Background and Aims: Challenges in stroke care exist at multiple levels. In India, medical colleges are crucial in connecting rural and tertiary care public health systems. Our study aims to implement a uniform stroke care pathway (USCP) and assess its sustainability. Methods: IMPETUS Stroke was a multicentric, prospective, multiphase, mixed method, quasi experimental implementation study conducted at 22 government funded medical colleges to examine the changes in a select set of stroke care related indicators over time. It included a pre-implementation phase (Phase-1), followed by an implementation phase (Phase-2) where residents and nursing officers and caregivers were trained and Phase 3, where the sustainability of the USCP was assessed. Results: Patient recruitment in each phase was n=2,018 (19.8%), n=2,179 (21.3%), and n=5,996 (58.8%). Mean age was 59-years and males were higher. Ischemic stroke constituted the largest proportion (60-62%) in all phases. In phase-2, a total of 2103 residents, 2199 nursing officers and 6038 caregivers were trained. Nine of the 22 sites (40%) established their first-ever stroke units. Key stroke care indicators improved from the phase-1 to phase-3: at admission, NCCT (69.6%, 78.1% and 77.0%), CT-angiograms (18.2%, 25.3% and 38.4%), NIHSS (20.3%, 23.7% and 33.1%), thrombolysis rates (39.2%, 65.8% and 70.7%) (p-trend<0.001). The average door-to-CT time significantly decreased (p-trend<0.001), in-hospital stroke management in select indicators improved significantly (p-trend<0.001), in-hospital mortality decreased from 19.4% to 13.5% (p-trend<0.001) and three-months good functional outcome (mRS:0-2) increased from 41.6% to 46.0% (p-trend<0.001) across the phases. Conclusion: The data presented holds significance in showing the effect of implementation in improving stroke services and patient outcomes.
Gupta et al. (Thu,) studied this question.