Barriers to Effective Prehospital and Hyperacute Stroke Care in India: A Physician Perspective

Abstract

Introduction:

The incidence of stroke is increasing in India. Prehospital stroke care is crucial for reducing stroke morbidity and mortality, but its implementation in India faces several challenges. Limited original research exists on prehospital stroke care in India, making it essential to identify the problems in implementing effective prehospital stroke care.

Methods:

A web-based survey was conducted among registered medical practitioners in India who treat acute stroke. The survey questionnaire was developed in English and included 26 questions divided into five parts: questions about the physician’s practice setup/hospital in India, perception of community awareness, existing prehospital care/systems, in-hospital stroke care availability, and specific issues faced.

Results:

Eighty-three doctors in India participated in the survey (43% response rate). Most of the respondents worked in private hospitals (68%) and urban areas (76%). While 89% of hospitals had ambulance services, over 33% reported that patients had to pay for ambulance transport. Among respondents, 12% reported a community stroke care network, with infrequent prehospital procedures such as random blood glucose measurement (22%), stroke identification (15.7%), “last seen normal” documentation (14.5%), and low prehospital notification to hospitals (5%). Delays in referral from peripheral centers were reported by 73% of respondents. Most hospitals had standard operating procedures (SOPs) (84%), computed tomography (CT) (94%), magnetic resonance imaging (MRI) (85%), and offered intravenous thrombolysis (IVT) (77%). However, 24 h availability of CT was reported only by 6%, MRI by 19% and IVT by 12%. Nearly half (45%) reported treatment with thrombolysis was not covered by insurance. Mechanical thrombectomy was available in 34% of hospitals and 63% of hospitals conducted in-hospital audits for stroke patients.

Conclusions:

The capabilities of stroke-catering hospitals in urban settings are encouraging, with many having SOPs, imaging capabilities, and thrombolysis and mechanical thrombectomy services. However, there is much room for improvement, in making the essential stroke care services financially accessible to all and available around the clock.

INTRODUCTION

Stroke is a major global health challenge, characterized by a disturbance of cerebral function that can lead to disability or death. Despite advancements in stroke diagnosis and treatment, it remains a leading cause of disability and the second leading cause of death worldwide.[1] The lifetime risk of developing a stroke has increased by 50% over the past 17 years and now 1 in 4 people is estimated to have a stroke in their lifetime. In India, stroke prevalence rates vary between rural and urban areas, highlighting the need for tailored stroke management strategies, adapted to address the unique risk factors and health-care challenges present in each of these settings.[2]

Current stroke treatment options include intravenous thrombolysis and endovascular therapy with mechanical thrombectomy, which aim to reverse the effects of stroke within a limited time window.[3] Quick access to these therapies is crucial for successful outcomes. However, delivering timely prehospital management of stroke is challenging, particularly in developing countries like India. Ensuring prehospital management of stroke is quite difficult even in developed countries where living alone, nocturnal onset and a past history of stroke were prominent factors causing delay in treatment.[4,5] In developing nations, factors such as large rural population, poor access to healthcare and imaging modalities, and transportation difficulties contribute to delay in treatment. India also has striking diversity in terms of quality of healthcare, socioeconomic status, and education with a distinct rural–urban divide.[6,7] These factors vary in importance across states and regions.[6,7,8,9] As a preliminary step in conducting a situational analysis of the region, our survey aimed to understand the perspectives of physicians regarding the barriers to effective stroke care in India.

METHODS

Study design, study setting, and duration of study

A web-based semi-structured, nonrandomized, exploratory survey was conducted to determine the barriers to stroke care as perceived by the physicians in their respective regions. We planned to survey registered medical practitioners in India who cater to stroke victims on a daily basis. We excluded those physicians who did not provide informed consent to undertake the questionnaire and those who did not complete the form or left >90% of questions unanswered, from which no meaningful data could be abstracted.

