In‐hospital care pathways for stroke

Joseph Kwan; Peter AG Sandercock

doi:10.1002/14651858.CD002924.pub2

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Analysis 1.1

Comparison 1 Care pathway care versus standard care, Outcome 1 Death by the end of follow‐up.

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Analysis 1.2

Comparison 1 Care pathway care versus standard care, Outcome 2 Death in hospital.

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Analysis 1.3

Comparison 1 Care pathway care versus standard care, Outcome 3 Dependency at discharge (mean Functional Indepedence Measure).

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Analysis 1.4

Comparison 1 Care pathway care versus standard care, Outcome 4 Dead or dependent (modified Rankin Score >2) by the end of follow‐up.

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Analysis 1.5

Comparison 1 Care pathway care versus standard care, Outcome 5 Discharged to Institutional care.

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Analysis 1.6

Comparison 1 Care pathway care versus standard care, Outcome 6 Death in hospital or discharged to institutional care.

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Analysis 1.7

Comparison 1 Care pathway care versus standard care, Outcome 7 Discharged to home.

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Analysis 1.8

Comparison 1 Care pathway care versus standard care, Outcome 8 Complication: Pneumonia.

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Analysis 1.9

Comparison 1 Care pathway care versus standard care, Outcome 9 Complication: Urinary tract infection.

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Analysis 1.10

Comparison 1 Care pathway care versus standard care, Outcome 10 Complication: Deep vein thrombosis.

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Analysis 1.11

Comparison 1 Care pathway care versus standard care, Outcome 11 Complication: Pressure sores.

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Analysis 1.12

Comparison 1 Care pathway care versus standard care, Outcome 12 Complication: Dehydration.

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Analysis 1.13

Comparison 1 Care pathway care versus standard care, Outcome 13 Complication: Fluid and electrolyte imbalance.

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Analysis 1.14

Comparison 1 Care pathway care versus standard care, Outcome 14 Complication: Fever (all causes).

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Analysis 1.15

Comparison 1 Care pathway care versus standard care, Outcome 15 Complication: Seizures.

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$Comparison 1 Care pathway care versus standard care, Outcome 16 Complication: Falls or fractures.$

Analysis 1.16

Comparison 1 Care pathway care versus standard care, Outcome 16 Complication: Falls or fractures.

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Analysis 1.17

Comparison 1 Care pathway care versus standard care, Outcome 17 Complication: Constipation.

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Analysis 1.18

Comparison 1 Care pathway care versus standard care, Outcome 18 Complication: Myocardial infarction.

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Analysis 1.19

Comparison 1 Care pathway care versus standard care, Outcome 19 Investigation: First or second computed tomography brain scan.

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Analysis 1.20

Comparison 1 Care pathway care versus standard care, Outcome 20 Investigation: Computed tomography brain scan within 24 hours.

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Analysis 1.21

Comparison 1 Care pathway care versus standard care, Outcome 21 Investigation: Carotid duplex study.

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Analysis 1.22

Comparison 1 Care pathway care versus standard care, Outcome 22 Investigation: Echocardiography.

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Analysis 1.23

Comparison 1 Care pathway care versus standard care, Outcome 23 Investigation: Electrocardiography.

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Analysis 1.24

Comparison 1 Care pathway care versus standard care, Outcome 24 Investigation: Chest x‐ray.

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Analysis 1.25

Comparison 1 Care pathway care versus standard care, Outcome 25 Investigation: Cerebral angiography (catheter or MR angiography).

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Analysis 1.26

Comparison 1 Care pathway care versus standard care, Outcome 26 Medication: Use of heparin (subcutaneous or intravenous) in acute period.

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Analysis 1.27

Comparison 1 Care pathway care versus standard care, Outcome 27 Medication: Use of new antihypertensive therapy in the acute period.

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Analysis 1.28

Comparison 1 Care pathway care versus standard care, Outcome 28 Medication: Use of intravenous fluids.

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Analysis 1.29

Comparison 1 Care pathway care versus standard care, Outcome 29 Procedure: Urinary catheterisation for patients with incontinence.

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Analysis 1.30

Comparison 1 Care pathway care versus standard care, Outcome 30 Procedure: Use of thrombo‐embolism deterrent stockings.

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Analysis 1.31

Comparison 1 Care pathway care versus standard care, Outcome 31 Patient satisfaction.

