Early management of acute ischemic stroke cases

Article on Quality

Early management of acute ischemic stroke cases(Acute Stroke Protocols & Guidelines/Algorithms) @ Apollo

Hospitals, Hyderabad

Jammala Saritha Margaret a, Gaurav Loria b,*aSenior Executive Quality, Apollo Hospitals, Hyderabad, IndiabGroup Coordinator Quality, Apollo Hospitals, Hyderabad, India

a r t i c l e i n f o

Article history:

Received 2 November 2013

Accepted 5 November 2013

Available online 4 December 2013

Keywords:

Ischemic stroke

Thrombolysis

Stroke survivors

a b s t r a c t

Stroke is a medical emergency, with a mortality rate higher than most forms of cancer. It is

the second leading cause of death in developed countries and is the most common cause of

serious, long-term disability in adults. The incidence of stroke is increasing with the aging

of populations and hence there is a major challenge to health planners.

Evidence-based advances in acute stroke have included proof of the benefit of organized

care in stroke units, modern brain imaging, and thrombolytic therapy, the modest benefit

of acute aspirin in ischemic stroke clearly, a lack of awareness of the common symptoms

of stroke remains a major educational challenge, and the urgency of stroke treatment is

still poorly appreciated. Despite the proven benefit of stroke units, the majority of patients

in most countries cannot access specialized stroke care.

The article focuses on current treatment guidelines and new therapeutic prospects,

emphasizing the importance of early intervention and the need for a multidisciplinary

approach to the management of stroke patients.

Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Stroke is a medical emergency, with a mortality rate higher

than most forms of cancer. It is the second leading cause of

death in developed countries and is the most common cause

of serious, long-term disability in adults. The incidence of

stroke is increasing with the aging of populations and hence

there is a major challenge to health planners.

Evidence-based advances in acute stroke have included

proof of the benefit of organized care in stroke units, modern

brain imaging, and thrombolytic therapy, the modest benefit

of acute aspirin in ischemic stroke clearly, a lack of awareness

of the common symptoms of stroke remains a major educa-

tional challenge, and the urgency of stroke treatment is still

poorly appreciated. Despite the proven benefit of stroke units,

the majority of patients in most countries cannot access

specialized stroke care.

The article focuses on current treatment guidelines and

new therapeutic prospects, emphasizing the importance of

early intervention and the need for a multidisciplinary

approach to the management of stroke patients.1

* Corresponding author.E-mail address: [email protected] (G. Loria).

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier .com/locate /apme

a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 2 8e3 3 6

0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.http://dx.doi.org/10.1016/j.apme.2013.11.002

2. Successful care of acute stroke patientsrelies on a four-step process

(i) Prompt recognition and reaction to warning signs.

(ii) Immediate use of emergency services.

(iii) Priority transport with notification of the receiving

hospital and

(iv) Rapid and accurate diagnosis and intervention at the

hospital. This ‘chain of recovery’ has also been

described as a five-stage process, comprising the five Rs

of successful stroke management: recognition (of

symptoms), reaction (emergency services are called),

response (medical assessment), reveal (brain imaging)

and Rx (treatment initiation).1

3. Emergency department assessment

Once a diagnosis of acute ischemic stroke is suspected, the

duration since symptom onset should be determined as

accurately as possible, as time from onset is the single most

important determinant of therapeutic options. Patients

arriving at hospital with a symptom onset of <3e4.5 h should

be evaluated for potential treatment with rt-PA, although a

‘door to needle time’ of around 60 min usually means a hos-

pital arrival time within 2 h for rt-PA candidates.1

Every minute counts in brain stroke e “Time” has always

been an essential component in the early treatment and man-

agement of stroke.

Urgent and early treatment of acute ischemic stroke holds

a better promise of better neurological outcomes after acute

ischemic stroke.

