of clinical pathways. Review the evidence related to clinical pathwaysrecommendations in stroke. Identify and discuss key components for inclusion inischemic and hemorrhagic stroke clinical pathways.

DefinitionsClinical pathways and protocols in stroke

DefinitionsClinical Pathway“A clinical pathway is a method for the patient-care management of awell-defined group of patients during a well-defined period of time.A clinical pathway explicitly states the goal and key elements of carebased on Evidence Based Medicine (EBM) guidelines, best practiceand patient expectations by facitlitating the communication,coordinating roles and sequening the activities of the multidisciplinarycare team, aptients, and their relatives; by documenting, monitoringand evaluating variances; and by providing the necessary resourcesand outcomes.”De Bleser, L., et al. (2006) Defining Pathways

DefinitionsProtocols“Clinical protocols can be seen as more specific thanguidelines, defined in greater detail.Protocols provide a comprehensive set of rigid criteriaoutlining the management steps for a single clinical conditionor aspects of organization"Retrieved from: http://www.openclinical.org/guidelines.html

Definitions Clinical Pathway Multidisciplinary approach Physicians, nursing, ancillary services Evidence based approach to standardized patient care Focused on improving quality of care Protocols Guideline based outline of management of a specificcondition Focused on adherence to guidelines

Protocol vs PathwayWhat’s the difference? Protocols are treatment recommendations that are oftenbased on guidelines. Similar to clinical pathway, the goal of the clinicalprotocol may be to decrease treatment variation. Protocols are most often focused on guidelinecompliance rather than the identification of reducingunnecessary steps in the patient care process. Unlike critical pathways, protocols may or may notinclude a continuous monitoring or data-evaluationcomponents.

Clinical PathwaysBenefits of implementation To improve patient care To maximize the efficient use of resources To help identify and clarify the clinical processes To support clinical effectiveness, clinical audit and riskmanagement The aim of a clinical pathway is to improve the quality ofcare, reduce risks, increase patient satisfaction andincrease the efficiency in the use of resources.De Bleser, L., et al. (2006) Defining Pathways

Stroke SpecificPathways/ProtocolsEvidence Based Practice

Protocols and Pathways: StrokeEvidence Based Practice: from the literature Target: Stroke Key Practice Strategies Strategy #4: Stroke tools “A stroke toolkit containing clinical decision support, stroke-specific order sets,guidelines, hospital-specific algorithms, critical pathways, NIH Stroke Scale, and otherstroke tools should be available and used for each patient” Strategy #9: Team-based approach “The team approach based on standardized stroke pathways and protocols hasproven effective in increaseing the number of eligible patients treated and reducingtime to treatment in stroke. An interdisciplinary collaborative team is also essentialfor successful stroke performance improvement efforts. The team should meetfrequently to review your hospital’s processes, care quality, patient safety parametersand clinical outcomes, as well as to make recommendations for improvement.” Target: Stroke Phase II recommendations Rapid triage protocol and stroke team notification Facilitates timely recognition of stroke and reduces time to treatmentFonarow, G. et al. (2011) Improving door-to-needle times in acute ischemic stroke: thedesign and rationale for the AHA/ASA Target: Stroke InitiativeAHA Target: Stroke Phase II, 2014

Protocols and Pathways: StrokeEvidence Based Practice: from the literature Qualitative evaluation of “top performing” hospitals GWTG registryfound process to be a key theme to successful early administrationof IV tPA Process established care protocols and patterns National Health and Family Planning Commission of China findingsfrom testing of stroke clinical pathway Pathways streamline management of patients with stroke Avoid unnecessary delays Improve quality of treatment Improve quality of rehabilitation Resulted in decreased LOS and overall healthcare costs No sacrifice in treatment quality was noted in this trialOlsen, D, et al. (2011). A qualitative assessment of practices associated with shorterdoor-to-needle time for thrombolytic therapy in acute ischemic strokeDeng, et al. (2014) Reduction of length of stay and costs through implementation ofclinical pathways for stroke management in China

Pathways and Protocolsin StrokeNecessary components and considerations

Necessary ComponentsStroke Protocols and Pathways Multidisciplinary Team Nursing Vascular Neurology Neurosurgery Neurocritical Care (if available) Neurointerventional Surgery

Necessary ComponentsStroke Protocols and Pathways Other team members Emergency medicine Radiology Rehab medicine Physical therapy Occupational therapy Speech therapy Pharmacy Hospice services

