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Proceedings of a National Symposium on
Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996

Critical Pathways

Dennis Landis, M.D.
University Hospitals of Cleveland

Effective care of cerebrovascular disease requires a team of efficient, informed colleagues who can work together in carefully planned patterns appropriate to the problems posed by individual patients. Care pathways are essential tools in the evaluation and therapy processes. Every stroke care center has the responsibility to match its resources with generally agreed upon guidelines for each of the clinical presentations of cerebrovascular disease and to show that its patterns of care are effective and efficient.

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Components of a Care Pathway for Stroke

The early components of the pathway should be designed to protect the brain until the pathogenesis of injury is defined, and then to apply therapy appropriate to the pathogenesis and severity of the injury. At present, one of the greatest values of pathway-guided care is speed. The most powerful therapies for ischemic stroke are most effective only within the first few hours of the ischemia, and careful planning is necessary if the evaluation is to be completed in time. Pathways should plan care beyond initial decisions and management, making most effective use of resources and allowing care to be tailored to the needs of the individual patient.

A. Initial management

Initial management begins when emergency medical services personnel first begin transporting the patient to the hospital and continues into the emergency department (ED).

1. Prehospital care:

• How does the emergency transport service inform the stroke center?

• How and when do stroke center physicians learn of the problem?

• How is communication managed with transporting services?

2. Hospital ED care:

• Who is responsible for initial patient evaluation and treatment decisions?

• What initial support should be provided?

- Oxygenation

- Blood pressure management

- Cardiac evaluation

• What are the initial aids to diagnosis and management?

- Blood tests

- Electrocardiogram

- Pulse oximetry

- Cranial imaging with CT scan

B. Early management of acute stroke in the ED and for hospitalized patients

1. Ischemic disease

• Consideration of thrombolysis

• Consideration of anticoagulation

2. Primary intracerebral hemorrhage

• Consideration of operative intervention

- Ventricular shunt

- Hematoma evacuation

• Consideration of early angiography

3. Subarachnoid hemorrhage

• Consideration of angiography

• Consideration of early operation

C. Planned management of care after acute treatment

1. Level-of-care decisions, particularly intensive and intermediate care requirements

2. Selection of any further diagnostic evaluations

3. Initiation of rehabilitative therapy

4. Development of alternatives for care after discharge from the hospital

D. Posthospitalization planning and follow up

1. Anticoagulation supervision

2. Communication with primary care providers

3. Measures for secondary prevention of stroke and cardiac disease

4. Outcome measures

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Planning the Pathway

In general, the pathway is based on the best evidence for effective therapy, the severity of the deficit for a particular patient, and the resources available for care. It is essential that pathways respect the limitations of the institution and setting. For example, a regional stroke center must have pathways for surgical intervention when managing patients with subarachnoid hemorrhage, while a brain attack center should have plans in place for transport of patients with subarachnoid hemorrhage to a regional stroke center. A hospital that cannot provide timely expertise or cranial imaging should plan for rapid transfer after initial evaluation and institution of supportive therapy.

All members of the brain attack team should be involved in planning the pathway.

Team components:

· Neurological medical expertise

· Neurological surgery expertise

· Emergency medical expertise

· Critical care medical expertise

· Imaging (acquisition and interpretation)

· Laboratory support

· Nursing (emergency, intensive, and standard)

· Pharmacy

· Hospital communication

· Emergency medical services

· Hospital administration

· Social services

· Rehabilitation medicine

For each institution, the pathway should represent a synthesis of consensus guidelines and the resources of the institution. Whenever possible, planning should take advantage of the efforts of national organizations to provide reasonable guidelines for care. These include:

American Heart Association

1. Guidelines for management of patients with acute ischemic stroke

2. Guidelines for thrombolytic therapy for acute stroke

3. Guidelines for management of aneurysmal subarachnoid hemorrhage

National Stroke Association

1. Stroke center recommendations

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Monitoring and Improving the Pathway

All members of the team must take advantage of every opportunity to improve the design of the pathways, to assure that every patient has the benefit of the pathway, and to assess the efficacy and efficiency of the pathway. To accomplish these goals the brain attack team must monitor its own activities and learn the outcome of patients served by the pathway. The costs of the tests and therapies should be known and should be individually defensible.

In general, the brain attack team should systematically acquire information about its patients, the interventions, and the outcome. Databases are now being designed by the American Academy of Neurology that will facilitate local evaluation and comparison with data from other institutions.

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Last Edited: February 10, 2000

National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892

Last updated July 25, 2008