Fig. 1 e NINDS* and ACLS** recommended stroke

evaluation time benchmarks for potential thrombolysis

patient.8

Fig. 2 e Acute stroke algorithm.

a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 2 8e3 3 6 329

Guidelines focus on a multidisciplinary team of healthcare

professionals including pre-hospital personnel (EMS), ED

physicians, nurses, inpatient nurses, stroke team members,

general medicine physicians, hospital administrators, and

ancillary healthcare personnel.

The goal for the acute management of patients with stroke

is to stabilize thepatient and to complete initial evaluation and

assessment, including imaging and laboratory studies, within

a definitive time period of patient arrival to the hospital.

The reasons for the success depend on multidisciplinary

approach of improved prevention and improved care within

the early hours of acute stroke. To continue encouraging

trends, the public and healthcare professionals must remain

vigilant and committed to improving overall stroke care.2

4. Goals for early management of acutestroke

The goals for early management of patients with acute stroke

are to stabilize the patient and to complete initial evaluation

and assessment, including imaging and laboratory studies,

Fig. 3 e Pathway timelines.


within a definitive time period of patient arrival to the hospital

(Fig. 1).2,3 Critical decisions focus on the need for intubation,

blood pressure control, and determination of risk/benefit for

thrombolytic intervention.

The goal of these guidelines is to limit the morbidity and

mortality associated with stroke. The guidelines support the

overarching concept of stroke systems of care and detail

aspects of stroke care from patient recognition; emergency

medical services activation, transport, and triage; through the

initial hours in the emergency department and stroke unit.

The guideline discusses early stroke evaluation and gen-

eral medical care, as well as ischemic stroke, specific in-

terventions such as reperfusion strategies, and general

physiological optimization for cerebral resuscitation.4,5

Fig. 4 e Stroke activation system e process mapping.


Fig. 5 e Golden hour clock: started upon patient arrival & suspected stroke.7

Fig. 6 e Stroke operational unit.


Fig. 7 e Paradigm shift: early management of acute stroke over the years.


5. Acute stroke program: a multidisciplinaryteam approach for early management of acutestroke cases at Apollo Hospitals, Hyderabad

Being an “Acute Stroke e JCI Clinical Care Program Certified

Centre”, Apollo Hospitals, Hyderabad had an amplified need in

timely management of acute stroke cases efficiently & effec-

tively and thus reducing the morbidity & mortality rates,

focusing on better patient outcomes.

While Time plays a chief role from arrival of the patient till

discharge, and in every step starting from identification of

symptoms, availability of Neuro-physician & Radiologist,

emergent diagnostics & investigations (CT & MRI scan, Blood

samples and swallow tests on time), Early specific treatments

(thrombolisation, others), availability of healthcare providers

(Physiatrist, Physiotherapy, Dietician, Medical Social Worker

and Occupational therapist), following initiatives were put in

place for a timely & efficient management.

Fig. 8 e Graphical representation of the timelines of a sample case study.

Fig. 7 e (continued).


� Identified & formed a multidisciplinary acute stroke team

consisting of

� Emergency Physicians.

� EMS Paramedics.

� Neuro-Physicians.

� Radiologists.

� Laboratory Doctors & Technicians.

� Stroke Doctor.

� Stroke Nurse.

� Stroke Unit Doctor.

� Dietician.

� Rehabilitation Team e Physiatrist, Physiotherapist,

Occupational therapist & Speech therapist.

� Medical Social Worker.

� Quality Coordinators (Clinical & Non Clinical).

� Acute stroke algorithm developed (Fig. 2).

� Acute stroke clinical pathway developed based on evi-

dence-based guidelines taken from the Brain Attack

Coalition Thomas Jefferson University Hospital: Acute

ischemic stroke critical pathway card.6 Modified and

tailored to meet the needs of the Indian population

(Fig. 3).

� Acute stroke pathway mapping developed (Fig. 4).

� Acute Stroke Activation System/Acute Stroke SMS Alert

system: SMS alert to acute stroke team on patient arrival

with patient details, to all the stroke team members upon

patient’s arrival.

