The document discusses protocols and guidelines for the early management of acute ischemic stroke cases at Apollo Hospitals in Hyderabad, India. It outlines the multidisciplinary approach used, including establishing an acute stroke team, developing treatment algorithms and clinical pathways, and implementing systems to reduce time-to-treatment such as an acute stroke alert SMS system. The goals are to complete initial evaluations, imaging, and assessments quickly and provide urgent interventions and specialized stroke care to limit mortality and morbidity from stroke.

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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 Senior Executive Quality, Apollo Hospitals, Hyderabad, India
b Group 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: 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. a pol l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 2 8 e3 3 6 329
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
(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.

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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,

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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 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

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Fig. 5 e Golden hour clock: started upon patient arrival & suspected stroke.7
Fig. 6 e Stroke operational unit.

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

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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 & 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.

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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 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.
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 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.
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.

10. 336 a p o l l o me 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-library-golden-
hour-images.jsp.
8. http://emedicine.medscape.com/article/1159752-
overview#aw2aab6b2.

11. Apollo hospitals: http://www.apollohospitals.com/
Twitter: https://twitter.com/HospitalsApollo
Youtube: http://www.youtube.com/apollohospitalsindia
Facebook: http://www.facebook.com/TheApolloHospitals
Slideshare: http://www.slideshare.net/Apollo_Hospitals
Linkedin: http://www.linkedin.com/company/apollo-hospitals
BBlloogg:: http://www.letstalkhealth.in/