ORIGINAL ARTICLE
Role of a critical pathway for door-to-CT-completion intervalin the management of acute ischemic stroke patients in theemergency room
Masaru Suzuki1,5, Akira Imai2, Masanori Honda3, Kenji Kobayashi1 and Shujiro Ohtsuka4
Departments of 1Emergency Medicine, 2Neurology, 3Radiology, 4Surgery, Saisei-kai Utsunomiya HospitalTochigi, Japan(Received for publication on April 5, 2004)

Abstract. Objective: Door-to-CT-completion interval (DCI) for acute ischemic stroke patients is oneof the clinical indicators of quality assurance in an emergency room (ER). The aim was to clarify
whether the critical pathway improves the DCI for acute stroke patients in the ER. Methods: The
pathway describes each step in patient evaluation in sequence from the patient’s arrival in the ER until
the brain CT is completed. Whether to use the pathway when evaluating individual patients is left tothe discretion of the physician. After excluding 8 cases with insufﬁcient data, 52 cases diagnosed withacute stroke (29 males, 69.9 G 12.4 y/o) in the ER between January and February 2003 were retrospectively identiﬁed. A logistic regression analysis was used to assess the impact of application of thepathway on achievement of an acceptable DCI (H 25 min). Results: The pathway was applied in 21.2%of the cases included in the study, and the median DCI was reduced from 48 minutes to 22 minutes as aresult (P F 0.02). Comparing them with the DCI, the probability values for ambulance use, consciousness disturbance, history of stroke, and application of the pathway in univariate analyses were less than0.10. These variables were entered into the logistic analysis, which that indicated application of thepathway was the strongest variable related to acceptable DCI (OR: 10.92, 95% CI: 1.22 to 97.96).
Conclusion: Application of the pathway was associated with an improvement of the DCI. Use of thepathway will improve the quality of the process of care in the ER. (Keio J Med 53 (4): 247–250, December 2004)
Key words: critical pathway, cerebrovascular disorders, emergency care, quality indicator, computed
tomography

Introduction
Critical pathways have been developed not onlyfor nursing, but also for medical care, both to reduce
costs and improve quality of care.1,2 Many pathways for
cardiovascular diseases have been developed to date,including for emergency cardiovascular care.3–5
Early thrombolysis is given ﬁrst priority in the treatment of acute ischemic stroke in an emergency room,and there is considerable evidence of the importance of
reducing the interval between symptom onset and theinstitution of thrombolytic therapy.6–9 Based on the US
National Institute of Neurological Disorders and Stroke
trial (NINDS) protocol,7 the American Heart Associa-tion (AHA) recommended that the goal of emergency
care for acute stroke should be a door-to-CT-completion interval of less than 25 minutes.8 Previous studies
have reported that pathways signiﬁcantly reduced consuming time relating to quality of care in the emergency
room.3,5 However, measuring time intervals as clinicalindicators and application of critical pathways are not
yet popular among physicians in Japan.
The purpose of this study was to determine whether
application of a critical pathway in the emergency room
would reduce the door-to-CT-completion interval in themanagement of acute stroke patients in a tertiary
emergency center in Japan.

Present afﬁliation: 5Department of Emergency Medicine, School of Medicine, Keio University
Reprint requests should be addressed to Dr. Masaru Suzuki, Department of Emergency Medicine, School of Medicine, Keio University,
35 Shinanomachi, Shinjukuku, Tokyo 160-8582, Japan, e-mail: suzuki@sc.itc.keio.ac.jp
247

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Suzuki M, et al: A Critical Pathway for Acute Stroke in the ER

Table 1 Critical Pathway for the Management of Acute Stroke
Patients in the Emergency RoomPatient Name:
1.

:

2.

:

3.
4.

:
:

Date:
Signature of Physician:Arrival in the ER of a patient with suspected acutestroke
Immediate general assessment
Vital signs, Blood glucose
IV-line, CBC & blood chemistry12-lead ECG
Establish time of onset of symptoms
Review patient history
Physical and neurological examination
Order urgent noncontrast CT scanCT scan completion (goal < 25 minutes from arrival)

Methods
The present study was designed as a retrospective
observational study and was conducted in a single
tertiary emergency center of a community hospital, following the ethical guidelines for epidemiological studies(Ministry of Health, Labour and Welfare, 2002) basedon the principles outlined in the World Medical Association’s Declaration of Helsinki. Further, the ethics
committee of the emergency center and the executive
committee on clinical pathway of the hospital approved
the present study.
The critical pathway
The critical pathway for the management of acutestroke patients is shown in Table 1. Use of the pathway
when evaluating individual patients is left to the discretion of the physician. The pathway describes eachstep of the initial evaluation in sequence from thepatient’s arrival in the emergency room until completion of the brain CT scan. Physicians who use thepathway must ﬁll in the actual time when each step of
medical care was carried out.
Case series
Between January and February 2003, a total of
2,645 adults presented to the emergency room of Saiseikai Utsunomiya Hospital with an acute illness, and60 (2.3%) of them were diagnosed with acute stroke
and admitted to stroke care units. Eight cases wereexcluded, consisting of 6 had missing door time and 2
had missing brain-CT-completion time, the remaining
52 cases were identiﬁed as eligible and included in thestudy. The patients’ characteristics are shown in Table
2. Of the 52 patients, 67.4% had acute ischemic stroke.
None of those patients received intravenous thrombolytic therapy, because it was not approved for acute