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Analysis 1.32

Comparison 1 Care pathway care versus standard care, Outcome 32 Duration of hospital stay.

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Analysis 1.33

Comparison 1 Care pathway care versus standard care, Outcome 33 Readmission or emergency department attendance after discharge.

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Table 1. Organisational components of the care pathways assessed by the included studies

Author, Year	State, Country	Clinical Setting	Organisation of care
Baker 1998	Indianapolis, USA	Acute stroke	Patients were cared for in a neurology/orthopaedic ward in a community hospital. Stroke patients were screened according to specific guidleines for suitability for case management using a clinical pathway. Clinical pathway was also evaluated by variance analysis. A 2‐year pilot study was undertaken after implementation
Bowen 1994	Washington, USA	Acute stroke	Unclear what type of ward in which patients in either group were cared for, but mostly likely acute general internal medical ward within an urban community hospital. Nurse initiated stroke protocol on admission, starting with algorithm at the emergency department and continued to the hospital unit with standard order sheets and protocol. Protocol was approved by specialists and primary care physicians. Resident doctors received specific education on stroke protocol. Stroke protocol was introduced as a method for cost‐containment
Crawley 1996	Georgia, USA	Acute stroke and rehabilitation	Patients were cared for in a neurosciences unit in a teaching hospital. Case management using a criical path was developed by a multidiscplinary team and managed by a case manager (an assistant head‐nurse), who followed the patient from admission to discharge. Critical path was also evaluated by variance analysis
Falconer 1993	Illinois, USA	Stroke rehabilitation	Unclear what type of ward in which patients in either group were initially cared for (a general medical ward or acute stroke unit), but patients were transferred to a rehabilitation unit in a specialised rehabilitation institute. Leader of the multidisciplinary team was the physician. A critical path (and the ideal length of stay) was generated by the computer according the therapy required
Hamrin 1990	Linkoping, Sweden	Acute stroke and rehabilitation	Patients were cared for in a general internal medical ward in a teaching hospital. Numbers of nursing staff and therapists were similar in both groups. The project group was involved in multidisciplinary team meetings, educational meetings and communication with primary care team.
Kwan 2004	Edinburgh, UK	Acute stroke	Patients were managed on the acute stroke unit which was a 10‐bedded unit situated within a 25‐bedded elderly care ward. Medical cover was provided by two stroke specialist consultants, one senior and one junior medical officer. The nurse‐to‐bed ratio was between 0.15 (night shift) to 0.27 (early shift). Rehabilitative therapy was provided by 1.5 whole time equivalent (WTE) physiotherapist, 1.5 WTE occupational therapist, 0.5 WTE speech therapist, a dietician and a social worker. Patients' progress was discussed at the weekly multidisciplinary team meetings. The care pathway was developed by the stroke team to guide patient care during the first five days of admission. The development process consisted of review of research evidence and clinical guidelines, design of the ICP document, and its implementation on the unit with training sessions for the staff.
Mosimaneotsile 2000	Hawaii, USA	Stroke rehabilitation	Patients were cared for in a 100‐bedded private rehabilitation unit which catered for all types of patients including stroke. Multidisciplnary assessment was performed within 24 hours of admission. Reports of the assessments then guided treatment, goal‐setting and discharge planning. Regular multidisciplinary team conferences were conducted to discuss the patient's goals and progress.
Odderson 1993	Washington, USA	Acute stroke	Unclear what type of ward in which patients in either group were cared for, but mostly likely a rehabilitation ward within an urban community hospital. Care pathway was developed by teams of physicians and professions allied to medicine, with specific inclusion and exclusion criteria. Patient care followed specific guidelines (e.g. deep vein thrombosis prevention, artificial feeding, bowel programme). Medicare was introduced in 1982 and prospective payment system in 1983 ‐ hospital was asked to reduce length of stay for certain conditions such as stroke
Pasquarello 1990	Texas, USA	Acute stroke	Unclear what type of ward in which patients in either group were cared for, but mostly likely a general internal medical ward within a teaching hospital. Patients in the stroke programme were exclusively managed by a clinical nurse specialist (CNS). Patient education was provided by weekly group meetings (stroke recovery group) for 45 minutes. CNS was also involved in post‐discharge care, outpatient program and nursing education
Ross 1997	Michigan, USA	Acute stroke	Unclear what type of ward in which patients in either group were cared for, but mostly likely a general internal medical ward within a community hospital. Critical pathway was developed by multidisciplinary task force and consisted of specific protocols (e.g. telemetry, carotid duplex <24 hours, two CT scans) and pre‐defined outcome measures and items for variance analysis. There was pre‐implementation education program for every discipline
Schull 1992	Texas, USA	Acute stroke and rehabilitation	Patients were cared for in a neurology ward within a teaching hospital. There was a clinical nurse specialist as case manager. Case management was introduced as a cost‐containment tool
Sulch 2000	London, UK	Stroke rehabilitation	Unclear what type of ward in which patients in either group were initially cared for (a general medical ward or acute stroke unit), but after randomisation, patients were transferred to a stroke rehabilitation unit within a teaching hospital. Care pathway was developed by a multidisciplinary group and implemented by an experienced nurse. There were special training sessions and a 3‐month pilot study
Wee 200	Mississippi, USA	Acute stroke and rehabilitation	Unclear what type of ward in which patients in either group were cared for, but mostly likely a mixture of neurology and general internal medical ward within a community hospital. Organisation of care was poorly described. Clinical pathway was designed by the stroke team and approved by medical care committee. No care manager was employed.
Widjaja 2002	Singapore	Acute stroke and rehabilitation	Organsation of care was poorly described. Stroke pathway was designed by the multidisciplinary team.
Wilkinson 2000	Brisbane, Australia	Acute stroke	Patients were managed in a stroke unit within a district general hospital. Stroke pathway project was led by a geriatrician and pathway designed by a multidisciplinary team. The project also included opening of a new acute stroke unit and acquisition of new equipment. Implementation of the pathway involved focus groups, team meetings, visits to other hospital units, audits, and educational sessions for the healthcare staff.

