Ischemic stroke pathway relies on ED order sheets

Path computerization could standardize ED use

The second time was the charm for case managers at University Hospital-University of Colorado Health Sciences Center in Denver. The first time they tried to get an ischemic stroke pathway off the ground, it foundered because of a lack of physician support. The second time, however, case managers enlisted physician champions and secured the support of emergency department residents, steps that have helped facilitate the success of the current pathway.

In developing the pathway, it was thought that although ischemic stroke represents an individualized disease process, "there are some standard things you can do to help the patient along," says Sharon Baker, RN, MS, CNRN, a clinical nurse specialist/educator who was integral to the development of the pathway. "We felt that we could then decrease the length of stay if we could teach people what to do on specific days," she says. (See sample page from the pathway, p. 68.)

Another thing making ischemic stroke an attractive candidate for a pathway was that, at least in theory, much of the required care that traditionally had been performed in acute care could be delivered as effectively and in a more timely manner in an outpatient setting, says Kim Pollmiller, RN, MS, CNRN, clinical case manager for neurosciences at University Hospital.

One obvious difficulty inherent in managing stroke patients is predicting when they’ll be coming. Because almost all strokes are admitted through the emergency department, the pathway process starts there. Preprinted physician order sheets and copies of the pathway are stocked in the emergency department and can be easily accessed when a stroke patient comes in. "When the neurology doctors get calls saying we have a patient down here who looks like a stroke, all the paperwork is right there in their hands instead of in some place where they’d have to physically go get it," Pollmiller says.

Although the system has generally worked well so far, Pollmiller acknowledges that because of the turnover in residents in the emergency department, the preprinted orders haven’t been used as consistently as she’d like. On the other hand, Pollmiller says, "The doctors are good about notifying Sharon or me when they admit a stroke. Whether it’s a just voice mail over the weekend or a page during the week, they’ll let us know that a patient is being admitted. Then the data process starts."

Much of Pollmiller’s work with the stroke patients involves collecting and processing inpatient data. She tracks patients along the pathway to make sure services like the swallowing screen are being performed according to the time frame specified by the pathway. She also administers an assessment of a functional scale both at the time of admission and at discharge. In addition to measuring functional status, University Hospital also employs an informal severity-of-illness scale. Three months after discharge, Pollmiller follows up with patients to run through the health status questionnaire. Finally, the data are compiled in quarterly reports, which are distributed to and discussed by both case managers and the pathway’s physician champions.

Length of stay for the pathway is from five to seven days depending on the severity of the stroke and what the patients’ needs are. Work-ups typically are done within five days as long as the patient is medically stable. Patients are considered discharged when they move on to outpatient rehabilitation, a skilled nursing facility, or home. Although the pathway ends upon the patient’s discharge from acute care, case managers maintain some involvement with the patient in terms of education. They also make themselves available for questions from rehabilitation staff.

In addition to the clinical pathway itself, Baker developed a pathway to educate patients about their condition. "I’m very active in the neuroscience community and had seen in other areas where they were looking at patient education pathways," she says. "I thought, why can’t I do that for stroke patients?" After reviewing examples of patient pathways, Baker developed her own, which she then gave to the hospital’s patient education specialist. The specialist adjusted the pathway’s language to the appropriate reading level.

Other than development of the patient pathway, however, few revisions or additions to the pathway have been necessary, Pollmiller reports. That might change, however, in light of a new project now in the works at University Hospital: A pathway standardization committee has been developed for the purpose of bringing all the hospital’s pathways into conformity with a standard design.

Other changes under way include a move toward computerization. The hospital has just purchased a computer system from HBOC in Atlanta, which eventually will be used to store documentation for the pathway. The ultimate goal is to move to computerized pathways, Pollmiller says. "The stroke pathway has been involved in that [discussion]," she says. "But it’s too difficult to trial in the system because the admissions aren’t scheduled, and if the physicians don’t start out with the preprinted orders, you can’t backtrack." Under a fully automated system, that should be less of a problem, however: "If, for example, the physicians don’t start the patient off with the paperwork, the computer still starts them off with the pathway," Pollmiller says. "Down the road, it’ll be nice."

For more information, contact:

Kim Pollmiller, RN, MS, CNRN, clinical case manager for neurosciences; Sharon Baker RN, MS, CNRN, clinical nurse specialist/educator, University Hospital-University of Colorado Health Sciences Center, 4200 East Ninth Ave., Denver, CO 80262. Telephone: (303) 372-6470.