Table 2

Patient Characteristics
Patients n ¼ 52
number (%)

MaleAge median (range)
Type of stroke (discharge diagnosis)
Thrombosis
Embolism
Intracerebral hemorrhage
Subarachnoid hemorrhage
Mode of transportation
Ambulance
Door time
Day (8:30 to 17:30)
Glasgow coma scale score < 15
Atrial ﬁbrillation
History of stroke
Onset-to-door interval median (range)
Door-to-CT-completion median (range)
Application of critical pathway

29 (55.8)
72 (39 to 92) y/o24 (46.2)
11 (21.2)
9 (17.3)
8 (15.4)
35 (67.3)
32 (61.5)
19 (36.5)
8 (15.4)
15 (28.8)
2.2 (1 to 240) hours
42 (12 to 201) minutes
11 (21.2)

ischemic stroke in the hospital. Door time and brainCT-completion time were recorded on the medicalorder computer in our hospital.
Statistical analysis
The statistical analysis, including calculation ofmedian values and ranges, was performed using SPSS
11.5J software. Univariate analyses of variables wereperformed by using the w 2 test for categorical data andthe Mann-Whitney U-test for continuous data. Variables with probability values less than 0.10 wereentered in a logistic regression model with backwardelimination procedure to identify multivariate predictors of acceptable door-to-CT-completion interval(< 25 min).
Results
The pathway was applied in 11 (21.2%) of the52 cases included in the study and the median door-toCT-completion interval was shorter in the pathway
group (24 minutes; range: 13 to 84 minutes) than in
the no-pathway group (48 minutes; range: 12 to 201
minutes; Mann-Whitney U-test: P ¼ 0.02). The proportion of patients with an acceptably short door-to-CTcompletion interval (< 25 minutes) improved from
6.4% to 42.9% as a result of using the pathway (Table3).
Ambulance use, consciousness disturbance, application of the pathway, and history of stroke were selectedin the univariate analyses, and inserted into the logistic
regression model (Table 3), which indicated applicationof the pathway as one of the independent variables of

Keio J Med 2004; 53 (4): 247–250
Table 3249

Univariate Analysis
Door-to-CT-completion interval

Male
Age medianMode oftransportation
Ambulance
Door time
Day (8:30 to 17:30)
Glasgow coma
scale score < 15
Atrial ﬁbrillation
History of stroke
Application ofcritical pathway<25 minutes
n ¼ 14
Number (%)>¼25 minutes
n ¼ 38
Number (%)

P-value

9 (64.3)
64 y/o20 (52.6)
74 y/o0.54
0.21

14 (100)

21 (55.3)

0.00027 (50)
9 (64.3)

25 (65.8)
10 (26.3)

0.35
0.02

4 (28.6)
7 (50)
6* (42.9)

4 (10.5)
8 (21.1)
5 (6.4)

0.19
0.08
0.05

* Odds ratio ¼ 4.95 (95% Conﬁdence Interval: 1.20 to 20.40)

the acceptable door-to-CT-completion interval (Table4).
Discussion
Application of the pathway to patients suspected ofacute stroke was shown to be the strongest independent
variable in increasing the percentage of cases in which
the ACC/AHA criterion was met.8 Although there
have been no reports on the role of the pathway foracute stroke patients in the emergency room, application of pathways has been reported to reduce doorto-drug intervals for patients with acute myocardial
infarction receiving intravenous thrombolytic therapy.3,5 Door-to-drug intervals have been used as an indicator of the quality of medical care for acute myocardial infarction and acute ischemic stroke patientsin the emergency room. Pathways have been valuable
for continuously the improving quality of emergency
care.3,5,7–9
Since acute ischemic stroke is one of the most common diseases treated in emergency rooms, realistic
evaluation guidelines must be established in every institution. Critical pathways may clarify the goal of care
not only for physicians but also for all medical person-Table 4

