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August 9 Highlight and Commentary

The CASPR Investigators studied the impact of standardized stroke orders on quality of care at seven hospitals. Use of the orders was associated with improvement in five measures of quality of care for patients with ischemic stroke.

Figure. Mean treatment scores for Year 1 and Year 2 by individual hospital. Significantly improved (solid line); insignificant (dotted line). A single hospital did not implement standardized stroke orders (gray line).

see page 360

Do the right thing

Commentary by J.D. Bartleson, MD.

We want to do the right thing for our patients. We strive to practice the best care based on the best medical evidence. But, it is impossible to remember to do all of the right things for every patient every time. A reminder at the point of care is an obvious tool for helping to ensure that we do the right thing.

The California Acute Stroke Pilot Registry (CASPR) investigators show a modest, but still impressive incremental improvement in the evidenced-based care of stroke patients due largely, if not entirely, to implementing standardized stroke orders which forced providers to do the right thing or document why doing the right thing was wrong in a particular patient’s situation. There are other clinical tools to accomplish the same goals: critical pathways, protocols, checklists, and algorithms.^1–3

Is this "cookbook medicine?" No, cookbooks are to meal preparation as textbooks are to medical care. Are standardized order sets and other tools textbook care? In many instances, they are better than textbook care because they are based on current medical literature and expert consensus, can be updated rapidly, and are available at the point of care. Textbooks take years to reach our desks and even then we are unlikely to have the most recent edition open to the right page at the right time.

Stroke and TIA are common conditions. With sufficient commitment of hospital resources it should be possible to replicate the success reported by the CASPR investigators. There are many other potential opportunities to improve care in the hospital and in the clinic. Most of neurology is outpatient-based care. Neurologists should test the use of improvement tools in the outpatient setting. We should have at our fingertips order sets, checklists, and algorithms for helping us diagnose and treat patients with the most common conditions we see such as headache, spine and limb pain, cognitive impairment, loss of consciousness, and peripheral neuropathy.

This report of improved stroke care should serve as a call for neurologists to work in our hospitals and office practices to study and then implement simple tools that will enable us to do the right thing.

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References

1. Wolff AM, Taylor SA, McCabe JF. Using checklists and reminders in clinical pathways to improve hospital inpatient care. Med J Aust 2004;181:428–431.[Medline]
2. Treece PD, Engelberg RA, Crowley L, et al. Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit. Crit Care Med 2004;32:1141–1148.[Medline]
3. Cannon CP. Treatment algorithms and critical pathways for acute coronary syndromes. Semin Vasc Med 2003;3:425–432.[Medline]

This Article Full Text (PDF) Correspondence: Submit a response Alert me when this article is cited Alert me when Correspondence are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content PubMed PubMed Citation Related Collections Related Article