Uttar Pradesh is the cradle of Indian culture, a land steeped in history and cultural riches. The oldest inhabited region in the world, it boasts iconic landmarks like the Taj Mahal and the spiritual city of Varanasi. The Himalayas border the state to the north, with the smaller Vindhya range in the south, but between these mountains lies a vibrant tapestry of diverse traditions, where every corner tells a story through art, music, and cuisine.
Uttar Pradesh is the fourth largest state in India and the most populous, with its estimated 239 million people making up one sixth of the total population. The state is divided into 18 divisions which are in turn divided into 75 districts with 106,747 villages. The average population density of 828 people per square kilometer creates the need for a robust, organized, and strategic approach to providing essential health care, minimizing complications, and improving treatment for stroke patients who reach hospitals in time.
The demands on healthcare are magnified by the fact that neighboring states are almost equally large. They are Bihar in the east, Haryana and Rajasthan in the west, Nepal, and Uttarakhand in the north by, and Madhya Pradesh in the south.
Moving one stone at a time
Stroke incidence in Uttar Pradesh can be as high as 340,000 per year. At least 230 stroke-ready centers are needed to cover the 30 percent of the population with access to healthcare. Covering the entire population at risk for stroke would require approximately 755 stroke-ready hospitals.
Due to lack of infrastructure and a shortage of appropriately trained staff, the number of stroke centers falls well short of these targets.
In a resource-challenged scenario with budget limitations and demand schedules, stroke care optimization is a Herculean task. But Angels consultant Ravish Upadhyay sees evolving a stroke-ready state as an opportunity for which he has successfully courted the support of hospitals and key decision-makers.
Starting in Varanasi in 2021, he identified 20 hospitals in six cities located in the eastern part of Uttar Pradesh, that were equipped to support a stroke survice. Then he set out to topple the barriers one by one.
Some of the challenges were familiar ones – that were treatment delays and missed opportunities as the result of busy emergency departments, the absence of a stroke protocol, a lack of prioritization, a shortage of trained staff and a want of motivation. But the biggest challenge was changing mindsets. Ravish had to demonstrate to healthcare providers that significant numbers of patients did arrive within the therapy window for thrombolysis and convince them that it was therefore imperative that they optimize their stroke pathway.
Holding up a mirror
Ravish based his case on data collected from the hospitals, and initiated simulation training to rally stakeholders around the objective of improving the stroke pathway. These simulations took place late in the evening, when there were fewer stroke champions to supervise proceedings. This would give him insight into the standard of care around the clock.
Simulation training was piloted at five hospitals – Apex Hospital, Galaxy Hospital and the Neurocity Hospital in Varanasi, Lifeline Hospital in Azamgarh, and Anand Hospital in Prayag Raj. What Ravish hoped to observe was the hospitals’ readiness for stroke treatment, including their door-to-treatment and door-to-CT times, their stroke severity evaluation processes, and their use of checklists.
The debriefings that followed the simulations were eye-openers as Ravish highlighted gaps that were causing treatment delays. These events helped build consensus around improving the stroke pathway and capacity building across departments. A team was also assigned in each hospital to oversee the development and management of a stroke database.
These are some of the key mandates Ravish initiated with the hospitals:
- Creating a high impact team requires close collaboration and connection among a small team of stakeholders in. To this end a WhatsApp group of stakeholders must be created for continuous knowledge sharing.
- A training calendar must be shared via the admin department (a top-down approach) for attendees to ensure they are available.
- Staff who attend training sessions must complete the course and should be required to remain in their positions for at least eight months following completion of the training. (This was proposed as a measure to overcome challenges arising from staff turnover and short contracts.)
- Responsibility must be shared and distributed among department heads so ensure continuous emphasis on training completion and tools utilization.
- Flexible training hours should be available for both face-to-face and virtual and peer-learning programs, to accommodate fixed working hours and facilitate ownership of the process.
- Monitoring tools like checklists, the Helsinki poster and the RES-Q registry should be implemented for continuous progress monitoring.
- Hold regular stand-up meetings with all stakeholders present to address obstacles and effectiveness.
- Celebrate awards and certification with all stakeholders to improve morale.
Tasting success
These efforts to improve stroke care in these pilot hospitals not only helped Ravish to build confidence in himself. By sharing examples of best practice from these hospitals he has managed to expand the network of stroke-ready hospital. Having set out with a goal of 20 hospitals in 2021, there are now 65 hospitals in the stroke network in Uttar Pradesh that have partnered with Angels. In many cases the investment in training has gone hand in hand with improvements in medical infrastructure, such as the establishment of dedicated stroke units and better-equipped ambulances.
It is another measure of the success of this strategy that hospitals in Uttar Pradesh have so far won 16 WSO Angels Awards. First among this line-up of stars is Medanta Hospital in the capital city, Lucknow, whose nine awards includes four diamonds. Lifeline Hospital and Research Centre in remote Azamgarh has won three consecutive diamond awards, and there have been two awards each for the Neurocity Hospital in Varanasi and King George’s Medical University in Lucknow.
Uttar Pradesh is a challenging state due to strong political and cultural influences. For Ravish the journey so far has been a test of leadership, passion, and adaptability. He remains true to his goal of ensuring “every stroke patient receives the same standard of treatment” and the belief that success breeds success.
In the words of India’s veteran cricket captain Shree Kapil Dev, “Taste the success once, your tongue wants more”. The legacy continues!
