Stroke rehabilitation clinical pathway description
(I) Applicable objects
Patients with acute onset of stroke with functional impairment, including patients with cerebral infarction and cerebral hemorrhage.
(II) Diagnostic basis
According to the Clinical Diagnosis and Treatment Guide-Neurology Sub-volume (edited by the Chinese Medical Association, People’s Health Publishing House).
1.Clinical manifestations: patients with acute onset, clinical neurological localization signs and functional impairment.
2. Head CT or MRI confirmed cerebral hemorrhage or cerebral infarction.
(c) The standard inpatient period for stroke rehabilitation clinical pathway is 22-28 days.
(D) Entry pathway criteria
1. The first diagnosis must be in accordance with ICD-10: I61, 9 cerebral hemorrhagic disease and ICD-10: I63, 9 ischemic stroke/cerebral infarction disease.
2. Patients can enter the pathway when they have other disease diagnoses at the same time, but do not require special treatment during hospitalization nor affect the implementation of the clinical pathway process for the first diagnosis.
(E) Stroke rehabilitation treatment process
1.Patients in the acute stage of stroke admitted to the neurology ward or stroke unit of a general hospital
(1) Complete the collection of clinical data and necessary auxiliary examinations within 24 hours to clarify the disease diagnosis;
(2) According to the specific stroke type, disease duration and major complications, select appropriate clinical treatment measures according to the “Clinical Treatment Guideline I Neurology Sub-volume”.
(1) General treatment: low-salt and low-fat diet, smoking and alcohol cessation, maintenance of vital signs and internal environment stability.
2.Treatment of underlying diseases: treatment of hypertension, hyperlipidemia, diabetes, heart disease, etc.
3, clinical treatment: according to the course of the disease and major complications, ischemic stroke can be given thrombolysis, improve cerebral circulation, cerebral protection, anti-free radicals, antiplatelet, lipid regulation, anticoagulation if necessary; hemorrhagic stroke can be given to regulate blood pressure, cranial pressure, improve cerebral blood supply, cerebral neurotrophy, symptomatic support treatment, etc. Special treatment is needed, such as acute resuscitation, thrombolysis, intervention, surgery, etc., and treatment in the human intensive care unit. All patients are kept in good limb position in bed.
4, prevention and control of common complications, such as infection, pressure sores, deep vein thrombosis, etc.
(3) Within 72 hours, organized by neurorehabilitation physician, set up a stroke rehabilitation team and hold an initial rehabilitation evaluation meeting to initially evaluate post-stroke functional impairment.
(4) Develop rehabilitation treatment plan and rehabilitation goals.
(5) Initially judge the prognosis of stroke rehabilitation.
2. The initial evaluation includes.
(1) Evaluation of risk factors, medical complications and complications of stroke;
(2) Evaluation of the degree of coma: Glasgow Coma Scale;
(3) Evaluation of stroke severity: National Institutes of Health Stroke Scale (NIHSS);
(4) Motor impairment: Fugl-Myer motor and balance score, Ashworth spasticity assessment, walking ability assessment, etc;
(5) Cognitive function screening: Simple Mental State Examination (MMSE);
(6) Brief swallowing assessment: drinking test;
(7) Brief articulation and speech evaluation;
(8) Cardiopulmonary function evaluation;
(9) Evaluation of major secondary disorders according to the condition: shoulder pain, shoulder-hand syndrome, muscle circumference, etc;
(10) Evaluation of psychological status;
(11) Evaluation of bowel and urinary function;
(12) Activity of daily living (ADL): modified Barthel index;
3.Initiate secondary prevention measures to prevent complications and decide on treatment plan.
4.Implement rehabilitation treatment
After 48 hours of disease stabilization, the rehabilitation treatment plan is implemented according to the functional impairment and rehabilitation evaluation, and the clinical pathway standard inpatient rehabilitation treatment lasts 22-28 days.
The content of rehabilitation treatment includes.
(1) Rehabilitation of motor and balance disorders: good limb position retention training in bed, postural transfer training, joint mobility training, daily movement training, walking training, etc;
(2) Rehabilitation of sensory disorders;
(3) Rehabilitation of cognitive and emotional disorders;
(4) Rehabilitation of speech and communication disorders;
(5) Rehabilitation of swallowing disorders;
(6) Rehabilitation of urinary and bowel disorders;
(7) Rehabilitation of cardiopulmonary dysfunction;
(8) Rehabilitation of secondary disorders;
(9) Rehabilitation of ADL and quality of life.
5.Pre-discharge rehabilitation evaluation
Repeat the initial evaluation content, assess ADL and social participation ability, decide disease regression, adjust rehabilitation program, and develop post-discharge rehabilitation plan.
(VI) Discharge criteria and return to home/community criteria
1. The patient’s condition is stable.
2. No complications that require hospitalization.
3. The condition improves and the ADL is completely self-care, return to home or community rehabilitation and consolidate the therapeutic effect.
(VII) Criteria for continued rehabilitation
1.The functional impairment is still heavy.
2.ADL mostly dependent, transfer to rehabilitation department or rehabilitation center to continue rehabilitation.
3.The condition is improving, most of ADL is self-care, return to home or community rehabilitation, consolidate the effect of treatment.
(H) Variation and cause analysis
1.Persons with critical stroke condition need to be transferred to ICU or NICU and transferred to the appropriate pathway.
2.Abnormal auxiliary test results and the need for review, resulting in longer hospital stay and increased hospitalization costs.
3.The condition worsens during hospitalization and complications arise, requiring further consultation and treatment, leading to prolonged hospitalization and increased hospitalization costs.
4.The emergence of other diseases that require further consultation and treatment, resulting in longer hospitalization and higher hospitalization costs.
Note: Specific content of rehabilitation assessment.
(1) Initial assessment: Organized by the rehabilitation team leader (doctor in charge), each member of the rehabilitation team discusses the main functional impairment, problem summary; immediate and long-term goals; rehabilitation treatment plan and precautions, prediction of prognosis and judgment of factors affecting rehabilitation, and specific rehabilitation treatment measures according to their respective examination and assessment of the patient.
(2) Mid-term evaluation: According to the initial evaluation whether the goals set are completed, if not completed, the reasons should be sought and solutions to the problem should be found; according to the current functional status, the next rehabilitation treatment plan should be formulated; the next near-term and long-term goals should be determined.
(3) Final assessment: summary of rehabilitation treatment, degree of implementation of rehabilitation goals, degree of functional and capacity improvement, degree of effectiveness of various rehabilitation treatments, experience and lessons learned, post-discharge recommendations, and post-discharge rehabilitation guidance, etc.