Delay in Presentation and Evaluation for Acute Stroke

Abstract

Background and Purpose-Early treatment is a critical determinant of successful intervention in acute stroke. The study was designed to find current patterns of stroke care by determining delays in time from onset of signs or symptoms to arrival at the emergency department and to initial evaluation by physicians and by identifying factors associated with these delays. Methods-Data were prospectively collected by nurses and physicians from patients, patients' family members, and medical records from 10 hospitals of the Robert Wood Johnson Health System in New Jersey. Results-A total of 553 patients who presented with signs or symptoms of acute stroke were studied. Thirty-two percent of patients arrived at the emergency department within 1.5 hours of stroke onset. Forty-six percent of patients arrived within 3 hours and 61% within 6 hours. Delays in arrival time were significantly associated with sex, race, transportation mode, and history of cardiovascular disease. Patients arriving by ambulance were more likely to present earlier (odds ratio [OR] 3.7 for arrival within 3 hours; OR 4.5 for arrival within 6 hours). Patients arriving by ambulance (OR 2.3 within 15 minutes; OR 1.7 within 30 minutes) and those requiring admission to intensive care units (OR 4.5 within 15 minutes and OR 5.2 within 30 minutes) were examined sooner by physicians. Conclusions-Despite national efforts to promote prompt stroke evaluation and treatment, significant delays still exist. The lack of improvement throughout the past decade underscores the need for implementation of effective public health programs designed to minimize the time to evaluation and treatment of stroke.

Factors Associated with Prehospital Delay for Acute Stroke in Ulsan, Korea

“…Elderly patients may have less understanding of the signs and symptoms of acute stroke than younger patients do, with greater comorbidity with chronic neurological disease like dementia, previous strokes, and progressive cardiac or pulmonary disease that might interfere with recognizing acute stroke (15,(17)(18)(19). By contrast, in the study by Lacy et al, patients over the age of 65 years arrived earlier than younger patients did (20). The date of occurrence was not different here, but some reports indicate higher incidence at nighttime (11,12,14).…”

Racial Disparities in Intravenous Recombinant Tissue Plasminogen Activator Use Persist at Primary Stroke Centers

“…Paul, and Houston failed to show differences in delay to emergency department arrival for black patients 54, 55, 56, 57. More recent studies demonstrated significant differences in delay to arrival within 3 hours22, 52, 58 that persist after adjusting for age, sex, stroke severity, and insurance status 26. Boehme et al found that black women, specifically, are more likely to arrive outside of the 3‐hour time window than white men, black men, or white women 59.…”

“…Differences in time to presentation or utilization of EMS may also underlie differences in rt‐PA utilization 50, 51, 52, 53. Existing data on differences in prehospital delays and EMS use are conflicting.…”

Pre- and In-Hospital Delays From Stroke Onset to Intra-arterial Thrombolysis

“…22 In US stroke centers, up to 59% of the patients who presented within 24 hours of symptom onset arrived within 3 hours. [23][24][25] In countries such as the United Kingdom or Ireland, where tPA has not been approved for stroke treatment and systematic educational programs have not been performed, longer onsetto-arrival delays have been reported. 26 However, a third of the patients arrived within 3 hours and nearly half arrived within 6 hours of symptom onset.…”