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|THE EDITORIAL DEBATE: PROS AND CONS
|Year : 2016 | Volume
| Issue : 7 | Page : 2-3
Pathway to recovery
Department of Neurosciences, Apollo Speciality Hospitals, Madurai, Tamil Nadu, India
|Date of Web Publication||3-Mar-2016|
S N Karthik
Department of Neurosciences, Apollo Speciality Hospitals, Madurai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Karthik S N. Pathway to recovery. Neurol India 2016;64, Suppl S1:2-3
Stroke management has reached an exciting stage. There is an explosion of studies and protocols when it comes to management of acute stroke. But we still live in an era where for many primary care physicians, and unfortunately for many neurologist too, the first step in the management protocol of stroke seems to be referral to an imaging center far away from their outpatient department!
In this issue of Neurology India, Rai et al., have tried to ascertain how implementation of a simple clinical pathway could alter the outcome for stroke patients.  For this purpose, the authors have allotted patients going into specific wards into either the Clinical Pathway (CP) group or the Conventional Care (CC) group. Aspiration resulting in pneumonia is a leading cause of morbidity and mortality among stroke patients.  Targeting swallowing related issues in stroke patients seems to be a reasonable way to reduce aspiration and its related complications. The authors have understood this point and have included this as an important component in their Clinical Pathway. It is heartening to see the results of this small yet important study. The aspiration rate was 6.49% in the CP group while it was 15.29% in the CC group. The CP group had a significantly less need for mechanical ventilation with an absolute risk reduction rate of 9.8%. They have shown a significant reduction in the follow-up deaths in the CP arm at 90 days (7.8% vs. 20%, P = 0.022). Most of this benefit was due to reduction in the rate of aspiration pneumonia. The benefits of the CP arm are very much evident in the subgroup analysis where Glasgow Coma Scale (GCS) score at admission was taken into account. CP was better than CC in reducing the risk of death at 90 days of admission in the GCS subgroup scoring 9-15, and in reducing the risk of death by 84%, when compared with the CC arm. 
The major limitation in this study, as in other studies related to stroke, has been the limited number of subjects recruited. Also, as has been pointed out in the study in focus, there were more number of patients with severe hemorrhagic stroke in the CC group compared with the CP group. We should perhaps sub-analyze the stroke subtype also, particularly, the territory of involvement. For example, Oztop et al., have noted aspiration pneumonia more commonly in the anterior rather than posterior circulation stroke.  The number of patients on naso-gastric (NG) tube feed is not mentioned in the current study as improper placement of the NG tube could be one of the reasons for the increased frequency of aspiration especially in patients with a low GCS. 
The results of this study at the outset may look unrealistic considering that it is a non-randomized, non-blinded study. However, we need to give credit to the authors for the arguments placed by them. Some of the earlier studies have not shown a significant difference either in the aspiration rate or in the mortality rate between the two groups. This could be due to the differences in the implemented protocol in the assessment of swallowing in stroke patients; or, due to the already established standard of care. In a setting like ours, CP would help the stroke patients by preventing aspiration in them.
For a stroke neurologist, management of patients, who arrive at the hospital after a time interval that extends beyond the thrombolytic window, still remains an uncharted sea. Even in many of the state-of-the-art centers and government hospitals, stroke patients often end up in the general care area. As more and more stroke patients continue to be admitted in the hospital after a time duration that exceeds the therapeutic window, there is a clear need for CPs to adequately manage this sizable patient group. This article unequivocally emphasizes the role of a stroke unit and the CP protocol to be followed to save the patients from the dreaded complication of aspiration pneumonia. Aspiration pneumonia not only prolongs hospital stay but also results in the excessive use of antibiotics and increases the morbidity as well as mortality. Post stroke management, more often than not, requires the use of common sense. Most of the stroke patients with swallowing or aspiration difficulty have only a transient impairment of their neurological status and usually recover in a few weeks time. Hence, it becomes crucial for the care-givers to prevent aspiration during the period of neurological disability.
There is often a reluctance to accept care pathways due to the fear that implementing them on a regular basis could result in an unnecessary delay in the initiation of treatment. This study shows how a simple checklist, training of personnel, and educating the patients and relatives, can go a long way in preventing morbidity and mortality. Clinical pathways are not only easy to implement but can also be a boon for hospitals that cannot afford to have a dedicated stroke unit due to space constraints.
This study should encourage clinicians to try and adopt this model where ever possible and build upon it. A larger, perhaps a nationwide study, is not an improbable task as implementation of CPs mainly involves investing in manpower and training rather than any sophisticated technology. Implementation of a perfect CP that is also simple to follow would be the standard of care in most settings and remains a desirable goal.
| » References|| |
Rai N, Prasad K, Bhatia R, Vibha D, Singh MB, Rai VK, et al
. Development and implementation of acute stroke care pathway. A cluster randomized study. Neurol India 2016;64:2.
Armstrong JR, Mosher BD. Aspiration pneumonia after stroke: Intervention and prevention. Neurohospitalist 2011;1:85-93.
Oztop P, Ayas S, Ustaomer K, Cosar SN, Yemisci OU. Functional outcomes in anterior and posterior circulation ischemic strokes. Turk J Phys Med Rehabil 2013;59:13-7.
Lemyze M. The placement of nasogastric tubes. CMAJ 2010;182:802.