The survey did not employ randomization in selecting participants. Instead, it relied on convenience sampling based on personal contacts within the medical community. This approach was chosen due to the exploratory nature of the study and the practical constraints of reaching a wide range of physicians across different regions. Ethical committee clearance was not sought since this was a purely voluntary online survey, with less than minimal risk where there are no linked identifiers.

Development and pretesting

The questionnaire was developed by members of the research group (PR, SVA) from multiple group discussions, in English. The questions were phrased carefully to reduce the chances of possible misinterpretation since the survey population’s first language was not English. English was chosen as the language of the survey since the current medical curriculum in India was the same. The group discussed and resolved to continue with a relatively elaborate questionnaire (26 questions, 24 multiple choice, and 2 open-ended questions) since it was a convenience sample based on personal contacts [Table 1]. We resolved to have good-quality survey data with more data parameters, even if the response rate was low.

Table 1.

Characteristics of the participating physicians in the survey (n=83)

Respondent physician details	n (%)
Current expertise in stroke (years)
5–10	27 (32.5)
<5	36 (43.4)
>10	20 (24.1)
Physician specialty
Emergency medicine	52 (62.7)
General medicine	15 (18.1)
Neurology	7 (8.4)
Other specialties	9 (10.8)
Hospital type
Private	56 (67.5)
Government	23 (27.7)
Public–private cooperative	4 (4.8)
Hospital location
Urban	63 (75.9)
Rural	17 (20.5)
Suburban	3 (3.6)
Indian states
Andhra Pradesh	23 (27.7)
Kerala	14 (16.9)
Karnataka	14 (16.9)
Maharashtra	6 (7.2)
Other states	26 (31.3)

The Google Forms used for the survey was divided into six parts: an informed consent letter, questions about the physician’s practice setup/hospital in India, the physician’s perception of community awareness, existing prehospital care/systems, in-hospital details, and specific issues faced [Annexure 1].

An exploratory interview of experts was done to identify parameters of interest to design the structured questionnaire. Preliminary responses and feedback from the experts including the World Stroke Congress Taskforce Members on Prehospital Stroke Care were taken. Multiple revisions were done to minimize the length of the questionnaire and assess the physician’s comprehension of the parameters intended to be tested. A prepilot testing of the questionnaire was done among 10 emergency physicians of the same institute to get a rough idea of the variation in the response to different questions to justify moving ahead to a pilot test. A pilot test of one neurologist and one emergency physician (both with >5 years’ experience) from two different institutes was done and their feedback was collected, following which the questionnaire was finalized. The survey did not include adaptive questions. Participants had the option to review and change their responses before final submission.

Responding to the survey was voluntary and no individual patient information was requested, so ethical approval for the study was not required. No incentives were offered to the participants other than contribution to science to motivate participation.

Due to the pan-India nature of the survey, physicians were sent an online semi-structured survey on Google Forms. The questionnaire was sent out through E-mail and cross-platform, instant messaging, and voice-over-IP service (Whatsapp^®, Telegram^®). This strategy was chosen for its direct reach to medical practitioners involved in stroke care. No formal advertisements were used. While effective in engaging our target audience, this approach might limit the survey’s generalizability due to potential selection bias.

Sample size calculation

The sample population was calculated using Slovin’s formula. The total neurologist population in India was taken as the sample population.[10] Slovin’s formula: n = N (1 + Ne^2); where, n = number of samples, N = total population, e = error tolerance (level).

Each of the responses provided for the respective component was expressed either as a proportion of the total sample size or the highest and lowest extremes and mode was selected as the statistical average.

For an approximated population size of 1100, with a 5% margin of error, at 95% confidence interval, with an estimated 20% response rate, we initially intended to invite 1425 to achieve a sample of 285. Personal messages were forwarded to 189 individuals.

Time frame

Data collection commenced on August 27, 2022, and concluded by October 22, 2022, for a preplanned period of 6 weeks.