Table 1. Organisational components of the care pathways assessed by the included studies

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Comparison 1. Care pathway care versus standard care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Death by the end of follow‐up Show forest plot	3	783	Odds Ratio (M‐H, Random, 95% CI)	0.88 [0.49, 1.57]

1.1 Randomised studies	1	152	Odds Ratio (M‐H, Random, 95% CI)	1.77 [0.61, 5.14]
1.2 Non‐randomised studies	2	631	Odds Ratio (M‐H, Random, 95% CI)	0.69 [0.44, 1.07]
2 Death in hospital Show forest plot	4	1099	Odds Ratio (M‐H, Random, 95% CI)	0.86 [0.59, 1.25]

2.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Non‐randomised studies	4	1099	Odds Ratio (M‐H, Random, 95% CI)	0.86 [0.59, 1.25]
3 Dependency at discharge (mean Functional Indepedence Measure) Show forest plot	2	667	Mean Difference (IV, Random, 95% CI)	‐3.77 [‐7.31, ‐0.23]

3.1 Randomised studies	1	121	Mean Difference (IV, Random, 95% CI)	‐4.90 [‐14.58, 4.78]
3.2 Non‐randomised studies	1	546	Mean Difference (IV, Random, 95% CI)	‐3.60 [‐7.40, 0.20]
4 Dead or dependent (modified Rankin Score >2) by the end of follow‐up Show forest plot	1	152	Odds Ratio (M‐H, Random, 95% CI)	1.36 [0.68, 2.72]

4.1 Randomised studies	1	152	Odds Ratio (M‐H, Random, 95% CI)	1.36 [0.68, 2.72]
4.2 Non‐randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
5 Discharged to Institutional care Show forest plot	7	1613	Odds Ratio (M‐H, Random, 95% CI)	0.79 [0.55, 1.13]

5.1 Randomised studies	1	152	Odds Ratio (M‐H, Random, 95% CI)	0.57 [0.24, 1.35]
5.2 Non‐randomised studies	6	1461	Odds Ratio (M‐H, Random, 95% CI)	0.82 [0.55, 1.23]
6 Death in hospital or discharged to institutional care Show forest plot	3	842	Odds Ratio (M‐H, Random, 95% CI)	0.80 [0.61, 1.05]

6.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
6.2 Non‐randomised studies	3	842	Odds Ratio (M‐H, Random, 95% CI)	0.80 [0.61, 1.05]
7 Discharged to home Show forest plot	7	1613	Odds Ratio (M‐H, Random, 95% CI)	1.18 [0.88, 1.59]

