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|THE EDITORIAL DEBATE: PROS AND CONS
|Year : 2016 | Volume
| Issue : 7 | Page : 4-5
Acute stroke care pathway: Will the journey be smooth?
Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
|Date of Web Publication||3-Mar-2016|
Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kaul S. Acute stroke care pathway: Will the journey be smooth?. Neurol India 2016;64, Suppl S1:4-5
Stroke is a common disease known to mankind since antiquity. There has never been any proven treatment for stroke in any system of medicine, before the turn of this century. The sight of a semiconscious, hemiparetic old patient, with a nasogastric tube thrust in his nostril and glycerine syrup running down the angle of his mouth is etched in the memory of those trained in the pre computed tomographic (CT) scan era. In the absence of any meaningful emergent care, such patients were usually condemned to a bed in the verandah of the hospital which was tauntingly called "Verandah Care" by some. In the early seventies, a few European countries proposed that focused nursing care of stroke patients may lead to an improved outcome.  This led to the emergence of stroke units. Nearer home, Dr. PM Dalal (1978) in Bombay and soon thereafter, Dr. G Arjundas (1980) in Madras pioneered the concept of stroke unit/stroke team. Both these centres reported a definite drop in mortality in patients of stroke after setting up these facilities. [2.3] The strength of these stroke units came from the fact that these did not use any extra equipment or manpower, but only ensured focused nursing and physiotherapy care within the existing infrastructure. But even now, most of the hospitals do not have stroke units and where ever these exist, there is often times, encroachment by non-stroke patients due to the logistic compulsions of the hospital. There is also variability in the kind of care being delivered across different stroke units leading sometimes to the delivery of inadequate management. Under such circumstances, treatment according to a clinical care pathway in the stroke unit or even in a general ward is a welcome innovation.
The clinical pathway concept was introduced at the New England Medical Centre (Boston, USA) in 1985 with the objective to standardize clinical care, thereby improving the outcome.  The clinical pathways are developed by expert groups on the basis of evidence based guidelines so that a basic minimum standard of care is ensured for all patients. A single pathway may refer to guidelines on several diseases and may include any number of parameters for monitoring. A clinical care pathway also serves as an objective benchmark of the treatment a patient is likely to receive and also serves as a legal record of the care the patient has received. Even though the pathways are designed to provide standard care, the concerned clinician has the prerogative of deviating from it, if the clinical situation demands the modification. The need for deviation from the clinical pathway is also recorded. This helps in building the repository of variance in the clinical behavior, which in itself is useful data.
The available studies have shown equivocal results regarding the success of these clinical pathways, but many of these studies have one or more limitations in their design and execution. One of the well conducted studies on the implementation of clinical care pathway in acute stroke patients in Australia showed that patients strictly monitored for fever, sugar and swallowing (FeSS) were significantly more likely to be alive and independent at 90 days after admission.  Specifically, an adjusted absolute difference of 15.7% was shown in the rate of 90 day death and dependency. The benefit achieved by implementation of this clinical pathway was found to be better than other established clinical and organizational intervention, namely administration of aspirin within 48 hours, stroke unit care, and thrombolysis within 4.5 hours (all of which delivered an absolute benefit for independent survival of no more than 10%); all of the latter parameters showed higher numbers needed to treat (aspirin 79, stroke unit 18, thrombolysis 8-14, depending on the onset to treatment time) than the FeSS intervention which showed the number needed to treat of 6.4. Moreover, the benefit of thrombolysis is available only to a very specific ischemic stroke population, unlike FeSS which is applicable to all stroke patients.
This issue of Neurology India features the paper by Professor Kameshwar Prasad's group from AIIMS Delhi, in which they have found that development and implementation of acute stroke care pathway, consisting of close monitoring of fever, sugar and swallowing function, reduced the incidence of aspiration pneumonia, the need for mechanical ventilation, and the risk of death at 90 days follow-up.  The strength of this study is that the investigators have done adequate research for developing and adapting their clinical pathway to Indian circumstances. It has usually been observed that fever and hyperglycemia may not be paid urgent attention in our wards unless the nursing staff is instructed to do so. It is also common knowledge that in most of the hospitals, swallowing screening is not routinely done due to paucity of speech and language pathologists. Thispractice, coupled with the overenthusiasm of care givers to feed the patient orally puts patients at substantial risk of developing aspiration pneumonia. In this project, the speech and language pathologists have been successfully replaced by the resident doctors, proving thereby that any healthcare worker can be trained to perform the initial dysphagia screening in a limited resource setting. The 'purees and porridge' are replaced by 'khichdi, kheer and payasam.' Another strength of this study is that it has been conducted in a general ward and not a stroke unit, thereby establishing the applicability of this pathway in general wards. Although this study has tested only three parameters, it provides a proof of principle for developing a clinical pathway with more parameters like the serial blood pressure evaluation and early physiotherapy. It will be worthwhile to attempt similar studies in other hospitals of the country. If the success of acute stroke clinical pathway is reproducible, it will be a big step forward for stroke management in India, because of its widespread applicability, cost effectiveness and safety. It is true that diseases do not always follow standard text book descriptions and each patient's journey is an individual one. Adherence to the acute stroke pathway, however, will hopefully help the clinicians to take note of the rough patches and avoid preventable accidents.
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