Variables

Statistical data analysis

Descriptive analyses of physician responses including, ambulance accessibility, and prehospital procedures, standard operating procedures (SOPs) in hospitals, diagnostic imaging capabilities, treatment options, and in-hospital audits. Thematic analysis of open-ended questionnaires was done to identify common barriers and solutions. Orange data mining Ver 3.34.0 was used for thematic data visualizations and statistical analysis done using Statistical Package for Social Sciences SPSS- ver 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, New York, United States).

RESULTS

Eighty-three physicians responded to the web-based survey (43% response rate), of which 63% were emergency physicians, and 18% were general physicians. More than half of the responding physicians worked in private hospitals, and nearly three-fourths were in urban localities [Table 1]. Among all the states of India, south Indian states were represented majorly in our sample [Figure 1].

Figure 1.

Survey response across India. Frequency of responses-state-wise instance count

Prehospital stroke care

Our study found that 89.2% of our sample population had access to ambulance services, but more than one-third of patients had to pay to use the ambulance [Table 2]. A total of 28 out of 83 physicians (34%) responded that most suspected stroke patients use an ambulance to reach their hospital. While 12% of respondents reported the presence of a community stroke care network, a limited number of prehospital procedures were regularly performed in the ambulance, including random blood glucose measurement (22%), stroke identification (15.7%), and documentation of “last seen normal” (14.5%). It was noted that prehospital notification to the hospitals was sent infrequently in our community (5%). Nearly two-thirds of the physicians informed us that most suspected stroke patients (66%) reach their hospital within the window period.

Table 2.

Prehospital stroke care available in the community

Prehospital care details	n (%)
Ambulance services available	74 (89.2)
Stroke patients using ambulance (>50% cases)	28 (33.7)
Other common modes of transport
Private owned vehicles	79 (95.2)
Hired taxi or cabs	59 (71.1)
Auto-rickshaw	48 (57.8)
Public transport	26 (31.3)
Community stroke care network present	10 (12)
Following procedures are regularly done in the ambulance
Random blood glucose measurement	18 (21.7)
Stroke identification	13 (15.7)
Documentation of “last seen normal”	12 (14.5)
Electrocardiography	9 (10.8)
Stroke scale utilization	5 (6)
Thrombolysis checklist	4 (4.8)
Patients reaching the hospital within the window period of intravenous thrombolysis (>75% cases)	55 (66.3)
Prehospital notification to hospitals	4 (4.8)

Capabilities of the hospitals catering to stroke patients

In the majority of hospitals, which accounted for more than 80%, a SOP was in place for the management of stroke patients. Most of these hospitals also had the necessary imaging capabilities for the diagnosis of stroke, with computed tomography (CT) being operational in 94% of them, although only 6% offered 24-h CT services. As for treatment options, intravenous thrombolytics (IVT) and mechanical thrombectomy setups were available in 77% and 34% of the hospitals, respectively. Furthermore, regular in-hospital audits for stroke patients were conducted in almost two-thirds of the hospitals [Table 3].

Table 3.

Detailed characteristics of the participating hospitals caring for stroke patients

Capabilities in the hospitals	n (%)	24-h availability, n (%)
SOP for stroke management
Yes	70 (84.3)	-
No	13 (15.7)	-
Facilities available for stroke care
Dedicated stroke units	28 (33.7)	15 (18)
Imaging facilities
CT	78 (94)	5 (6)
MRI	71 (85.5)	16 (19.2)
Treatment facilities
Intravenous thrombolytics	64 (77.1)	10 (12.1)
Mechanical thrombectomy	28 (33.7)	13 (15.7)
In-hospital audit for stroke care
Done regularly	52 (62.7)	-
Monthly	30 (36.1)	-
Quarterly	14 (16.9)	-
Yearly	8 (9.7)	-
Never	31 (37.3)	-
Insurance cover for thrombolysis
Yes	46 (55.5)	-
No	37 (44.5)	-

CT: Computed tomography, MRI: Magnetic resonance imaging, SOP: Standard operating procedure

Inter-hospital stroke transfer

Inter-hospital transfer of stroke patients posed challenges, as 42.2% of respondents reported occasional delays, 31.3% reported frequent delays, and 12% reported consistent delays. Written SOPs for inter-hospital transfer were reported as present and implemented by 19.3% of respondents, while 8.4% had written SOPs that were not implemented, and 72.3% lacked SOPs. Pretransfer procedures were regularly performed, including random blood glucose measurement (57.8%), documentation of “last seen normal” (22.9%), electrocardiography (39.8%), stroke scale utilization (8.4%), and thrombolysis checklist (7.2%) [Table 4].

