Protocols and Pathways Ischemic and Hemorrhagic Strokes.ppt
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This document discusses protocols and clinical pathways for ischemic and hemorrhagic stroke. It defines clinical pathways as multidisciplinary and evidence-based approaches to standardized patient care, while protocols provide guideline-based outlines for managing specific conditions. The document reviews evidence that clinical pathways can streamline stroke care, avoid delays, and improve outcomes. It identifies key components for inclusion in ischemic and hemorrhagic stroke pathways, such as diagnostic testing, treatment guidelines, and monitoring plans. Examples of pathways are provided to illustrate components like blood pressure and nutrition management in the first 72 hours after different stroke types.
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Protocols and Pathways Ischemic and Hemorrhagic Strokes.ppt
- 1. Protocols and Pathways: Ischemic and Hemorrhagic Stroke Abby Doerr, APN, FNP-BC, ANVP, SCRN Procedural APN: Neurointerventional Surgery Northwestern Medicine Central DuPage Hospital
- 2. Disclosures • No disclosures related to this presentation
- 3. Objectives • Discuss the definitions of clinical pathways and protocols. • Identify and discuss the potential benefits of implementation of clinical pathways. • Review the evidence related to clinical pathways recommendations in stroke. • Identify and discuss key components for inclusion in ischemic and hemorrhagic stroke clinical pathways.
- 4. Definitions Clinical pathways and protocols in stroke
- 5. Definitions Clinical Pathway “A clinical pathway is a method for the patient-care management of a well-defined group of patients during a well-defined period of time. A clinical pathway explicitly states the goal and key elements of care based on Evidence Based Medicine (EBM) guidelines, best practice and patient expectations by facitlitating the communication, coordinating roles and sequening the activities of the multidisciplinary care team, aptients, and their relatives; by documenting, monitoring and evaluating variances; and by providing the necessary resources and outcomes.” De Bleser, L., et al. (2006) Defining Pathways
- 6. Definitions Protocols “Clinical protocols can be seen as more specific than guidelines, defined in greater detail. Protocols provide a comprehensive set of rigid criteria outlining the management steps for a single clinical condition or aspects of organization" Retrieved from: http://www.openclinical.org/guidelines.html
- 7. 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 specific condition Focused on adherence to guidelines
- 8. Protocol vs Pathway • Protocols are treatment recommendations that are often based on guidelines. Similar to clinical pathway, the goal of the clinical protocol may be to decrease treatment variation. • Protocols are most often focused on guideline compliance rather than the identification of reducing unnecessary steps in the patient care process. • Unlike critical pathways, protocols may or may not include a continuous monitoring or data-evaluation components. What’sthedifference??
- 9. Clinical Pathways • 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 risk management • The aim of a clinical pathway is to improve the quality of care, reduce risks, increase patient satisfaction and increase the efficiency in the use of resources. De Bleser, L., et al. (2006) Defining Pathways Benefits ofimplementation
- 10. Stroke Specific Pathways/Protocols Evidence Based Practice
- 11. Protocols and Pathways: Stroke • Target: Stroke Key Practice Strategies Strategy #4: Stroke tools • “A stroketoolkit containingclinicaldecisionsupport,stroke-specificorder sets, guidelines,hospital-specific algorithms,criticalpathways,NIH StrokeScale, and other stroketools shouldbe available and used for each patient” Strategy #9: Team-based approach • “The team approachbasedon standardizedstroke pathwaysand protocolshas proveneffective in increaseingthe number of eligiblepatientstreatedandreducing time to treatment in stroke. An interdisciplinary collaborative team is also essential for successfulstrokeperformance improvement efforts. The team shouldmeet frequentlyto reviewyour hospital’sprocesses,care quality, patient safety parameters and clinical outcomes, as well as to make recommendationsfor improvement.” • Target: Stroke Phase II recommendations Rapid triage protocol and stroke team notification • Facilitatestimely recognitionof stroke and reducestime to treatment Evidence Based Practice: fromtheliterature Fonarow, G. et al. (2011) Improving door-to-needle times in acute ischemic stroke: the design and rationale for the AHA/ASA Target: Stroke Initiative AHA Target: Stroke Phase II, 2014
- 12. Protocols and Pathways: Stroke • Qualitative evaluation of “top performing” hospitals GWTG registry found process to be a key theme to successful early administration of IV tPA Process = established care protocols and patterns • National Health and Family Planning Commission of China findings from 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 trial Evidence Based Practice: fromtheliterature Olsen, D, et al. (2011). A qualitative assessment of practices associated with shorter door-to-needle time for thrombolytic therapy in acute ischemic stroke Deng, et al. (2014) Reduction of length of stay and costs through implementation of clinical pathways for stroke management in China
