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Treatment Forms Promote Better Care for Stroke Patients

They outline optimal regimens for use by caregivers in hospitals, study reports

MONDAY, Aug. 8, 2005 (HealthDay News) -- Care for stroke patients appears to improve significantly in hospitals where standardized treatment forms are completed by attending physicians and nurses, a new study suggests.

Creating a template to help caregivers outline, reference and track the use of optimal care for stroke patients greatly increases the use of lifesaving treatments, according to researchers with the California Acute Stroke Pilot Registry.

"I think this kind of thing has worked in other disease areas, so it's not too surprising that it seems to work for stroke treatment," said study author Dr. S. Claiborne Johnston, director of the University of California, San Francisco Stroke Service. "We were surprised, though, at how much of an improvement we could see vs. how little effort was involved."

Reporting in the Aug. 9 issue of Neurology, Johnston and his team noted that the study focused on ischemic stroke -- which affects 80 percent of stroke patients.

Ischemic stroke occurs when an artery leading to the brain becomes blocked. At the onset of a stroke, symptoms typically include a sudden weakness or numbness of the arm, leg or face -- sometimes affecting just one side of the body. Sudden difficulty with speaking, seeing and walking can also be a sign of stroke, as can a loss of balance or the onset of a severe headache.

About 700,000 Americans suffer a stroke each year -- making it the third leading cause of death after heart disease and cancer -- and the number one cause of long-term disability.

Johnston and his colleagues reviewed the treatment experience of 413 ischemic stroke patients who sought care at one of six California hospitals between late 2002 and early 2004.

In the first year of the two-year study, no treatment form policy was in place at any of the hospitals. However, in the second year, stroke treatment forms were completed at both admission and discharge of all stroke patients.

The standardized forms included a checklist of six key treatment options to be either ticked off as administered, or cross-referenced with a list of acceptable reasons why any one treatment might not be offered in a particular case. In the year the forms were in place, they were utilized both during the admission and discharge of all stroke patients.

The six key observed treatments included: thrombolysis -- a radiologist-administered means of breaking up blood clots within three hours of stroke symptoms; anti-clotting medication offered within a 48-hour period after arrival at the hospital and at release; preventive treatment for blood clots in the leg veins offered within 24 hours of admission; pre-discharge anti-smoking counseling; and the provision of both cholesterol-lowering and anti-clotting drugs at discharge.

Johnston and his team found that when stroke forms were in use, patients were more likely to receive the best possible overall treatment.

They noted that in the second year when a form policy was in place, 63 percent of the patients received "perfect treatment" -- as compared with 44 percent in the prior non-form year.

The study authors noted that thrombolysis treatment numbers remained the same regardless of the form policy -- reflecting the fact that the number of patients who arrived for care within the relevant three-hour window did not change across the two-year period.

However, other more controllable in-hospital procedures did improve with form use. The administration of cholesterol-lowering drugs rose to 64 percent of the patients in the form-year, compared with 48 percent in the non-form year. Clot-busting medications were also dispensed more frequently when forms were used, rising from 89 percent in the non-form year to 96 percent in the form-year.

Johnston and his associates noted, however, that more study is needed to say with certainty that the treatment improvements were entirely the result of the standardized form use.

They noted that the mere fact that hospitals knew they were being monitored for care standards -- and were simultaneously being provided with the latest in optimal care recommendations -- may have prompted the rise in the quality of care.

"This is a big jump in numbers, so we feel good that the care in these hospitals improved," said Johnston. "And we know we were only doing two things at the time -- implementing these standard forms and tracking the results. Both are very easy to do and we can't say for sure which of them account for the jump, but we think it's the orders."

Dr. Barry T. Katzen, program director of the International Symposium on Endovascular Therapy and a clinical professor of radiology at the University of Miami School of Medicine, lauded the study but expressed some reservations about the use of the forms.

"Increasing everybody's awareness of the importance of rapid recognition of stroke is critical, because many stroke patients don't receive adequate therapy when it can make a difference," said Katzen.

"But while I think increasing early diagnosis and treatment is good, I'm not sure that putting forms in between the doctors and the patient is the best way to do it," he added. "I'm a little concerned about forms, because it can put speed bumps in the way of expeditious care."

Johnston, however, indicated that his study saw no evidence of such a problem.

"What we found is that at the facilities where this was implemented the forms were very well accepted because it made the job of the doctors easier," he said. "Because they didn't have to think as much. So it didn't slow care. It speeded it up. And going forward, most treatment orders are probably going to be electronic, so this may well become even easier to do."

More information

To learn more about the warning signs of a stroke, visit the National Institute of Neurological Disorders and Stroke.

SOURCES: S. Claiborne Johnston, M.D., Ph.D., director, University of California, San Francisco Stroke Service; Barry T. Katzen, M.D., program director, International Symposium on Endovascular Therapy, and clinical professor, radiology, University of Miami School of Medicine; Aug. 9, 2005, Neurology
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