Table 4.

Information regarding inter-hospital transfer of stroke patients

Inter-hospital transfer of stroke	n (%)
Are there delays in the referral of stroke cases by peripheral centers to the participating center?
Sometimes	35 (42.2)
Often	26 (31.3)
Occasionally	12 (14.5)
Always	10 (12)
SOP for inter-hospital stroke transfer
Written SOP present and implemented	16 (19.3)
Written SOP present, not implemented	7 (8.4)
No SOP available	60 (72.3)
Following procedures are regularly done before the inter-hospital transfer
Random blood glucose measurement	48 (57.8)
Documentation of “last seen normal”	19 (22.9)
Electrocardiography	33 (39.8)
Stroke scale utilization	7 (8.4)
Thrombolysis checklist	6 (7.2)

SOP: Standard operating procedure

The respondents were asked an open-ended question where they were prompted to specify any additional barriers they face, and they were also asked to comment on their top three priorities for solutions to improve stroke care in India.

In analyzing the responses, several common themes emerged. Approximately 60% of respondents stressed the urgent need for improved public awareness and education regarding stroke, while around 40% emphasized the significance of training health-care professionals, especially general practitioners, to better recognize and manage stroke cases. Approximately 50% highlighted the importance of prehospital stroke care, efficient emergency medical services (EMS), and early activation of stroke care protocols. About 30% of respondents suggested leveraging telemedicine, portable CT scans, and mobile stroke units to enhance stroke care and diagnosis. In addition, approximately 30% called for the establishment and reinforcement of dedicated stroke units and centers at various health-care facilities. Roughly 20% of respondents mentioned financial barriers and the necessity of affordable stroke care, including insurance coverage for thrombolytic treatment. Moreover, approximately 20% recommended improved coordination among health-care teams and the use of dedicated stroke helplines and referrals, with about 10% advocating for the early involvement of specialists such as neurologists and neurosurgeons. Finally, around 10% proposed utilizing various media channels, including TV, radio, and social platforms, to educate and raise awareness about stroke [Figure 2].

Figure 2.

Word cloud of participant responses identifying the problems and solutions required in bettering prehospital stroke care in India

When asked to summarize into three most critical solutions for enhancing stroke care in India, approximately 60% of respondents emphasized the need, for comprehensive public education, followed by physician training (highlighted by around 40% of respondents), and addressing cost and financial accessibility barriers (mentioned by roughly 20% of respondents) to ensure timely and effective stroke management.

DISCUSSION

Prehospital stroke care, which encompasses EMS, referral systems, and inter-hospital transfers, plays an essential role in delivering timely and effective care to patients with stroke. There are several barriers to delivering acute stroke care, as perceived by physicians treating acute stroke in the country. Addressing these barriers may require multidisciplinary approaches, such as educating the public, improving communication, and collaboration among stroke care team members, increasing access to specialized care, and improving resource allocation in remote areas.

Access to care

Access to timely and efficient prehospital stroke care is of paramount importance to ensure favorable patient outcomes. Ambulance services stand as a critical component in this process, facilitating rapid transportation of stroke patients to specialized medical facilities. Although approximately three-fourths of the surveyed population have access to these services, it is crucial to acknowledge that there are many regions in India with a nonexistent prehospital care system. In Andhra Pradesh when ambulance care was reported as “easily accessible,” “just that the people don’t call for it” from Tripura, Assam, the respondents uniformly said “they had no prehospital stroke care system.” Moreover, amongst those who had access to prehospital ambulance care, over one-third reported that patients have to pay out of their own pocket, for access. This raises concerns about equity and accessibility, potentially deterring individuals from seeking immediate medical attention during a stroke event.