7.1 Randomised studies	1	152	Odds Ratio (M‐H, Random, 95% CI)	1.14 [0.56, 2.32]
7.2 Non‐randomised studies	6	1461	Odds Ratio (M‐H, Random, 95% CI)	1.20 [0.84, 1.70]
8 Complication: Pneumonia Show forest plot	4	797	Odds Ratio (M‐H, Random, 95% CI)	0.89 [0.53, 1.50]

8.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
8.2 Non‐randomised studies	4	797	Odds Ratio (M‐H, Random, 95% CI)	0.89 [0.53, 1.50]
9 Complication: Urinary tract infection Show forest plot	6	1283	Odds Ratio (M‐H, Random, 95% CI)	0.51 [0.34, 0.79]

9.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
9.2 Non‐randomised studies	6	1283	Odds Ratio (M‐H, Random, 95% CI)	0.51 [0.34, 0.79]
10 Complication: Deep vein thrombosis Show forest plot	2	490	Odds Ratio (M‐H, Random, 95% CI)	1.92 [0.22, 16.70]

10.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
10.2 Non‐randomised studies	2	490	Odds Ratio (M‐H, Random, 95% CI)	1.92 [0.22, 16.70]
11 Complication: Pressure sores Show forest plot	2	401	Odds Ratio (M‐H, Random, 95% CI)	0.55 [0.09, 3.45]

11.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
11.2 Non‐randomised studies	2	401	Odds Ratio (M‐H, Random, 95% CI)	0.55 [0.09, 3.45]
12 Complication: Dehydration Show forest plot	1	50	Odds Ratio (M‐H, Random, 95% CI)	0.06 [0.00, 1.11]

12.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
12.2 Non‐randomised studies	1	50	Odds Ratio (M‐H, Random, 95% CI)	0.06 [0.00, 1.11]
13 Complication: Fluid and electrolyte imbalance Show forest plot	1	50	Odds Ratio (M‐H, Random, 95% CI)	0.48 [0.04, 5.65]

13.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
13.2 Non‐randomised studies	1	50	Odds Ratio (M‐H, Random, 95% CI)	0.48 [0.04, 5.65]
14 Complication: Fever (all causes) Show forest plot	1	351	Odds Ratio (M‐H, Random, 95% CI)	0.81 [0.50, 1.32]

14.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
14.2 Non‐randomised studies	1	351	Odds Ratio (M‐H, Random, 95% CI)	0.81 [0.50, 1.32]
15 Complication: Seizures Show forest plot	2	401	Odds Ratio (M‐H, Random, 95% CI)	0.85 [0.30, 2.42]

15.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
15.2 Non‐randomised studies	2	401	Odds Ratio (M‐H, Random, 95% CI)	0.85 [0.30, 2.42]
16 Complication: Falls or fractures Show forest plot	2	401	Odds Ratio (M‐H, Random, 95% CI)	0.88 [0.20, 3.87]

16.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
16.2 Non‐randomised studies	2	401	Odds Ratio (M‐H, Random, 95% CI)	0.88 [0.20, 3.87]
17 Complication: Constipation Show forest plot	1	351	Odds Ratio (M‐H, Random, 95% CI)	0.72 [0.39, 1.31]

17.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
17.2 Non‐randomised studies	1	351	Odds Ratio (M‐H, Random, 95% CI)	0.72 [0.39, 1.31]
18 Complication: Myocardial infarction Show forest plot	1	139	Odds Ratio (M‐H, Random, 95% CI)	1.56 [0.06, 39.39]

18.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
18.2 Non‐randomised studies	1	139	Odds Ratio (M‐H, Random, 95% CI)	1.56 [0.06, 39.39]
19 Investigation: First or second computed tomography brain scan Show forest plot	4	1315	Odds Ratio (M‐H, Random, 95% CI)	2.42 [1.12, 5.25]

19.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
19.2 Non‐randomised studies	4	1315	Odds Ratio (M‐H, Random, 95% CI)	2.42 [1.12, 5.25]
20 Investigation: Computed tomography brain scan within 24 hours Show forest plot	2	491	Odds Ratio (M‐H, Random, 95% CI)	2.12 [1.33, 3.38]

20.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
20.2 Non‐randomised studies	2	491	Odds Ratio (M‐H, Random, 95% CI)	2.12 [1.33, 3.38]
21 Investigation: Carotid duplex study Show forest plot	3	766	Odds Ratio (M‐H, Random, 95% CI)	1.79 [0.76, 4.20]

