Implementation of a Physician-Based Stroke Unit in a Remote Hospital of North-East India-Tezpur Model

Abstract

Objective The study aims to determine the effects of implementing stroke unit (SU) care in a remote hospital in North-East India. Materials and Methods This before-and-after implementation study was performed at the Baptist Christian Mission Hospital, Tezpur, Assam between January 2015 and December 2017. Before the implementation of stroke unit care (pre-SU), we collected information on usual stroke care and 1-month outcome of 125 consecutive stroke admissions. Staff was then trained in the delivery of SU care for 1 month, and the same information was collected in a second (post-SU) cohort of 125 patients. Statistical Analysis Chi-square and Mann–Whitney U test were used to compare group differences. The loss to follow-up was imputed by using multiple imputations using the Markov Chain Monto Carlo method. The sensitivity analysis was also performed by using propensity score matching of the groups for baseline stroke severity (National Institute of Health Stroke Scale) using the nearest neighbor approach to control for confounding, and missing values were imputed by using multiple imputations. The adjusted odds ratio was calculated in univariate and multivariate regression analysis after adjusting for baseline variables. All the analysis was done by using SPSS, version 21.0., IBM Corp and R version 4.0.0., Armonk, New York, United States. Results The pre-SU and post-SU groups were age and gender matched. The post-SU group showed higher rates of swallow assessment (36.8 vs. 0%, p < 0.001), mobility assessment, and re-education (100 vs. 91.5%, p = 0.037). The post-SU group also showed reduced complications (28 vs. 45%, p = 0.006) and a shorter length of hospital stay (4 ± 2.16 vs. 5 ± 2.68 days, p = 0.026). The functional outcome (modified ranking scale) at 1-month showed no difference between the groups, good outcome in post-SU (39.6%) versus pre-SU (35.7%), p = 0.552. Conclusion The implementation of this physician-based SU care model in a remote hospital in India shows improvements in quality measures, complications, and possibly patient outcomes.

Strategies for Specialty Training of Healthcare Professionals in Low-Resource Settings: A Systematic Review on Evidence from Stroke Care

“…External to this review, expert opinion provided in other articles regards multidisciplinary SUs to be a gold standard in stroke care with numerous bene ts. 4,20,21 A key strength of the "train-the-trainer" approach is potential sustainability -the Indian study by John et al (2021) 17 and Wessex-Ghana 14 study by Johnson et al (2017) demonstrated that healthcare professionals can educate their co-workers upon training, and the Wessex-Ghana Stroke Partnership has appointed deputies to support clinical leaders with the aim of succession planning. Furthermore, while a train-the-trainer approach may be effective and implemented with existing human resources, successful approaches, such as in the Wessex-Ghana Stroke Partnership, have involved signi cant input from external healthcare expert professionals.…”

“…Training the Trainer for the Implementation of Multidisciplinary Stroke Units An Indian pre/post implementation study used a "train-the-trainer" approach to implement a stroke unit (SU). 17 The trainer (one physician) was trained by local experts for two hours via video conference (Skype), three times a week for four weeks. The trainer then conducted two-hour training sessions with healthcare professionals in nursing, physiotherapy, and occupational therapy for ve days per week over four weeks.…”

Rural Stroke Surveillance and Establishment of Acute Stroke Care Pathway Using Frontline Health Workers in Rural Northwest India: The Ludhiana Experience

“…Strengthening the stroke care systems requires a multidisciplinary approach, which includes dedicated infrastructure by training the ambulance crew, physician, nurses, and therapists to implement protocol-driven care [26]. Establishing stroke units in district-level hospitals will help improve key indicators like in-hospital secondary stroke prevention, swallowing assessment, mobility, and re-education [27]. Moreover, providing intravenous rtPA free of cost or by insurance coverage using the hub-and-spoke structure model can increase the thrombolysis rate [28].…”

Establishing Organized Stroke Care in Low- and Middle-Income Countries: From Training of Non-specialist to Implementation

“…10 A successful implementation of the non-specialist model was illustrated in Tezpur district, a remote area of Northeast India with improvements in quality measures and reductions in in-hospital complications. 11 Advances in technology can facilitate both training of nonspecialists and stroke care delivery. For example, telestroke offers the opportunity to provide stroke care in locations deprived of specialists physically on-call.…”