Stroke Care Path Primes Patients for Successful Rehabilitation

By Zeshaun Khawaja, MD

In 2010, Cleveland Clinic’s Neurological Institute debuted its care path for acute ischemic stroke. This guide provides comprehensive protocols for evaluation and management of patients during the acute stroke phase to help optimize patient outcomes. It streamlines care, helps reduce hospital length of stay and ensures that every patient receives the same standard of care. Since its implementation, we have seen the Stroke Care Path benefit patients not only during the acute phases of care, but throughout their rehabilitation.

In the past few years, Cleveland Clinic has developed more than 25 care paths for other diseases and conditions, including congestive heart failure, knee and hip replacement, spine care, and dementia. All the guides are based on medical research, clinical guidelines, clinician experience and evidence collected via our Knowledge Program — a health information data collection system that gives physicians a comprehensive view of a patient’s medical status and enables researchers to broadly and quantitatively assess the effectiveness of medical decisions and processes. The Knowledge Program includes information obtained from patients by electronic questionnaires as well as clinical data extracted from Cleveland Clinic’s electronic medical record.

As we treat more patients and as medical technology advances, information in the Knowledge Program constantly evolves. So, too, must our care paths. We recently completed a revision of our Stroke Care Path to ensure that it reflects the latest evidence-based care, in addition to standards of care provided by The Joint Commission and the American Heart Association/American Stroke Association in their certification program for Primary Stroke Centers and Comprehensive Stroke Centers.

Priming Patients for Rehabilitation

Our Stroke Care Path focuses on the period from initial presentation at the emergency department or hospital with acute stroke symptoms to 90 days after hospital discharge. The care provided during that time is paramount to successful rehabilitation. It is critically important that, as soon as patients enter the hospital, we are not only thinking about their diagnosis and treatment, but their rehabilitation. Evidence indicates that the sooner patients begin rehabilitation, the better their outcome.

Figure. Cleveland Clinic’s Neurological Institute has developed a care path for acute ischemic stroke that standardizes inpatient treatment (including for venous thromboembolism, as shown here) and rehabilitation to improve patient outcomes. ICS = Intermittent Compression Stockings EX = Enoxaparin 40mg subcutaneous daily UFH = Unfractionated Heparin 5000 units TID tPA = Tissue plasminogen activator.

By utilizing the treatment guidelines in our Stroke Care Path, physicians prepare patients for rehabilitation. The following are some of the steps we take:

• Patients admitted with a stroke diagnosis are evaluated by a physical therapist and an occupational therapist as soon as they are medically able. This often occurs the day after admission. Patients with National Institutes of Health stroke scale scores between 4 and 20 receive a full evaluation by a physical medicine and rehabilitation physician.
• Nurses administer a dysphagia screen to all patients immediately upon admission unless they first require advanced procedures such as hyperacute MRI. If patients fail the swallow screening, they automatically are evaluated by a speech-language pathologist.
• We encourage early mobility. In the past, stroke patients often remained in bed. Now we urge them to ambulate and spend more time in a chair. We have incorporated lift devices and lift teams to help patients with limited mobility move to chairs. Early mobility has several advantages: It helps prevent urinary retention, constipation, pressure ulcers, pneumonia and deep vein thrombosis. It also is an important component of physical and occupational therapy.
• Patients undergo a comprehensive evaluation by a case manager within 24 hours of admission. The case manager examines all aspects of the patient’s plan of care, including finances, insurance and family/social situations. They look for anything that might prevent or limit patients’ early rehabilitation. Case managers also provide a list of rehab facilities that meet each patient’s needs and work closely with families to help select the ideal one.
• Each patient receives a mood screening prior to discharge and during follow-up outpatient visits. If patients suffer from poststroke depression, they are less likely to participate in their own care, thereby hindering rehabilitation efforts. Cleveland Clinic uses the Patient Health Questionnaire for Depression and Anxiety (PHQ-4) to assess mood. If patients score high, a social worker or therapist intervenes and treatment is initiated.
• Prior to discharge, all medications are reviewed and coordinated to reduce the risk of recurrent stroke. In addition, the discharge summary includes advice on managing personal stroke risk factors (such as blood pressure, weight and cholesterol) and a description of stroke warning signs and symptoms.

Examining Early Urinary Catheter Removal

One recommendation in the Stroke Care Path that facilitates rehabilitation and prevents infection is removal of urinary catheters as soon as possible. However, it is important to note that the guide also cautions physicians against early removal in certain situations. They may delay removal if:

• Patients are intermittently drowsy and unable to communicate their need to urinate
• Patients are taking opiates, anticholinergic medications or other medications that cause obtundation or urinary retention
• Patients are diabetic and have a history of outlet obstruction or urinary retention that predict a failed early catheter removal
• Patients are unable to speak

In short, catheter removal requires that patients are adequately alert and physically able to say when they need to use the bathroom.

Guiding Informed Decisions

The Stroke Care Path is an invaluable tool for our physicians to provide evidence-based poststroke care and prepare patients for successful rehabilitation. It is used not only within Cleveland Clinic hospitals, but in ambulatory therapy centers and subacute and rehabilitation facilities. This allows us to implement best practices and a high standard of care through the entire course of our patients’ medical and rehabilitative treatment.

Dr. Khawaja is a member of the Cleveland Clinic’s Cerebrovascular Center.