21.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
21.2 Non‐randomised studies	3	766	Odds Ratio (M‐H, Random, 95% CI)	1.79 [0.76, 4.20]
22 Investigation: Echocardiography Show forest plot	2	491	Odds Ratio (M‐H, Random, 95% CI)	2.08 [0.94, 4.58]

22.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
22.2 Non‐randomised studies	2	491	Odds Ratio (M‐H, Random, 95% CI)	2.08 [0.94, 4.58]
23 Investigation: Electrocardiography Show forest plot	3	1035	Odds Ratio (M‐H, Random, 95% CI)	0.92 [0.45, 1.89]

23.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
23.2 Non‐randomised studies	3	1035	Odds Ratio (M‐H, Random, 95% CI)	0.92 [0.45, 1.89]
24 Investigation: Chest x‐ray Show forest plot	2	491	Odds Ratio (M‐H, Random, 95% CI)	0.55 [0.23, 1.31]

24.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
24.2 Non‐randomised studies	2	491	Odds Ratio (M‐H, Random, 95% CI)	0.55 [0.23, 1.31]
25 Investigation: Cerebral angiography (catheter or MR angiography) Show forest plot	2	491	Odds Ratio (M‐H, Random, 95% CI)	3.55 [0.24, 51.91]

25.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
25.2 Non‐randomised studies	2	491	Odds Ratio (M‐H, Random, 95% CI)	3.55 [0.24, 51.91]
26 Medication: Use of heparin (subcutaneous or intravenous) in acute period Show forest plot	2	491	Odds Ratio (M‐H, Random, 95% CI)	1.23 [0.25, 6.01]

26.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
26.2 Non‐randomised studies	2	491	Odds Ratio (M‐H, Random, 95% CI)	1.23 [0.25, 6.01]
27 Medication: Use of new antihypertensive therapy in the acute period Show forest plot	2	491	Odds Ratio (M‐H, Random, 95% CI)	0.15 [0.00, 4.65]

27.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
27.2 Non‐randomised studies	2	491	Odds Ratio (M‐H, Random, 95% CI)	0.15 [0.00, 4.65]
28 Medication: Use of intravenous fluids Show forest plot	1	351	Odds Ratio (M‐H, Random, 95% CI)	0.96 [0.62, 1.47]

28.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
28.2 Non‐randomised studies	1	351	Odds Ratio (M‐H, Random, 95% CI)	0.96 [0.62, 1.47]
29 Procedure: Urinary catheterisation for patients with incontinence Show forest plot	1	155	Odds Ratio (M‐H, Random, 95% CI)	0.78 [0.41, 1.48]

29.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
29.2 Non‐randomised studies	1	155	Odds Ratio (M‐H, Random, 95% CI)	0.78 [0.41, 1.48]
30 Procedure: Use of thrombo‐embolism deterrent stockings Show forest plot	2	491	Odds Ratio (M‐H, Random, 95% CI)	1.46 [0.31, 6.94]

30.1 Randomised studies (no data)	0	0	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
30.2 Non‐randomised studies	2	491	Odds Ratio (M‐H, Random, 95% CI)	1.46 [0.31, 6.94]
31 Patient satisfaction Show forest plot	1	121	Mean Difference (IV, Random, 95% CI)	‐1.10 [‐1.91, ‐0.29]

31.1 Randomised studies	1	121	Mean Difference (IV, Random, 95% CI)	‐1.10 [‐1.91, ‐0.29]
31.2 Non‐randomised studies (no data)	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
32 Duration of hospital stay Show forest plot	6	1915	Mean Difference (IV, Random, 95% CI)	‐1.39 [‐2.80, 0.02]

32.1 Randomised studies	2	273	Mean Difference (IV, Random, 95% CI)	3.99 [‐0.29, 8.27]
32.2 Non‐randomised studies	4	1642	Mean Difference (IV, Random, 95% CI)	‐1.89 [‐2.95, ‐0.82]
33 Readmission or emergency department attendance after discharge Show forest plot	2	110	Odds Ratio (M‐H, Random, 95% CI)	0.11 [0.03, 0.39]

33.1 Randomised studies	1	60	Odds Ratio (M‐H, Random, 95% CI)	0.15 [0.04, 0.59]
33.2 Non‐randomised studies	1	50	Odds Ratio (M‐H, Random, 95% CI)	0.03 [0.00, 0.63]

Comparison 1. Care pathway care versus standard care

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