IMPROVING NEUROLOGICAL OUTCOMES THROUGH STRUCTURED CLINICAL PATHWAYS. A MULTIDISCIPLINARY APPROACH.

Abstract

Background: The aim of structured clinical pathways is to help standardize evidence-based, multidisciplinary care during time-sensitive periods of neurological disease. With stroke, intracerebral hemorrhage (ICH), and major traumatic brain injury (TBI), prompt coordination among emergency, neurology/neurosurgery, intensive care, nursing, and rehabilitation teams, has the potential of leading to enhanced functional outcome, reduced complications, and an efficient provision of care. Objectives: To conduct a systematic review of original research focused on assessing the effect of structured clinical pathways, including patient-important neurological and other outcomes, across acute stroke/ICH and severe TBI, and to determine the feasibility of quantitative synthesis to support a meta-analysis. Methodology: The systematic review was focused and was based on five predetermined original studies: (i) an emergency clinical pathway of stroke; (ii) a randomized controlled trial of a multidisciplinary clinical pathway in hypertensive ICH; (iii) a controlled interventional study clinical-pathway-guided functional training post-cerebral hemorrhage; (iv) a prospective pathway cohort with historical controls severe TBI; and (v) a quasi-experimental pathway study in severe TBI. The study designs, populations, interventions, comparators, and outcomes were extracted in duplicate and the risk of bias assessed with design-specific instruments (RoB-2 or randomized trials; ROBINS-I or equivalent for nonrandomized studies). The main outcomes included neurological/ functional outcomes (e.g., NIHSS, Barthel Index, Glasgow outcome scale), complication rates, death, and indicators of care efficiency (e.g., thrombolysis access, stroke-unit referral, ICU/hospital length of stay). Due to the heterogeneity of designs, settings, and outcome reporting, we pre-specified narrative synthesis and evaluated but withheld meta-analysis where assumptions of statistical pooling were not satisfied. Results: In conditions and settings, structured clinical pathways demonstrated consistent, key-process and patient-outcomes improvements compared with usual care. Pathway implementation in acute stroke improved appropriate stroke-unit referral and access to time-sensitive reperfusion with evidence of superior early complications, whereas multidisciplinary nursing pathways in ICH were associated with better neurological/functional outcomes, reduced in-hospital complications, and improved patient/family satisfaction; in severe traumatic brain injury, pathway adoption resulted in reduced length-of-stay in the ICU/hospital and reduced complication burden, and with pathway groups experiencing better overall outcome at discharge in nonrandomized comparisons. Pathway-related gains in process measures and functional recovery have strong randomized support; nonrandomized studies are directionally consistent. Nevertheless, heterogeneity in components of pathways, timing, and outcome descriptions, as well as risk-of-bias patterns, precluded quantitative pooling and precision of the effects estimates. Conclusion: Multidisciplinary structured clinical pathways in acute stroke/ICH and severe TBI are linked to improvements in process quality (e.g., access to stroke-units, timely interventions) and neurological and functional outcomes along with a decrease in complications and resource use. Convergent results across types of design provide greater certainty regarding benefit, but larger, multicenter randomized trials with standardized pathway components and harmonized reporting of outcomes would be useful to establish magnitude of effect and pathway design most suitable to the wide range of health-system settings.