Although the “scoop and run” strategy employed by Thailand EMS could be useful in this situation too, the importance of prehospital notification remains paramount, even for hospitals equipped to manage stroke cases.[11] This practice plays a pivotal role in mitigating delays in stroke care by helping in moving the pegs of essential stroke care. However, for this system to function effectively, individuals need to be aware of the occurrence of a stroke event and be willing to make the necessary call. The prominence of private-owned vehicles as a transportation mode for stroke patients highlights the challenges in getting professional medical care during these critical moments. Failure to recognize the symptoms of stroke is a pivotal factor in delayed presentation at hospitals.[12,13] Many have attributed the success and impactfulness of stroke care to the ability of the population in recognizing the symptoms when someone might be having a stroke.

Hence, community education is often suggested as a method of primary prevention of stroke-related mortality and disability.[13,14,15,16] Nevertheless, it is important to note that public education alone might not prompt individuals to call for ambulance assistance if such systems are nonexistent, and especially if people are unaware of the benefits such services entail, especially in India where the “wait for the family” approach is quite prevalent.[17]

Hospital capabilities

Hospital capabilities are a cornerstone of effective stroke care, significantly influencing patient outcomes. The results reveal a nuanced scenario in terms of hospital capabilities for stroke care. On the one hand, a substantial percentage of hospitals had implemented SOPs (84%), high availability of computed tomography (CT) facilities (94%), and the provision of IVT, (77%) are positive indicators of the potential for timely diagnosis and intervention. However, around-the-clock (24-h) availability of CT was reported only by 6%, magnetic resonance imaging by 19% and IVT by 12%. This lack of availability of critical resources unveils a gap between overall capacity and continuous accessibility. While most hospitals have functional imaging services, only a very small percentage of them were reported to be operational at night. As imaging is crucial in planning the next step of treatment in stroke, it is important that it is not restricted by time. This discrepancy, often missed during capacity assessment surveys and inspections, could potentially impact the timeliness of stroke care delivery.

The practice of regular in-hospital audits for stroke care (62.7% conducted regularly) stands as a testament to the hospitals’ commitment to maintaining high-quality standards. These audits, coupled with established SOPs, foster a culture of continuous improvement and ensure that stroke care aligns with best practices.

Inter-hospital transfer

Inter-hospital stroke patient transfer is a critical aspect of the stroke care pathway that merits careful consideration. Often in low and middle income country, the first point of contact is often quite away from the stroke center and appropriate and timely transfer could potentially save more brain cells. The observed delays, as reported by a significant portion of respondents, present a concerning issue that may impact the timeliness of receiving appropriate medical attention. A substantial proportion of respondents reported delays in referring stroke cases from peripheral centers to specialized stroke care units. Potential reasons behind these delays are multifaceted, possibly including inadequate infrastructure, lack of trained personnel, and communication gaps between referring and receiving centers.

Deficiencies in CT infrastructure were conspicuous in government hospitals including community health centers and primary ealth centers. Meanwhile, neighboring private hospitals boasted ready access to CT facilities, albeit accompanied by prohibitive costs for thrombolysis treatment. In this context, the presence of written SOP for inter-hospital transfers holds significance. These SOPs can act as a structured framework to streamline the transfer process, ensuring that vital information is communicated effectively and promptly, ultimately reducing delays and minimizing potential risks to patients. Furthermore, an analysis of the inter-hospital transfer process reveals the variability in the utilization of certain procedures before transfer, such as random blood glucose measurement, documentation of “last seen normal,” electrocardiography, and stroke scale utilization. These variations in practice highlight the need for standardized protocols to ensure consistent and comprehensive care during the transfer process.

