AUTHOR=Tunkl Christine , Paudel Raju , Bajaj Sunanjay , Thapa Lekhjung , Tunkl Patrick , Chandra Avinash , Shah Bhupendra , Karmacharya Balgopal , Subedi Ashim , Jalan Pankaj , Ghimire Pradesh , Ghimire Mahesh Raj , Dorje Gampo , Begli Nima Haji , Golenia Jessica , Gajurel Bikram Prasad , Shreyan Shirsho , Sharma Nooma , Krauss Alexandra , Pandian Jeyaraj , Fischer Thomas , van der Merwe Jan , Wick Wolfgang , Hacke Werner , Gumbinger Christoph 

TITLE=Implementing stroke care in a lower-middle-income country: results and recommendations based on an implementation study within the Nepal Stroke Project

JOURNAL=Frontiers in Neurology

VOLUME=Volume 14 - 2023

YEAR=2023

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2023.1272076

DOI=10.3389/fneur.2023.1272076

ISSN=1664-2295

ABSTRACT=BACKGROUND: 
Globally, the majority of strokes affect people residing in lower- and lower-middle income countries (LMICs) but translating evidence-based knowledge into clinical practice in regions with limited healthcare resources remains challenging. As a lower-middle income country of South Asia stroke care had remained a healthcare problem previously unaddressed at a national scale in Nepal. The Nepal Stroke Project (NSP) aims to improve acute stroke care in the tertiary health care sector of Nepal. We hereby describe the methods applied and analyze the barriers and facilitators of the NSP after 18 months. 

METHODS: 
The Nepal Stroke Project follows a four-tier strategy: 1) Quality improvement by training of health care professionals in tertiary care centers 2) Implementation of in - hospital stroke surveillance and quality monitoring system 3) Raising public awareness of strokes 4) Collaborating with political stakeholders to facilitate public funding in stroke care. We performed a qualitative, iterative analysis of observational data to analyze the output indicators and identify best practices. 

RESULTS: 
Both offline and online initiatives were taken to address quality improvement and public awareness. More than 1000 healthcare professionals across 9 tertiary care hospitals had attended 26 stroke related workshops conducted by Nepalese and international stroke experts.  Monthly webinars were organized, and chat groups were made for better networking and cross-institutional case sharing. Social media based public awareness campaigns reached more than 3 million individuals. Moreover, live events and other mass media campaigns were instituted. For quality monitoring The Registry of Stroke Care Quality (RES-Q) was introduced. Collaboration with stakeholders (both National and International) has been initiated.

DISCUSSION: 
We identified six actions which may support the development of tertiary care centers in a resource-limited setting to an essential stroke center. We believe that our experiences will contribute to the body of knowledge on translating evidence into practice in LMICs, although the impact of our results must be verified with process indicators of stroke care.