Assessment of Acute Stroke Care, Stroke Metrics and Patient Outcomes: Analysis from the Pre-implementation Phase of the IMPETUS Stroke Study

Shweta Gupta¹Rohit Bhatia^1*Padma Vasantha¹Partha Haldar²mamta b Singh¹Manish Salunkhe¹Imnameren Longkumer¹Deepshikha Prasad¹Risha Sarkar¹Vijay Sardana³Dilip Maheshwari³Bharat Bhushan³Alok Verma⁴Nikhil Dongre⁴Nikhil Sahu⁴Samhita Panda⁵Sucharita Anand⁵Biman Kanti Ray⁶Inder Puri⁷Paresh Zanzmera⁸Amit Gamit⁹Sanjeev Kumar Bhoi¹⁰Menka Jha¹⁰Priyanka Samal¹⁰Seepana Gopi¹¹Garuda Butchi Raju¹¹Amit Bhardwaj¹²Raminder Singh Sibia¹³Rupinderjeet Kaur¹³Ashutosh Tiwari¹⁴Niraj Kumar¹⁴Mritunjai Singh¹⁴Kiran Bala¹⁵Surekha Dabla¹⁵M.P.S Chawla¹⁶Jyoti Garg¹⁷Shishir Chandan¹⁸Rupali Malik¹⁹Thomas Iype²⁰Chithra P²⁰Ashok kumar²¹Abhay Ranjan²¹Ravinder Garg²²Sulena Sulena²³Pramod Darole²⁴Gurpreet Chhina²⁵Shalin Shah²⁶Sudhir Shah²⁶Gajendra Ranga²⁷Smita Nath²⁷Alvee Saluja²⁸L H Ghotekar²⁹Venugopalan Y Vishnu¹Roopa Rajan¹Anu Gupta¹Deepti Vibha¹Rajesh Kumar Singh¹Awadh kishor Pandit¹Ayush Agarwal¹Amit Rohila³⁰Pushpinder Khera³¹Sarbesh Tiwari³¹S Bhaskar³²Mayank Garg³²Anupam Dey³³Satyabrata Guru³⁴Suprava Naik³⁵T.Sateesh Kumar¹¹Minakshi Dhar³⁶Naman Agrawal³⁷Mayank Patel²⁶Pranav Joshi²⁶

• ¹Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
• ²Department of Community Medicine, All India Institute of Medical Sciences, New Delhi, India
• ³Department of Neurology, Government Medical College Kota, Kota, India
• ⁴Department of Neurology, GSVM Medical College, Kanpur, India
• ⁵Department of Neurology, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
• ⁶Department of Neurology, Institute of Postgraduate Medical Education and Research Bangur Institute of Neurology, Kolkata, India
• ⁷Department of Neurology, Sardar Patel Medical College, Bikaner, India
• ⁸Department of Neurology, Government Medical College Surat, Surat, India
• ⁹Department of Medicine, Government Medical College Surat, Surat, India
• ¹⁰Department of Neurology, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, India
• ¹¹Department of Neurology, Andhra Medical College, Visakhapatnam, India
• ¹²Department of Neurology, Dr Rajendra Prasad Government Medical College, Kangra, India
• ¹³Department of Medicine, Government Medical College Patiala, Indra Puri Colony, India
• ¹⁴Department of Neurology, All India Institute of Medical Sciences Rishikesh, Rishikesh, India
• ¹⁵Department of Neurology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
• ¹⁶Department of Medicine, Atal Bihari Vajpayee Institute of Medical Sciences & Dr Ram Manohar Lohia Hospital, New Delhi, India
• ¹⁷Department of Neurology, Atal Bihari Vajpayee Institute of Medical Sciences & Dr Ram Manohar Lohia Hospital, New Delhi, India
• ¹⁸Department of Neurology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
• ¹⁹Department of Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
• ²⁰Department of Neurology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, India
• ²¹Department of Neurology, Indira Gandhi Institute of Medical Sciences, Patna, India
• ²²Department of Medicine, Guru Gobind Singh Medical College and Hospital, Faridkot, India
• ²³Department of Neurology, Guru Gobind Singh Medical College and Hospital, Faridkot, India
• ²⁴Department of Medicine, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Mumbai, India
• ²⁵Department of Medicine, Government Medical College Amritsar, Amritsar, India
• ²⁶Department of Neurology, Sardar Vallabhbhai Patel Institute of Medical Sciences and Research, Ahmedabad, India
• ²⁷Department of Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
• ²⁸Department of Neurology, Lady Hardinge Medical College, New Delhi, India
• ²⁹Department of Medicine, Lady Hardinge Medical College, New Delhi, India
• ³⁰Department of Medicine, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
• ³¹Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
• ³²Department of Neurosurgery, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
• ³³Department of Medicine, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, India
• ³⁴Department of Emergency Medicine, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, India
• ³⁵Department of Radiology, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, India
• ³⁶Department of Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, India
• ³⁷Department of Emergency Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, India

Background: Stroke is a major cause of death and disability in India. Many stroke patients seek care at government medical colleges but studies haven’t comprehensively assessed the quality of acute stroke care. This study aims to evaluate key indicators for optimal stroke care in the pre- implementation phase of implementation of an evaluation and treatment package for uniform stroke care (IMPETUS) study across 232 medical colleges in India. Methods: IMPETUS stroke is a multicentric, prospective, multiphase, mixed-methods, quasi- experimental implementation study, comprising three phases. During its pre-implementation phase, baseline assessment of stroke care was performed using pre-structured case report form, among prospectively enrolled acute stroke patients. Results: A total of 2,018 patients were enrolled during the pre-implementation phase. The mean (SD) age was 59.08 (14.4) years, with male preponderance (64.2%); 69.06% had an onset <24 hours, majority had ischemic stroke (60.1%), followed by intracerebral hemorrhage (38.4%). Key risk factors were hypertension, diabetes, smoking, alcohol and previous stroke. Imaging performed included non-contrast computed tomography (NCCT) (69.6%), computed tomography angiography (CTA) (25.618%) and magnetic resonance angiography (MRA) (24.614%). Intravenous thrombolysis (IVT) was administered in 39.2% eligible patients, predominantly with tissue plasminogen activator (tPA) (72%). In-hospital delay was the most common reason for not receiving thrombolysis (44.8%). The median door-to-CT, CT-to-needle and door-to-needle time were 95, 36.5 and 67 minutes respectively. Other important stroke care indices were also evaluated. In-hospital mortality was 19.4% and 33.1% patients achieved modified rankin scale (mRS) score 0–2 at 90-days. Conclusion: This comprehensive data provides a representative baseline status of acute stroke care in select medical colleges across India, which will be useful in comparing advancements during the implementation phase and improve policy making.