A Liaison Critical Pathway for Stroke Rehabilitation: Current Status and Features of Western District of Saitama in Japan

Special Article : Stroke Rehabilitation

Phys Med Rehabil Int. 2015;2(1): 5.

A Liaison Critical Pathway for Stroke Rehabilitation: Current Status and Features of Western District of Saitama in Japan

Shinichiro Maeshima1*, Aiko Osawa1 and Norio Tanahashi2

1Department of Rehabilitation Medicine, Saitama Medical University International Medical Center, Japan

2Department of Neurology, Saitama Medical University International Medical Center, Japan

*Corresponding author: Shinichiro Maeshima, Department of Rehabilitation Medicine II, School of Medicine, Fujita Health University, Japan

Received: December 03, 2014; Accepted: December 26,2014; Published: January 05, 2014


In Japan, division of functions among medical institutions has been promoted as a national policy and a liaison critical pathway (LCP) communitybased has been promoted for stroke treatment. We examined our 3-year experience with operation of such a LCP and its effects from the perspectives of an acute care hospital. We examined the contents of 819 LCP forms returned from the cooperation hospitals during the 3-year period and we investigated changes in activities of daily living, duration of hospital stay, outcomes and compared differences in functional outcomes among the cooperation hospitals. Based on comparison by year, no difference was observed in duration of hospital stay, functional independence measure (FIM) scores on admission and at discharge, FIM gain, the rate of discharge to home during the 3-year period, or FIM efficiency improved in the third year. Based on comparison among the hospitals, there were differences in length of stay, FIM scores on admission and at discharge, FIM gain, FIM efficiency and rate of discharge to home among the cooperation hospitals. The LCP is a valuable tool that promotes closer cooperation among medical institutions and allows them to obtain patient information easily. Reducing incomplete entries and providing feedback on variations in functional assessment results to each cooperation hospital should allow qualitative improvement of rehabilitation services to be attempted.

Keywords: Stroke care; Rehabilitation; Critical pathway; Activities of daily living


LCP: Liaison Critical Pathway; FIM: Functional Independence Measure; ADL: Activities of Daily Living; mRS: modified Rankin Scale


Medical care for stroke has been greatly transformed by improvements in emergency medical systems [1], advancements in treatments, such as thrombolytic therapy [2,3] and neuro endovascular therapy [4], team-based medicine at the stroke unit [5], guidelines for stroke treatment [6] and so on. Meanwhile, the Japanese medical system has changed remarkably since the beginning of this century [7]. In an effort to promote "division of functions among medical institutions," the Diagnosis Procedure Combination (prospective payment system) was introduced [8]. As a result, acute and chronic care hospitals were clearly distinguished by indices, such as mean duration of hospital stay and referral rate. The nursing care insurance system and the convalescence rehabilitation ward were also introduced. Furthermore, the basic framework of the medical programs was recently included in the Medical Service Law and policies to achieve functional division and cooperation among medical institutions, seamless continuation of medical care and early return to life at home were developed [9,10]. With such a social background, the "community-based liaison critical pathway (LCP)" is drawing attention as a path from an acute care hospital through a convalescence rehabilitation ward/hospital to home. Although the critical pathway [11] has been introduced on a hospital-by-hospital basis in the past, functional division and cooperation among medical institutions in each region are necessary for efficient medical care. The LCP began to be integrated into the Japanese medical system a few years ago. However, little is known about efficacy and problem on that medical system using the LCP generally. From the perspective of an acute care hospital engaging in rehabilitation, we would like to discuss our experience with 3-year operation of the LCP and its effects, as well as the position and role of the acute care hospital in this system.

Materials and Methods

Community medical program and LCP for stroke

In Saitama Prefecture, with a population of 7 million people, there are 18 healthcare management hospitals (acute care hospitals) registered as medical institutions engaging in the medical service system for stroke and 28 community cooperation participating hospitals (cooperation hospitals) with convalescence rehabilitation wards. At the acute care hospital, a treatment plan form (LCP for stroke) is prepared [12] by attending physician and nurses according to the LCP within 7 days after a patient is hospitalized. The treatment plan is explained, and provided to the patient and family members in written form. Then, the acute care hospital becomes eligible to receive medical treatment fees. At the cooperation hospital, the information on the LCP form brought by the patient is checked. After the form has been filled out with the provided rehabilitation services and patient status at discharge, it is returned to the acute care hospital. However, if the patient is still hospitalized after the hospital stay limit (180 days), medical treatment fee for the LCP will not be reimbursed. Meetings are regularly held for information exchange approximately 3 times a year. The necessary agenda is to share clinical information and to confirm whether assessment and revision of the cooperation path are appropriately performed. Furthermore, our hospital holds conferences and lectures annually with the staff of the hospitals in our neighboring regions. By presenting data using the LCP on stroke treatment and the rehabilitation services provided to patients, we are also providing educational opportunities.

