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Am J Emerg Med. 2014 Aug;32(8):884-9. doi: 10.1016/j.ajem.2014.04.049. Epub 2014 May 11.

Implementation of a clinical pathway based on a computerized physician order entry system for ischemic stroke attenuates off-hour and weekend effects in the ED.

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Department of Emergency Medicine, Yonsei University College of Medicine, Seoul 135-720, Republic of Korea.
Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul 135-720, Republic of Korea.
Department of Emergency Medicine, Yonsei University College of Medicine, Seoul 135-720, Republic of Korea; Department of Emergency Medicine, Gangwon National University, Graduate School of Medicine, Chuncheon, 200-701, Republic of Korea. Electronic address:
Department of Emergency Medicine, National Health Insurance Corporation Ilsan Hospital, Goyang, 410-719, Republic of Korea.



Admission on weekends and off-hours has been associated with poor outcomes and mortality from acute stroke. The purpose of this study was to investigate whether an organized clinical pathway (CP) for ischemic stroke can effectively reduce the time from arrival to evaluation and treatment in the emergency department (ED) and improve outcomes, regardless of the time from arrival in the ED.


We conducted a retrospective analysis of all consecutive patients included in the prospective registry database in the Brain Salvage through Emergency Stroke Therapy program, which uses the computerized physician order entry (CPOE) system. Patients were classified based on their time of arrival in the ED: group 1, normal working hours on weekdays; group 2, off-hours on weekdays; group 3, normal working hours on weekends; and group 4, off-hours on weekends. Clinical outcomes were categorized according to 30 days in-hospital mortality, in-hospital mortality, and the modified Rankin score during a single length of stay (LOS).


No time intervals differed significantly among the 4 patient groups who received intravenous administration of tissue plasminogen activator (IV-tPA). Use of IV-tPA (P = .5110) was not affected by arrival in the ED on off-days or weekends. The overall mortality rate was 3.9%, and the median LOS was 7 days (Interquartile range (IQR), 5-10). By Kaplan-Meier analysis, the cumulative probability of mortality and survival did not differ significantly among the 4 groups over 30 days (P = .1557).


An organized CP, based on CPOE, for ischemic stroke can effectively attenuate disparities in the time interval between ED arrival to evaluation and treatment regardless of ED arrival time. This pathway may also help to eliminate off-hour and weekend effects on outcomes from ischemic stroke.

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