Necessary ComponentsStroke Protocols and PathwaysPT, OT, SpeechDietaryMusic & PetTherapyEMSStroke APNsER Physicians* &StaffRespiratoryTherapyStroke Neurology &Code Neuro RNs*Neuro RehabPATIENTNeurointerventionalSurgery & StaffNeuroradiologyHospitalists* & NeuroStep-Down StaffNeuro CriticalCare Physicians*& agement,Social WorkIt takes an ARMY to care for the acute stroke patient

Necessary ComponentsStroke Protocols and Pathways A smaller “core team” should bedeveloped within the largerteam creating the pathway. The team’s lead person (orpeople) should be charged with Coordination of the project Ensuring the opinions of allneeded have been obtainedand considered Finally coordination of theapproval/roll out phase

Necessary ComponentsStroke Protocols and Pathways Re-evaluation Consider re-evaluation and updating of protocols andpathways per hospital policy ( every 2 years) Updated guidelines? Consider meeting with core team Develop updated pathways/protocols Submit for multidisciplinary team approval Have a plan! What to do when updates are needed How to proceed with update, approval and implementationof practice/guideline changes

Protocols and PathwaysSpecific components for Ischemic andHemorrhagic stroke

Necessary ComponentsStroke Protocols and Pathways Ischemic Stroke/TIA: first72 hours Diagnostic testing Treatments IV tPA (if appropriate) Rapid reversal ofanticoagulation (if appropriate) Blood pressure management Nursing considerations Monitoring Neuro assessments Cardiac monitoring Temperature Glucose Dysphagia screening Fluid balanceMiddleton, Grimley & Alexandrov (2015) Triage, treatment andtransfer: :

Necessary ComponentsStroke Protocols and Pathways Ischemic Stroke/TIA: first 72hours Nutrition Nutrition and hydration needs? NG feeding within 24 hrs for thoseunable to safely swallow Referrals/Consults Education Discharge Planning Prevention of complications GI prophylaxis Aspiration pneumonia Oral care VTE prophylaxis Chemical vs mechanical? Infection risk Avoiding unnecessary use ofindwelling urinary catheters SKINMiddleton, Grimley & Alexandrov (2015) Triage, treatment and transfer: :

Necessary ComponentsStroke Protocols and Pathways Hypertension management: Goals for target BP are uncertain currently,however, the following are recommended Prethrombolysis: SBP 185 mm Hg and DBP 110 mm Hg class I: level of evidence B Post–r-tPA bolus: target 180 mm Hg SBP, 105 mm Hg DBP Nonthrombolysed ischemic stroke: BP lowering by 15% during the first24 h after stroke Withhold medications unless SBP 220 mm Hg or DBP 120 mm Hg (class I: level of evidence C) ICH: Intensive BP lowering is safe and feasible BP lowering within 6 h of ICH onset to a target systolic BP of 140 mm Hg may improvefunctional outcome at 3 mo after stroke as compared with a traditional BP-lowering target of 180 mm Hg (class I: level of evidence B) Subarachnoid hemorrhage: Reduction of systolic BP to a target of 90/160mm Hg until the aneurysm has been occluded by endovascular or surgicalmeans (GPP)Middleton, Grimley & Alexandrov (2015) Triage, treatment and transfer: :

Necessary ComponentsStroke Protocols and Pathways Hemorrhagic: first 72 hours Diagnostic testing CT brain Treatments Blood pressure management Anticoagulation reversal Nursing considerations Monitoring Neuro checks BP/temp/glucose Nutrition Hydration/nutrition needsMiddleton, Grimley & Alexandrov (2015) Triage, treatment and transfer: :

Necessary ComponentsStroke Protocols and Pathways Considerations How long to wait for trach and peg? Aspiration precautions Dietary considerations – when to begin tube feedings? When to get out of bed? Early mobilization Baseline/repeat imaging? Post bleed imaging, timeline preference? Labs? Hypercoagulation work up? keeping in mind the TJC mandated timelines (Lipids, glucose, etc) Cardiac work up? ECHO, TEE?

Protocols and Pathways:StrokeSamples and Examples

Protocols and Pathways: StrokeExamples Samples/examples are available for download www.heart.org Get with the Guidelines – Stroke Clinical Tools Library St. Vincent’s Medical Hemorrhagic Non-hemorrhagic/TIA Stroke Massachusetts General protocols

Originally from the Michael E. DeBakey VA Medical Center

SummaryPathways and Protocols in Stroke Pathways require a multidisciplinary approach Pathways and protocols promote a systematic, evidencebased, potentially streamlined hospitalization Pathways: improving quality care Protocols: adherence to guidelines Creating pathway: research, review others work, determinewhat is best for YOUR clinical setting Remember: do not reinvent the wheel! Phone a friend www.heart.org Review the evidence

Questions?Thank you!