Limitations and future research

While our study offers valuable insights into the obstacles facing effective prehospital stroke care in India from the viewpoint of physicians, it is essential to acknowledge that these findings are based on the perceptions of these physicians and may not reflect the ground reality. The sample size calculated was not achieved and those of the physicians who participated, may not fully represent the diverse perspectives of all health-care professionals involved in stroke care. In this study, the total neurologist population in India was used as a proxy for calculating the sample size. While this provided a feasible framework for our study design, it presents a notable limitation. Neurologists, while key in stroke care, are just part of a wider group of professionals managing stroke. This approach may not capture the full range of perspectives from other relevant specialists such as emergency physicians and general practitioners, potentially affecting the study’s comprehensiveness in reflecting diverse stroke management practices. The sampling also has a bias towards urban responders, potentially implying a nonresponse bias since physicians in remote areas might be less inclined to openly share their experiences. This discrepancy could be attributed to urban physicians experiencing the challenges of patient referral more acutely, given their position as the receiving end of such transfers.

Our study on prehospital stroke care revealed that only 12% of healthcare professionals were aware of community stroke care networks, and an equal percentage expressed uncertainty about their existence. The absence of a standardized definition for “community stroke care network” in our survey might have led to varied interpretations, affecting response reliability. However, this approach was intentionally adopted to underscore the ambiguity among physicians regarding the existence, absence, or need for these networks, highlighting a significant area for educational enhancement and awareness in prehospital stroke care.

In addition, the study respondents are mostly from southern states in India, with their focus on a specific geographic region might limit the generalizability of the findings to other parts of the country. Furthermore, the survey-based nature of the study may introduce response bias since it relies on the accuracy of self-reported information. Future research endeavors could extend beyond physician perspectives to encompass the experiences of patients and their families, offering a more comprehensive understanding of the challenges faced in seeking and providing prehospital stroke care, exploring the economic, infrastructural, and cultural factors contributing to the observed barriers that could inform targeted interventions and policy recommendations.

CONCLUSIONS

The physician perspective highlights challenges in ambulance services, hospital capabilities, and inter-hospital patient transfers. The significance of these findings lies in their potential to guide policy and practice improvements. By recognizing financial barriers to ambulance services, enhancing hospital resources, and streamlining inter-hospital transfers, we can significantly enhance the quality of prehospital stroke care in India’s health-care landscape.

Research quality and ethics statement

This was a survey-based study and no individual patient information was requested and so ethical approval was waived off. The authors followed applicable EQUATOR Network (https://www.equator-network.org/) guidelines during the conduct of this research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

ANNEXURE

Annexure 1: Survey questionnaire

Setting

Information about practicing setup/hospital where you practice in India

1. Which state do you practice in?

   ________________________

2. Which district do you practice in?

   ________________________

3. Practice setting

   • Urban
   • Rural

4. Details about hospital

   • Private
   • Government
   • Other

5. Number of beds in your hospital

   • <30
   • 30–100
   • 100–500
   • 500–1000
   • >1000

6. What is your current level of expertise in stroke care? (after MBBS)

   • <5 years
   • 5–10 years
   • >10 years
   • Please mention the years if you wish to be specific: ____

7. Your primary specialty?

   • Primary care physician (MBBS graduate)
   • General physician (MD or DNB general medicine)
   • Emergency medicine (MD or DNB emergency medicine)
   • Neurology (MD or DNB neurology)
   • Neurosurgery (MCh or DNB neurosurgery)
   • Emergency physician (any other postgraduation degree)
   • Other: ______________________

8. Stroke care capabilities/capacity: Which of these facilities are available at your center for stroke victims? (select all that is applicable)

   • CT facility
   • MRI facility
   • IV thrombolytics
   • Mechanical thrombectomy
   • Dedicated Stroke unit
   • Mobile stroke units
   • Other: _______________

9. If any of the above that you checked is not available 24 × 7 at your center, please specify:

   • CT facility
   • MRI facility
   • IV thrombolytics
   • Mechanical thrombectomy
   • Dedicated Stroke unit
   • Mobile stroke units
   • Other: _______________

