Abstract-We describe the development, implementation, and outcomes of the first 2 years of the Electronic Stroke CarePath, an initiative developed for management of ischemic stroke patients in an effort to improve efficiency and quality of care for patients. The CarePath consists of care pathways for ischemic stroke that are integrated within the electronic health record. Patient-reported outcomes are collected using an external software platform. Documentation tools, order sets, and clinical decision support were designed to improve efficiency, optimize process measure adherence, and produce clinical data as a byproduct of care that are available for future analyses. Inpatient mortality and length of stay were compared before and after CarePath implementation in ischemic stroke patients after adjustment for case-mix. Postdischarge functional outcomes of patients with ischemic stroke were compared between the first 3 months of rollout and remainder of the study period. From January 2011 to December 2012, there were 1106 patients with ischemic stroke on the CarePath. There was a decline in inpatient mortality in patients with ischemic stroke, but not in control patients with intracerebral or subarachnoid hemorrhage.Completion rate of patient-reported questionnaires at postdischarge stroke follow-up was 72.9%. There was a trend toward improved functional outcomes at follow-up with CarePath implementation. Implementation of the Electronic Stroke CarePath is feasible and may be associated with a benefit in multiple different outcomes after ischemic stroke. This approach may be an important strategy for optimizing stroke care in the future. Goals and Vision of the ProgramImprovements in efficiency, quality, and coordination of care are essential for healthcare institutions to adapt successfully in an era of decreasing reimbursement. Heart disease and stroke, which are leading causes of morbidity, mortality, and healthcare costs in the United States, are often among the first diseases to be involved in healthcare innovations and policy changes. 1,2 They were among the first to have disease-specific process and outcome measures publically reported by the Center for Medicare and Medicaid services (CMS) and to have society supported quality registries. Regional and national systems of care are more advanced in stroke and myocardial infarction than in most other diseases. Solutions developed to improve delivery of care for patients with heart disease, and stroke can serve as models for the treatment of other conditions.One important strategy to improve the efficiency and quality of healthcare is standardization of care. This is often done by implementing evidence-based protocols that incorporate guidelines into care algorithms. Evidence-based protocols can improve quality by providing guidance on indications for tests or interventions. A related method is the use of care paths, also referred to as critical pathways or care pathways. These are management plans that additionally provide the sequence and timing of actions ...
Background: There is a continuous need to improve efficiency and quality of care. In response, the Electronic Stroke CarePath (ESCP) was developed for management of ischemic stroke patients. We describe the development, implementation and outcomes of the first 2 years of this initiative. Methods: The ESCP consists of care pathways for ischemic stroke that are integrated within the EHR (Epic) and includes systematic collection of patient-reported outcomes (PROs). Main components of the EHR integration included a navigation panel, the use of structured forms with elements that autopopulate templates, and clinical decision support. An external software platform was used to collect PROs. Inpatient mortality and length of stay (LOS) were compared before and after implementation in ischemic stroke patients and in 2 control groups: ICH and SAH patients, after adjustment for case-mix. Postdischarge functional outcomes of ischemic stroke patients were compared between the 1st 3 months of rollout and remainder of the study period.<br Results: The ESCP was implemented in Sep 2010 and modified over the first 3 months. Data were analyzed from Jan 2011- Dec 2012. There were 1106 patients with mean age 66.2 yrs and admission NIHSS 5; 46.1% were women. There was a significant reduction in observed/predicted inpatient mortality after implementation of the ESCP in ischemic stroke patients (OR 0.59 [95% CI 0.42-0.83], but not in the control patients with ICH (OR 0.90 [0.59 - 1.38]) or SAH (OR 1.05 [0.67 - 1.65]). . Similarly, a significant increase in the proportion with LOS < predicted after ESCP implementation was seen only in ischemic stroke pts (51.4% vs 56.0%, p=0.047). Compared to those admitted within the 1st 3 mo of ESCP rollout, ischemic pts admitted in the remainder of the study period demonstrated nonsignificant improvements in degree of impairment (NIHSS, 3.9 to 2.7, p=0.059), IADLs (modified Rankin, 2.6 to 2.2, p=0.079) and physical function (SIS16, 67.8 - 76.0, p=0.084) at followup. Conclusion: Implementation of the ESCP is feasible and may be associated with a benefit in multiple different outcomes after ischemic stroke. This approach, which combines carepaths, HIT, and the systematic collection of PROs, may be an important strategy for optimizing stroke care in the future.
Checklists and disease-specific order sets are increasingly being used in health care to reduce medical errors and improve the quality of patient care. Stroke, which has standardized and well-defined care processes, is an idea/ideal condition for the use of checklists. We describe the Stroke 8 checklist, designed to be part of the daily assessment of patients hospitalized with acute stroke. It consists of 8 items classified into 3 categories as follows: (1) stroke prevention: antithrombotic use, statin use, glucose control, blood pressure control; (2) prevention of complications: deep venous thrombosis prophylaxis, temperature control; and (3) recovery and disposition: fluids and nutrition, mobility and therapy. The Stroke 8 checklist has been implemented in 3 formats over an 8-year period: laminated cards, an electronic documentation template, and an electronic template supplemented with clinical data autopopulated from the electronic health record. We have found the Stroke 8 to be a valuable tool in the daily inpatient management of patients with acute stroke.
Background: Systematic follow-up after hospital discharge for stroke is an important part of optimizing transitions of care, although its feasibility is not well known. Advances in healthcare technology provide a means to accomplish this. Methods: The Cleveland Clinic Neurological Institute implemented a technology-based follow-up system for patients hospitalized on the Stroke service. The system includes two major components to assist with follow-up: an electronic health record-based method for physicians to order a 30 day follow-up appointment electronically during patients’ admissions (similar to ordering a lab test), and system-generated messages that are sent to a nursing pool in cases where patients either do not have a scheduled appointment or their appointment was not kept. These activities are also monitored with standard reports. In addition, structured templates were developed to allow discrete capture of clinical data at the time of follow-up. Data on stroke patients from the first 15 months were analyzed after excluding patients who died prior to discharge or were discharged to hospice care. Results: Of the 574 patients in the study, from 3/2010 - 6/2011, 42.9% were discharged to home and 57.1% were discharged to other facilities. The rate of scheduled follow-up appointments within 45 days of discharge was 31.6% at baseline, although many of those were scheduled post-discharge. Successfully completed follow-up appointments within 45 days occurred in 10.5% at baseline and increased steadily over the 15 month period to 58.1% in June 2011 (see Table). Patients discharged to home had higher rates of completed follow-up compared to patients discharged to other facilities (63.6% vs 33.1%, p<0.01). Conclusion: Implementation of systematic, electronic processes for establishing post discharge follow-up in stroke patients is associated with a progressive increase in rate of successfully completed appointments. There were lower rates of successful follow-up in patients not discharged to home, and coordinated efforts across facilities may be required for full implementation of follow-up care. Informatics technology will play an increasingly important role in systems-based care for the stroke patient population.
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