- 13. Pathways and Protocols in Stroke Necessary components and considerations
- 14. Necessary Components • Multidisciplinary Team Nursing Vascular Neurology Neurosurgery Neurocritical Care (if available) Neurointerventional Surgery Stroke Protocols andPathways
- 15. Necessary Components • Other team members Emergency medicine Radiology Rehab medicine Physical therapy Occupational therapy Speech therapy Pharmacy Hospice services Stroke Protocols andPathways
- 16. Necessary Components Stroke Protocols andPathways Stroke APNs ER Physicians* & Staff PATIENT Stroke Neurology & Code Neuro RNs* Neurointerventional Surgery & Staff Neurosurgery Neuro Critical Care Physicians* & Staff Hospitalists* & Neuro Step-Down Staff Neuroradiology PT, OT, Speech Respiratory Therapy Pharmacy Case Management, Social Work Neuropsychology Lab Dietary Music & Pet Therapy EMS Neuro Rehab It takes an ARMY to care for the acute stroke patient
- 17. Necessary Components • A smaller “core team” should be developed within the larger team creating the pathway. • The team’s lead person (or people) should be charged with Coordination of the project Ensuring the opinions of all needed have been obtained and considered Finally coordination of the approval/roll out phase Stroke Protocols andPathways
- 18. Necessary Components • Re-evaluation Consider re-evaluation and updating of protocols and pathways 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 implementation of practice/guideline changes Stroke Protocols andPathways
- 19. Protocols and Pathways Specific components for Ischemic and Hemorrhagic stroke
- 20. Necessary Components •Ischemic Stroke/TIA: first 72 hours Diagnostic testing Treatments IV tPA (if appropriate) Rapid reversal of anticoagulation (if appropriate) Blood pressure management Nursing considerations Monitoring Neuro assessments Cardiac monitoring Temperature Glucose Dysphagia screening Fluid balance Stroke Protocols andPathways Middleton, Grimley & Alexandrov (2015) Triage, treatment and transfer:…:
- 21. Necessary Components • Ischemic Stroke/TIA: first 72 hours Nutrition Nutrition and hydration needs? NG feeding within 24 hrs for those unable 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 of indwelling urinary catheters SKIN Stroke Protocols andPathways Middleton, Grimley & Alexandrov (2015) Triage, treatment and transfer:…:
- 22. Necessary Components • 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: levelof evidenceB Post–r-tPA bolus: target <180 mm Hg SBP, <105 mm Hg DBP Nonthrombolysed ischemic stroke: BP lowering by ~15% during the first 24 h after stroke • WithholdmedicationsunlessSBP >220 mm Hg or DBP >120 mm Hg (class I: levelof evidenceC) ICH: Intensive BP lowering is safe and feasible • BP loweringwithin6 h of ICH onset to a target systolicBP of <140 mm Hg may improve functionaloutcome at 3 mo after stroke as comparedwitha traditionalBP-loweringtarget of <180 mm Hg (classI: levelof evidence B) Subarachnoid hemorrhage: Reduction of systolic BP to a target of 90/160 mm Hg until the aneurysm has been occluded by endovascular or surgical means (GPP) Stroke Protocols andPathways Middleton, Grimley & Alexandrov (2015) Triage, treatment and transfer:…:
- 23. Necessary Components • 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 needs Stroke Protocols andPathways Middleton, Grimley & Alexandrov (2015) Triage, treatment and transfer:…:
- 24. Necessary Components • 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? Stroke Protocols andPathways
- 25. Protocols and Pathways: Stroke Samples and Examples
- 26. Protocols and Pathways: Stroke • 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 • MassachusettsGeneral protocols Examples
- 35. Originally from the Michael E. DeBakey VA Medical Center
- 37. Summary • Pathways require a multidisciplinary approach • Pathways and protocols promote a systematic, evidence based, potentially streamlined hospitalization Pathways: improving quality care Protocols: adherence to guidelines • Creating pathway: research, review others work, determine what is best for YOUR clinical setting • Remember: do not reinvent the wheel! Phone a friend www.heart.org Review the evidence Pathways andProtocols inStroke
Editor's Notes
- Literature review By De Bleser et al found 84 different defintions of clinical pathways in 82 articles – suggested definition based on those studies
- The obvious team members to include in developing, writing and approval of pathways in stroke As we all know, each of these team members have different goals and objectives on the various days of the hsopitalization and recovery in stroke. It is critical to establish an agreed upon plan with buy in from each of these teams. If you don’t have the buy-in the pathways will struggle to succeed and will struggle to make a positive impact on outcomes.