Multivariate Analysis

Application of critical pathway
History of stroke

Odds ratio

95% CI

P-value

10.92
9.50

1.22 to 97.96
1.35 to 66.78

0.03
0.02

nel involved in providing emergency care. They also
promote good collaboration among the entire emergency room team.1
This is the ﬁrst report from Japan on the applicationof a critical pathway in the emergency room to reducethe door-to-CT-completion interval as the emergency
evaluation goal. The pathway used in this study clearlystated the process of patient care and rationalized thesequence of orders of treatment by medical personnel.
Similar pathway sheets for patients with acute myocardial infarction that signiﬁcantly reduced consuming
time relating to quality of care in the emergency room
have been previously reported.3,5 Those pathways will
be effective in reducing physician delay (door-tophysician evaluation interval), which is considered oneof the reasons for in-hospital delay. Actually, themedian door-to-CT-order-given interval in this study
was shorter in the pathway group than in the nopathway group (11 minutes, 33 minutes, respectively;
Mann-Whitney U-test: P ¼ 0.006), but order-to-CTcompletion intervals between the groups was notdifferent (6 minutes, 8 minutes, respectively; MannWhitney U-test: P ¼ 0.47).
There were potential limitations in this study. First, it
was a retrospective study conducted in a single center.
Although the study includes some selection bias, consecutive cases were included in the study to reduce selection bias. Second, the sample size was small, but it
was estimated to be sufﬁcient to detect statistically signiﬁcant differences. The criterion for signiﬁcance (alpha) for 2-tailed test in this study was set at 0.05. The
study had a power of 81% to yield a statistically signiﬁcant result. Third, the patients had a variety of different
types of acute stroke. It is difﬁcult to diagnose the typeof acute stroke solely on the basis of the clinical presentation.10 A CT scan of the brain is the deﬁnitive testfor differentiating ischemic stroke from hemorrhagic
stroke, and thus the type of acute stroke may not inﬂuence the door-to-CT-completion interval. Finally, theproportion of the patients to whom the pathway wasapplied less than 25%. Although the actual reasons forthis were not identiﬁed in this study (Table 5), physicians’ reluctance use the pathway may be a contributing
factor. It may be associated with unavailablility of intravenous thrombolytic agents for acute ischemic strokein the hospital. Further, the fact that the pathway had tobe applied at the initial evaluation may have decreased
its use.
The effectiveness of the pathway on patients’ outcome in Japan, where intravenous thrombolytic therapy
for acute ischemic stroke has not yet been adopted, islimited, and the long-term outcome of the patients wasactually not included in the analysis. However, the result of this study indicated that the pathway was valuable in reducing physician delay.

250
Table 5

Suzuki M, et al: A Critical Pathway for Acute Stroke in the ER
Application of Critical Pathway
Application of critical pathway

MaleAge medianMode oftransportation
Ambulance
Door time
Day (8:30 to 17:30)
Glasgow coma
scale < 15
Atrial ﬁbrillation
History of stroke

3.

Pathway groupn ¼ 11
Number (%)

No-pathway groupn ¼ 41
Number (%)

P-value

6 (54.5)
71 y/o23 (56.1)
73 y/o1.00
0.62

9 (81.8)

26 (63.4)

0.30

9 (81.8)
3 (27.3)

23 (56.1)
16 (39.0)

0.17
0.73

1 (9.1)
4 (36.4)

7 (17.1)
11 (26.8)

1.00
0.71

4.
5.

6.

7.

8.

References9.
1. Pearson SD, Goulart-Fisher D, Lee TH: Critical pathways as astrategy for improving care: problems and potential. Ann Intern
Med 1995; 123: 941–948
2. Every NR, Hochman J, Becker R, Kopecky S, Cannon CP:

10.

Critical pathways: a review. Committee on Acute Cardiac Care,Council on Clinical Cardiology, American Heart Association.
Circulation 2000; 101: 461–465
Cannon CP, Johnson EB, Cermignani M, Scirica BM, Sagarin
MJ, Walls RM: Emergency department thrombolysis criticalpathway reduces door-to-drug times in acute myocardial infarction. Clin Cardiol 1999; 22: 17–20
Kwan J, Sandercock P: In-hospital care pathways for stroke: aCochrane systematic review. Stroke 2003; 34: 587–588
Nakamura I, Hori S, Suzuki M, Asakura Y, Yoshikawa T,Ogawa S, Aikawa N: Critical pathway improves arrival-in-cathlab interval for patients with acute myocardial infarction in theemergency department. Jpn Circ J 2001; 65: 849–852
Barsan WG, Brott TG, Broderick JP, Haley EC, Levy DE,Marler JR: Time of hospital presentation in patients with acutestroke. Arch Intern Med 1993; 153: 2558–2561
Tissue plasminogen activator for acute ischemic stroke. TheNational Institute of Neurological Disorders and Stroke rt-PA
Stroke Study Group. N Engl J Med 1995; 333: 1581–1587
Guidelines 2000 for Cardiopulmonary Resuscitation andEmergency Cardiovascular Care. Part 7: the era of reperfusion:section 2: acute stroke. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation 2000; 102: I 204–216
Wardlaw JM, Zoppo G, Yamaguchi T, Berge E: Thrombolysis
for acute ischaemic stroke. Cochrane Database Syst Rev 2003:
CD000213
Gilman S: Imaging the brain. First of two parts. N Engl J Med
1998; 338: 812–820