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ORIGINAL ARTICLE   Free accessfree

European Journal of Physical and Rehabilitation Medicine 2020 December;56(6):713-24

DOI: 10.23736/S1973-9087.20.06195-X


language: English

Development and implementation of a stroke rehabilitation integrated care pathway in an Italian no profit institution: an observational study

Francesca CECCHI 1, Manuela DIVERIO 1, Chiara ARIENTI 2, Elena CORBELLA 2, Federico MARRAZZO 1, Gabriele SPERANZA 1, Elisabetta DEL ZOTTO 2, Giuliana POGGIANTI 1, Francesco GIGLIOTTI 1, Paola POLCARO 1, Margherita ZINGONI 1, Desiderio ANTONIOLI 1, Lucia AVILA 1, Manuele BARILLI 1, Emanuela ROMANO 1, Lucilla LANDUCCI PELLEGRINI 1, Massimo GAMBINI 1, Sonia VERDESCA 1, Federica BERTOLUCCI 1, Irene MOSCA 1, Paola GEMIGNANI 1, Anita PAPERINI 1 , Chiara CASTAGNOLI 1, Ines HOCHLEITNER 1, Maria L. LUISI 1, Giulia LUCIDI 1, Bahia HAKIKI 1, Maria A. GABRIELLI 2, Morena FRUZZETTI 1, Annalisa BRUZZI 1, Enrico BACCI BONOTTI 1, Silvia PANCANI 1, Silvia GALERI 2, Claudio MACCHI 1, Irene APRILE 1

1 IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy; 2 IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy

BACKGROUND: To standardize assessment and coordinate processes in stroke rehabilitation, an integrated care pathway (ICP) was developed in an Italian Rehabilitation and Research Institution by a knowledge-translation interdisciplinary process, from evidence-based guidelines to rehabilitation practice. The ICP was implemented in two pilot Tuscan rehabilitation Centers.
AIM: The purpose of this study was to describe ICP development and assess the ICP effects on postacute stroke inpatient rehabilitation outcomes.
DESIGN: Prospective observational study, before and after comparison.
SETTING: Two Tuscan inpatient rehabilitation centers.
POPULATION: Patients accessing either centers for intensive rehabilitation after acute stroke.
METHODS: Two cohorts were prospectively recruited before (2015-2017) and after (2018) implementation of the pathway. The primary outcome was change in activities of daily living disability, assessed by the modified Barthel Index (mBI) from admission to discharge. Secondary outcomes included length of stay (LOS), adverse outcomes, and changes in communication ability, trunk control, pain, ambulation, bladder catheter (Y/N), bedsores (Y/N).
RESULTS: In 2015-2017, 443 postacute stroke patients (mean age 77±11 years, 47% women), while in 2018, 84 patients (mean age 76±13 years, 61% women) were admitted to the two facilities. Comparing the 2018 vs. the 2015-17 cohort, the mean mBI increase was not substantially different (26 vs. 24 points), nor were LOS (37±18 vs. 36±16 days), adverse outcomes, discharge destination, and improvement of ambulation, pain, and communication (P>0.05). Instead, a significantly higher improvement of trunk control (trunk control test: 69.6±33.2 vs. 79.0±31.3, P=0.019), and a higher percentage of bedsore resolution (13% vs. 5%, P=0.033), and bladder catheter removal (37% vs. 17% P<0.001) were observed in 2018 vs. 2015-2017.
CONCLUSIONS: Compared to prior practice, ICP was associated to improvement of trunk control recovery, bladder catheter removal, and bedsores resolution. Further ICP implementation on a larger scale is needed to verify improvements of stroke inpatient rehabilitation outcomes.
CLINICAL REHABILITATION IMPACT: An evidence-based stroke rehabilitation ICP was interdisciplinary developed and implemented in two rehabilitation centers of a multicenter Italian health group. ICP implementation as to inpatient intensive postacute stroke rehabilitation was associated to improved trunk control recovery, bladder catheter removal, and bedsore resolution. Further ICP implementation will allow multicenter studies and quality benchmarking.

KEY WORDS: Delivery of health care, integrated; Stroke rehabilitation; Evidence-based practice; Quality improvement

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