# Bhutan's Response Against Increasing Number of Stroke (BRAINS): A Hybrid Type II Effectiveness-Implementation Study

## TL;DR

Bhutan improved stroke care by implementing a physician-led model, which boosted care quality and reduced in-hospital deaths, though staff retention remains a challenge.

## Contribution

Demonstrates the adaptation of organized stroke care in low-resource settings through a physician-led model with protocol standardization.

## Key findings

- Stroke care quality indicators adherence nearly doubled from 30% to 57% post-intervention.
- In-hospital mortality decreased from 29% to 9% after implementing the physician-led stroke care model.
- High staff attrition (55%) threatened the sustainability of the intervention.

## Abstract

Introduction

Bhutan faces a growing stroke burden as the third leading cause of death, compounded by delayed hospital arrivals, fragmented care, and near-absent thrombolysis due to systemic gaps in protocols and trained workforce.

Methods

This hybrid type II implementation study (2020-2023) employed the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate a physician-led stroke care model across Bhutan's referral hospitals. Interventions included capacity-building for non-neurologists, protocol standardization, and stroke unit (SU) establishment. We used an uncontrolled pre-post design, comparing six months of retrospective baseline data (January 2020 to June 2020) to prospective post-intervention data (October 2022 to March 2023).

Results

The introduction of a physician-led stroke care model in Bhutan's national referral hospitals led to measurable gains across all RE‑AIM domains. Adherence to stroke care quality indicators nearly doubled (30%-57%), and unadjusted in-hospital mortality decreased substantially from 29% to 9% post‑intervention (adjusted odds ratio {aOR}, 0.65; 95% CI, 0.50-0.85). However, the causal interpretation of the mortality reduction is limited by the lack of adjustment for baseline stroke severity. The sustainability of the intervention faced challenges from high staff attrition (55%), affecting protocol fidelity. This highlighted the need for systemic workforce retention strategies and sustained leadership to ensure long-term maintenance.

Conclusion

The findings of the Bhutan's Response Against Increasing Number of Stroke (BRAINS) initiative suggest that key elements of organized stroke care may be successfully adapted to low-resource settings. The outcomes in Bhutan, consistent with experiences in India and South Africa, suggest that models built around dedicated units, trained teams, and standard protocols hold promise for replication. The long-term sustainability of such improvements, however, seems to rely on addressing systemic constraints. The initiative implies that challenges such as workforce retention and limited specialist availability may be addressed by strategies such as training non-neurologist physicians and establishing clear career pathways for nursing staff. Taken together, the initiative's experience supports the inference that with local tailoring, a structured and team-based approach to stroke care could be a viable model for similar low-middle-income country (LMIC) contexts.