- Other team members to include in planning and writing pathways as well as final approval. Having the opinions and recommendations of the various therapy services and rehabilitation would be key to development of a comprehensive set of pathways in stroke. What about ER and Radiology?? They too should have input on their respective areas. A smaller “core team” should be developed within the larger team creating the pathway. This person (or people) should be charged with coordination of the project, ensuring the opinions of all needed have been obtained and considered and finally coordination of the approval/roll out phase. Often when creating protocols less comprehesive list of team members is needed for the development of the protocol. These are typically based on a guideline or other recommendation. Again, as mentioned before, protocols are more of a step by step list where the pathway is a comprehensive – multidisplinary set of goals, tasks and objectives for each day of a hospitalization. The rehabilition services are critical to the various stages of recovery in the stroke population.
- Pathway and protocol development is NO DIFFERENT! IT TAKES AN ARMY! Multiple people from multiple specialties.
- The project lead needs to be able to coordinate a mutlitude of moving parts throughout the creation of the pathways and protocols. This person needs to be knowledgeable of the program, its goals, the guidelines and the politics within the groups/practices/departments. Yes, that’s right the politics. The person needs to be able to navigate the various groups to be able to get the buy in to make the pathways successful.
- When looking at the ever changing world of medicine your team must have a plan for what to do when clinical practice updates occur. The team should have an established plan for updating, approving and implementing the practice change
- Diagnostic testing: Treatments: Nursing considerations Monitoring Comprehensive nursing care assessment within 4 h of stroke unit admission for nutritional and hydration needs, positioning and mobilization needs, bladder control and \ incontinence management, pressure ulcer risk, cognitive and language capacity, hearing and visual needs, and family/carer needs (GPP)5
- VTE: The use of anticoagulation provides superior VTE prophylaxis in patients with acute ischemic stroke (class I: level of evidence A). The use of intermittent pneumatic compression for immobile patients reduces the risk of VTE and possibly death (class I: level of evidence B).
- As you may have seen previously there are a variety of BP parameters and recommendations – this contributes to the need for SEPARATE pathways/protocols for hemorrhagic vs ischemic stroke.
- Tools shared by sites utilizing GWTG for stroke – variety of tools and resources to aid in development of order sets, pathways, protocols. Do not recreate the wheel, perhaps try to redesign it to fit your program
- Protocols, pathways and algorithms
- Large variety of best practice tools available for download and viewing.
- Note the activities, assessments and goals are designated per day Diagnostic testing, nursing care, nutrition etc have their own specific section
- Similar structure is noted in the hemorrhagic pathway; designated by hospital day
- Both the hemorrhagic and ischemic pathways include an interdisciplinary care plan. These can and should be included in the facilities pathway. The nursing diagnosis here should be familiar to most here. Note the comment on the intervention performed and whether the outcome has been met.
- Mass general shared various protocols such as ICH – note the first step in the protocol is the ICH score? Determining severity prior to treatment This enables the team to have appropriate risk/benefit and outcome conversations between the family, patient and other team members
- Other protocols from Mass Gen such as BP management in acute stroke. Note the stepwise fashion utilized to manage HTN. The use of protocols help to ensure consistency in treatment and use of best practice/EBP
- Other protocols may look like a flow chart as this one does from Central DuPage hospital. A series of yes/no responses within a decision tree leading to the treatment recommendations for a particular patient presentation. Again leading to standardized, evidence based (presumably!) care for the patients