Liaison clinical pathway and flow of patients

At the acute care hospital, the following items are given in the LCP form in addition to basic information, such as date of onset and disease name: neurological symptoms, details of drug treatment, the presence or absence of behavioral problems, explanation of prognosis, date of discharge, daily living functional assessment at discharge, activities of daily living (ADL) assessed with the functional independence measure (FIM) [13], modified Rankin Scale (mRS) [14] and eating conditions. In the procedure to transfer a patient from the acute care hospital, a medical social worker who receives a request from the doctor in charge of the patient informs several convalescence rehabilitation hospitals near the residential area of the patient. The patient's family members directly visit those hospitals and decide which hospital the patient will be transferred to. Then, the patient is transferred from the acute care hospital to the cooperation hospital with the referral and LCP forms.

At the cooperation hospital, the LCP form, brought by the patient, is filled out with the following items: ADL or eating conditions on admission and at discharge, mRS at discharge, daily living functional assessment, independence degree of daily living for the disabled and demented elderly, date of discharge and outcome after discharge. After the patient is discharged, the form is sent to the acute care hospital by mail.

In this study, we reviewed all patients who underwent rehabilitation at our hospital and were then transferred to cooperation hospitals with LCP forms.


During 3 years of operating the LCP (July 2008 to June 2011), there were 2, 241 stroke patients for whom rehabilitation was requested. This study involved 819 of these patients (36.5%) who were transferred to cooperation hospitals with convalescence rehabilitation wards along the LCP of Saitama Prefecture. The ages ranged from 11 to 98 (69.9 ± 12.4) years. There were 516 men and 303 women. The primary diseases included cerebral infarction in 378 patients, intracranial hemorrhage in 353, sub arachnoid hemorrhage in 78 and other cerebrovascular disorders in 10. The time from onset to the start of rehabilitation was 3.0 ± 4.6 days and the mean duration of hospital stay was 33.8 ± 16.1 days.


When the LCP forms were not returned by 6 months after patients had been transferred from the acute care hospitals, the staff of the regional liaison office contacted the cooperation hospitals by telephone or facsimile to urge them to return the forms and to ascertain the reasons for not returning them. Then, we examined the contents of returned forms in ADL, duration of hospital stay, outcomes, etc., at the cooperation hospital during the 3-year period. Differences in functional outcomes were also compared among 6 cooperation hospitals returning 10 or more LCP forms.

Statistical analysis

Data were statistically analyzed using Kruskal-Wallis tests and chi-square tests. Significance was set at the p<0.05 level. Statistical analyses were performed using the JMP version 8.02 for Macintosh software (SAS Institute Inc., Cary, NC, USA).


Status of collection and entries of the LCP forms

The ultimate collection rate of the LCP forms prepared during the 3-year period was 78.6% (644 patients). The reasons for the LCP forms of the remaining 175 patients not being collected from the cooperation hospitals were as follows: 64 patients (36.6%) were "not admitted to the convalescence rehabilitation ward but rather to another ward (sanatorium) on admission"; 13 patients (7.4%) were "transferred to another hospital due to acute deterioration in their conditions"; 9 patients (5.1%) were "transferred from the convalescence rehabilitation ward to another ward (medical care type)"; "the duration of stay at the convalescence rehabilitation ward exceeded the computation period (6 months)" in 9 patients (5.1%); 6 patients (3.4%) "died"; 14 patients (9.7%) did "not bring their LCP forms" and the reason was "unknown or no reply" in 60 patients (34.3%).

Functional improvement and outcomes at convalescence rehabilitation wards

The time from admission to our hospital to transfer to the convalescence rehabilitation hospitals (duration of stay at the acute care hospital) was 33.8± 16.1 (median: 31, range: 3-158) days. The FIM scores on admission to the cooperation hospitals were 66.1± 33.6 (median: 67, range: 18-126). The FIM scores at discharge from the cooperation hospitals were 95.9± 29.8 (median: 107, range: 18-126). The FIM gain (FIM score at discharge - FIM score on admission) was 29.6± 23.3 (median: 25, range: -24 to 109). The mean duration of hospital stay was 97.1± 59.3 days (median: 90, range: 3-317). The FIM efficiency (FIM gain/duration of hospital stay) was 0.41 ± 0.42 (median: 0.31, range:-0.44-3.55).

We compared 6 cooperation hospitals returning 10 or more LCP forms. A difference was observed in duration of hospital stay among the acute care hospitals, and there were differences in duration of hospital stay, FIM scores on admission and at discharge, FIM gain, FIM efficiency and rate of discharge to home among the cooperation hospitals (Table 1).