� Golden hour clock in the ER (Fig. 5)e Patient suspectedwith

stroke, the clock is started and the timings are recorded.

� Operational stroke unit (Fig. 6).

� Timelines with benchmarks (Fig. 7) (Fig. 8).

� Acute stroke clubs for stroke survivors.

� Performance improvement measures.

� In hospital training programs.

� Stroke campaigns for community awareness.

� Apollo stroke clubs for stroke survivors.

� Learning from the misses/hitches e Continuous CMEs &

stroke committee meets.

There is no question that time is brain. The faster someone

calls EMS, arrives to the hospital and receives treatment, the

greater the likelihood of survival and reduced disability.

The stroke team at Apollo Hospitals, Hyderabad is aware of

this fact and is constantly striving for quality improvement.

The idea of bringing in a platform where everyone could

come together as a team at the very point of patient arrival into

the hospital and coordinate in the entire care process till

discharge and follow ups.

The objective was to streamline the entire process for

timely management, addressable of issues on time at the

point of care, “Acute Stroke SMS Alert System”.

Concern was to bring in quality care measurable for acute

stroke protocols, made more effective and efficient in delivering

quality patient care at the earliest. Full proof mechanism to be

in place to check and correct errors instantaneously.

A lot can be done to prevent and treat stroke, rehabilitate

those who suffer stroke, while professional and public aware-

ness are the first steps to act on time.

6. Conclusion

All of the above treatment advances are based on immediate

intervention, underlining the urgency of stroke recognition

and early treatment. A systematic multidisciplinary protocol

based acute stroke care management system, can reduce the

mortality & morbidity of the patients affected with acute

stroke.

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448697/.2. http://stroke.ahajournals.org/content/suppl/2013/01/29/STR.

0b013e318284056a.DC1/Executive_Summary.pdf.3. Adams Jr HP, del Zoppo G, Alberts MJ, et al. Guidelines for the

early management of adults with ischemic stroke: a guidelinefrom the American Heart Association/American StrokeAssociation Stroke Council, Clinical Cardiology Council,Cardiovascular Radiology and Intervention Council, and theAtherosclerotic Peripheral Vascular Disease and Quality ofCare Outcomes in Research Interdisciplinary Working Groups:the American Academy of Neurology affirms the value of thisguideline as an educational tool for neurologists. Stroke. May2007;38(5):1655e1711.

4. Guidelines for the early management of patients with acuteischemic stroke: a guideline for healthcare professionals fromthe American Heart Association/American Stroke Association.

Best practices for stroke management at Apollo Hospi-

tals, Hyderabad.

� Acute stroke protocols.

� Adherence to timelines.

� Acute stroke activation system/stroke alerts e SMS system.

� Dedicated neuro team.

� Dedicated stroke unit & tracheotomy ward e Operational

stroke unit.

� Controlled supervision.

� Medical social worker counseling.

� Post stroke follow Up e Walk-in, Telephonic.

� Stroke clubs for stroke survivors: talks, activities, sharing

experiences etc.

� Stroke campaigns for community awareness.

� Acute stroke tracers for tracking the cases e team based

approach with focus on quality.

� Focused stroke rounds with Interdisciplinary team & neuro-

physicians.


Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ,Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI,Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M,Yonas H; American Heart Association Stroke Council; Councilon Cardiovascular Nursing; Council on Peripheral VascularDisease; Council on Clinical Cardiology.

5. http://stroke.ahajournals.org/content/44/3/870.6. http://www.stroke-site.org/pathways/tjuh_pathways.html.7. http://www.activase.com/resource-center/image-library-

golden-hour-images.jsp.8. http://emedicine.medscape.com/article/1159752-

overview#aw2aab6b2.


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Early management of acute ischemic stroke cases

Health & Medicine

Transcript of Early management of acute ischemic stroke cases