   Physicians perspective on community awareness

10. Are you conducting regular community awareness programs pertaining to the identification of stroke?

    • Monthly
    • Quarterly
    • Twice a year
    • Yearly
    • Less than once a year
    • Not involved

    Prehospital care/system

    Through this section, we intend to understand the existing prehospital care available in your hospital

11. Does your population have access to an emergency ambulance service?

    • Yes
    • No

12. How often do stroke patients come to your hospital using ambulance/EMS?

    • Regular (>75%)
    • Often (50%–75%)
    • Sometimes (25%–50%)
    • Rarely (<25%)

13. What are the other commonly used modes of transport that stroke patients use in your community? (tick all that is applicable)

    • Public transport
    • Private owned vehicles
    • Hired taxi/cab
    • Auto rickshaw
    • Others: _______________________

14. How often do you get a prehospital notification of stroke patient’s arrival?

    • Regular
    • Often
    • Sometimes
    • Rarely
    • Never

15. Is there a stroke care network in your community transferring patients directly to stroke care units?

    • Yes
    • No
    • I do not know

16. Mark how often the following are done in the ambulance before the arrival of a stroke victim at your center?

    • Blood glucose: Regular/often/sometimes/rarely/never
    • ECG: Regular/often/sometimes/rarely/never
    • Stroke identification: Regular/often/sometimes/rarely/never
    • Documentation of last seen normal: Regular/often/sometimes/rarely/never
    • Stroke Scale use: Regular/often/sometimes/rarely/never
    • Thrombolytic checklist use: Regular/often/sometimes/rarely/never

17. Is there the following care done by the referring hospital before referring to your center? (if applicable)

    • Blood glucose: Regular/often/sometimes/rarely/never
    • ECG: Regular/often/sometimes/rarely/never
    • Stroke identification: Regular/often/sometimes/rarely/never
    • Documentation of last seen normal: Regular/often/sometimes/rarely/never
    • Stroke scale use: Regular/often/sometimes/rarely/never
    • Thrombolytic checklist use: Regular/often/sometimes/rarely/never

18. Are there delays in identifying and referral by peripheral centers to your center for stroke?

    • Occasionally/rarely
    • Sometimes
    • Often
    • Always

19. Does your hospital have a standard operating procedure for the transfer of stroke patients from nearby hospitals?

    • Written SOP present
    • No SOP
    • Written SOP present, not implemented
    • I do not know

    In-hospital details

20. Does you hospital have a protocol for the management of stroke patients?

    • Yes
    • No
    • I do not know

21. What percentage of your patients reach the hospital in the window period for intravenous thrombolysis (<4.5 hours)?

    • <25%
    • 25%–50%
    • 50%–75%
    • 75%–100%
    • I do not know

22. How regularly do you audit stroke patients?

    • More than once a month
    • Monthly
    • Quarterly
    • Yearly
    • Never

23. Are there insurance policies that cover thrombolysis among your patients?

    • Yes
    • No
    • Some might have
    • I do not know for sure

    Issues faced

    In this section, we intend to understand the barriers to thrombolytic therapy faced from a physician’s perspective

    Please answer keeping your work/setting/hospital in mind

24. Which of the following are the barriers to stroke care in your setting (strongly agree/agree/maybe/disagree/strongly disagree)

    • Lack of public awareness about stroke
    • No stroke-specific prehospital activation number
    • Lack of prehospital care/EMS
    • Lack of nearby stroke care capable hospitals in my community
    • Lack of awareness among the medical fraternity in recognizing stroke
    • Lack of imaging facility
    • Lack of radiologist availability 24/7
    • Lack of neurologist availability 24/7
    • Lack of designated stroke centers
    • Financial constraints
    • Lack of Insurance coverage schemes available for thrombolysis

25. If there are other barriers, please specify the issues you face:

    ____________________________________________________________________

26. Comments: (Please let us know THREE important solutions you think we should work toward in India):

    ____________________________________________________________________