Early management of acute ischemic stroke cases

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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.

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Early management of acute ischemic stroke cases

  1. 1. Early management of acute ischemic stroke cases
  2. 2. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 2 8 e3 3 6 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme 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,* a b Senior Executive Quality, Apollo Hospitals, Hyderabad, India Group Coordinator Quality, Apollo Hospitals, Hyderabad, India article info abstract Article history: Stroke is a medical emergency, with a mortality rate higher than most forms of cancer. It is Received 2 November 2013 the second leading cause of death in developed countries and is the most common cause of Accepted 5 November 2013 serious, long-term disability in adults. The incidence of stroke is increasing with the aging Available online 4 December 2013 of populations and hence there is a major challenge to health planners. Keywords: care in stroke units, modern brain imaging, and thrombolytic therapy, the modest benefit Ischemic stroke of acute aspirin in ischemic stroke clearly, a lack of awareness of the common symptoms Thrombolysis of stroke remains a major educational challenge, and the urgency of stroke treatment is Stroke survivors still poorly appreciated. Despite the proven benefit of stroke units, the majority of patients Evidence-based advances in acute stroke have included proof of the benefit of organized 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 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.1 * Corresponding author. E-mail address: gaurav_l@apollohospitals.com (G. Loria). 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
  3. 3. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 2 8 e3 3 6 329 (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. Fig. 1 e NINDS* and ACLS** recommended stroke evaluation time benchmarks for potential thrombolysis patient.8 2. Successful care of acute stroke patients relies 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 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 hospital 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 management of stroke. Urgent and early treatment of acute ischemic stroke holds a better promise of better neurological outcomes after acute ischemic stroke. Fig. 2 e Acute stroke algorithm.
  4. 4. 330 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 2 8 e3 3 6 Fig. 3 e Pathway timelines. 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 the patient 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 acute stroke 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,
  5. 5. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 2 8 e3 3 6 331 Fig. 4 e Stroke activation system e process mapping. 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 general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation.4,5
  6. 6. 332 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 2 8 e3 3 6 Fig. 5 e Golden hour clock: started upon patient arrival & suspected stroke.7 Fig. 6 e Stroke operational unit.
  7. 7. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 2 8 e3 3 6 Fig. 7 e Paradigm shift: early management of acute stroke over the years. 333
  8. 8. 334 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 2 8 e3 3 6 Fig. 7 e (continued). 5. Acute stroke program: a multidisciplinary team approach for early management of acute stroke 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 & effectively 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.
  9. 9. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 2 8 e3 3 6 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 evidence-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 suspected with 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. 335 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 awareness 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 Best practices for stroke management at Apollo Hospitals, 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 neurophysicians. All authors have none to declare. references 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 guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. May 2007;38(5):1655e1711. 4. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
  10. 10. 336 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 2 8 e3 3 6 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; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; 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-librarygolden-hour-images.jsp. 8. http://emedicine.medscape.com/article/1159752overview#aw2aab6b2.
  11. 11. A o oh s i l ht:w wa o o o p a . m/ p l o p a : t / w .p l h s i lc l ts p / l ts o T ie: t s / ie. m/o p a A o o wt rht :t t r o H s i l p l t p /w t c ts l Y uu e ht:w wy uu ec m/p l h s i ln i o tb : t / w . tb . a o o o p a i a p/ o o l ts d F c b o : t :w wfc b o . m/h A o o o p a a e o k ht / w . e o k o T e p l H s i l p/ a c l ts Si s ae ht:w wsd s aen t p l _ o p a l e h r: t / w .i h r.e/ o o H s i l d p/ le A l ts L k d : t :w wl k d . m/ mp n /p l -o p a i e i ht / w . e i c c a y o oh s i l n n p/ i n no o a l ts Bo : t :w wl s l e l . / l ht / w . t a h a hi g p/ e tk t n

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