Organisational learning and the evolution of ischaemic stroke care in a resource-constrained public hospital: a seven-year case study

Health system constraints challenge the organisation of acute ischaemic stroke care in low- and middle-income countries (LMICs). While stroke unit effectiveness is well established in high-income settings, evidence gaps remain regarding the implementation and sustainability of organised stroke services in LMICs. This study aimed to describe and analyse the longitudinal implementation, adaptation, and sustainability of organised ischaemic stroke care in a public hospital in rural India. We conducted a seven-year mixed-methods longitudinal implementation case study at a 1,000-bed teaching hospital in Punjab, India. Data were collected from a prospective ischaemic stroke registry and routine process documentation. Quantitative data captured patient demographics, risk factors, treatments, process indicators, and outcomes for adults admitted with acute ischaemic stroke. Qualitative data included clinician narratives and contemporaneous process records, analysed thematically using the WHO Health System Building Blocks and RE-AIM frameworks to assess service evolution, adaptations, and sustainability. Lessons from cumulative implementation experience informed an emergent, practice-derived framework. Between 2017 and 2023, 1,880 adults with acute ischaemic stroke were registered. Admissions increased from 249 in 2017 to 402 in 2018, then declined during the COVID-19 pandemic (232 in 2020; 225 in 2021), and stabilised thereafter (204 in 2022; 208 in 2023) (χ² = 355.5, p < 0.001). The mean age was 60 ± 14 years, and 61% were males. Hypertension (n = 1428, 76%) and diabetes (n = 789. 42%) were the most common risk factors. Intravenous thrombolysis was administered to 3% (n = 62) of patients, with a median door-to-needle time of 83 min (IQR 70–96). Functional outcome data at three months were available for 1,504 patients (80%), of whom 73% (n = 1098) achieved independence (mRS 0–2). Qualitative analysis identified five interconnected organisational learning processes that formed a Stroke Unit Corridor (SUC), a coordinated, non-physical model that integrates emergency, imaging, and neurology services through standardised workflows rather than dedicated infrastructure. Organised ischaemic stroke care in resource-constrained public hospitals may be developed and sustained through iterative organisational learning, even without external funding or dedicated facilities. The SUC framework highlights how adaptive coordination using existing resources may strengthen hospital readiness for acute stroke care. However, hospital-level improvements alone may be insufficient, and strengthening pre-hospital, referral, and post-acute systems is likely necessary to improve access and stroke outcomes. Clinical trial number: not applicable.