1236 / Intergrated clinical pathway for stroke patients

Classification of the PSP
Type of Patient Safety Practice
Clinical Practice (CP)
“Best fit” category of the reported practice
Patient involvement
Topic of the reported practice
Clinical guidelines or pathways
Aim and the benefit of the Patient Safety Practice
Principal aim of the Programme is to adopt a standardized clinical pathway for incident cases with an acute stroke, that integrate a Hub Hospital with two Health Trusts in an Area of 350.000 inhabitants. The Integrated Clinical Pathway (ICP) for stroke patients aims to improve, in the long term, a reduction of incidence and mortality for cerebrovascular accidents, the re-hospedalization of this patients and disability for all people with a stroke from an area of near 350.000 inhabithants. In the middle term, some of the objectives of the Programme are: – From the people or patient’s point of view: to increase the awareness of people on personal risk factors, on early symptoms and sign of a stroke event, on the organization of the clinical pathway they can use, and when use, in their health District; to empower their participation to the process of care and maintenance of their wellbeing at home. – From the organizations’ point of view: to offer the same level of care to all people and to all patients that occurred in the catchment area; to refer appropriately the right patient to the best level of care, when necessary; to perform as well as possible the intended standardized clinical protocols; to be accountable for the care they offer to the patients, their caregivers and community; to know the level of engagement of the patient they have care. – From the professionals’ point of view: to know the most evident and appropriate approach to the patient; to know what are the standards of their activities; to measure and evaluate performance; to account for patients’ needs, to respect her/his point of view and desires; to co-operate in a multidisciplinary team.
Description of the Patient Safety Practice
In 2014, four Public health Institutions (two Health Trusts, one Teaching Hospital and one Specialized Research Institute) of Friuli Venezia Giulia co-operate for a common framework on seven clinical pathways. One of those was organized on the Integrated Clinical Pathway (ICP) for stroke patients. Each Hospital or Trust selected multi-professional working team that were exposed to two education sessions. At the end of this period, for each clinical pathway were described the access criteria of patients into their hypothetical pathway. The ICP Stroke working group evaluated the current and most adopted clinical guidelines, then defined twelve clinical phases on the care/treatment of people with an acute Stroke. Then were described the clinical protocols of care currently adopted in the four public Institutions, and were selected the standard of care for the twelve ICP Stroke phases. When a current protocol failed to reach an organizational or care standard, then it was modified and adapted to the best practice goal. From each standard the working team selected a number of measures on inputs, process, and outcomes that, after two RAND (consensus method) modified sessions and an agreement conference, were reduced to 12 indicators. Moreover, a special working group was established on continuity of rehabilitation care, a smart area of good co-operation between the Teaching Hospital and the main Health Trust of this area. Then, regular audit were performed over the years, utilizing brief reports about numbers of events, time of hospitalizations, specific referral to emergency, number of trombolizations, residence, and so on. A parallel, more important, activity was developed on patient’s engagement and of her/his caregivers. Some meetings with a local patients’ Association were conducted aiming to organize the first survey on patients’ point of view and their perspective. In June, 2015 a cohort of 300 patients discharged in 2014 from the Teaching Hospital received the questionnaires and responded to the questions (38% of respondents rate without any recall). In fifteen months from the starting of the Programme, the main indicators show an improvements in correct hospital referral from emergency system to hospital, an increase of patients from the Gorizia Province, and increase referral to Stroke Unit or Neurological ward of the patients, an increase of trombolization of Stroke patients, an increase of patients’ multi-disciplianary evaluation, a reduction of LOS, an increase of congruence between multi-discipliary evaluation and continuity of care. The measures selected by the working group derived from a long panel of measures and indicators highlighted from scientific literature. Each measure referred to a particular standard specific for the phases or activity listed in the ICP. We adopted a RAND modified method to select the most pertinent indicators useful and feasible to describe the process phases. All the indicators and measures have an IT bases, as administrative source or local data-base ad hoc implemented. At each audit (or rehabilitation meeting) a specific session was dedicated to the evaluation of the process, by discussing the main data (volume of activities, time of Hospitalization, demography, time to care or rehabilitation, and so on). For the patients’ point of view we adopted a survey technique with questionnaires compiled at home from survivors discharged in the previous year from the Teaching Hospital.
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
Effectiveness of the Patient Safety Practice
Degree of implementation of reported practice
Yes, partly
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
A baseline measurement before implementation of the reported practice was obtained
A measurement after full implementation of the reported practice was obtained
Evaluation of a “positive” effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Both/mixed (qualitative and quantitative)
Enclosure of a reference or attachment in case of published evaluation’s results
Lamprecht G, Delli Quadri N, Fragiacomo E, et Al. PDTA Stroke a Trieste: audit riabilitazione. European Pathway Association (EPA.org) Conferenza Nazionale ed Internazionale sui PDTA 2015. I PDTA in azione: livelli di sviluppo e applicazione, esperienze in corso e prospettive future. Reggio Emilia, 29-31 ottobre 2015. Abstract
Health care context where the Patient Safety Practices was implemented
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Specification of implementation in another health care setting(s)
Home care
Successful implementation’s level  of this Patient Safety Practice across settings
Yes, across multiple local/national health systems
Involved health care staff
Social workers
Clinical support
Clinical manager
Other or not relevant
Patient Involvement
Direct service user’s involvement as integral part of this Patient Safety Practice
Specification of the service users or their representatives’ involvement in the implementation of this Patient Safety Practice
Patient organisation(s)
Point of time in which service user or their reprasentatives’ involvement takes place
During the implementation of the Patient Safety Practices
Active seeking of service users’ opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
Short description of the service users’ level of involvement
Collaboration, such as co-designing a Patient Safety Practice or active partnership in implementation
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
List of sources where public information is accessible
Implementation of the Patient Safety Practice
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
Not known or not relevant
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
There is no specified text here
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Regular data feed back to involved staff
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Not relevant
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Costs of the Patient Safety Practices
Completion of cost calculation related to this Patient Safety Practice
Total number of person days required to implement this Patient Safety Practice
Clinical staff: 69
External consultants: 0
Support staff: 0
Managerial staff: 69
Others: 0
Not relevant: 0
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: 0
External consultants: 0
Support staff: 0
Managerial staff: 0
Others: 0
Not relevant: 0
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice