Delays in the Presentation of Stroke Patients to Hospital and Possible Ways of Improvement

Abstract

Objective Stroke patients often came late to hospital and arrived beyond the therapeutic time window for thrombolytic therapy. We studied the time from stroke onset to arrival at Accident and Emergency (A&E) department and examined what barred them from early medical attendance. Methods All acute stroke patients attending A&E between 15 March 1999 to 14 June 1999 were recruited. For those brought in by ambulance, their time intervals were divided into three: phase I was between stroke onset to call 999; phase II was between call 999 to A&E arrival; and phase III was between A&E arrival to being seen by doctor. For those who did not come by ambulance, they were divided into two groups: those who consulted other doctors and those who did not consult other doctors before coming to A&E. Their time lags from stroke onset to A&E consultation were compared. Results One hundred and fifteen stroke patients were consecutively recruited. Sixty-five ambulance users had median time for phase I as 151 minutes, for phase II as 32 minutes, for phase III as 17 minutes. The total median time lag was 190 minutes. Fifty were ambulance non-users. For those who did not consult other doctors before A&E attendance, the median time lag was 641 minutes. For those who consulted others doctors before A&E attendance, their median time lag was 3,672 minutes. As a group their median time lag was 950 minutes. For the 65 ambulance users, we further studied the time intervals between A&E arrival and being seen by doctors; and the median waiting time for doctors was 17 (range 0 to 60) minutes. Conclusions Public education was of paramount importance. Some common stroke signs could be widely propagated for recognition. Phase I should be less than 80 minutes. The median time for phase II would likely remain to be 32 minutes. Further shortening could be achieved in phase III. As category III & IV patients were most likely potential candidates for thrombolysis, they should be seen within 15 minutes. This would leave only 53 minutes for clinical assessment, CT brain and preparation of thrombolytic agent. These measures could increase the chance of providing thrombolytic treatment within the therapeutic time window.

Ambulance use affects timely emergency treatment of acute ischaemic stroke

“…In 1999, a study in Hong Kong investigated how patients attended EDs after stroke. 4 At that time, stroke was classified as category II, and patients were not treated as urgent. Therefore, such stroke patients were often seen several hours after arrival.…”

“…The study suggested that stroke should be treated as category I, and that immediate treatment should be given. 4 Public education on recognising the signs and symptoms of stroke was also recommended. 4 A collective effort at the social ORIGINAL ARTICLE ambulance users than for non-ambulance users (64.6% vs 29.6%; P<0.001).…”

“…4 Public education on recognising the signs and symptoms of stroke was also recommended. 4 A collective effort at the social ORIGINAL ARTICLE ambulance users than for non-ambulance users (64.6% vs 29.6%; P<0.001). For phases I, II and III, the median times were significantly shorter for ambulance users (77.5, 32 and 8 min, respectively) than for non-ambulance users (720, 44.5 and 15 min, respectively; all P<0.001).…”

Short-term outcomes of Chinese transient ischaemic attack patients in an Emergency department in Hong Kong: Result of management with an agreed protocol with neurologists

“…23,24 As public awareness is increasing in ‘Golden hours in stroke’ through social media, patients were presenting much earlier over the past two decades in Hong Kong. 24,25 A long, or imprecise ODT, and day-of-stroke measured from the time-of-presentation would result in unreliable 2-and 7-day stroke risk, as most strokes recur very early, patients who arrive 3 days after TIA are past the period of highest risk. 2,6 When TIA patients with very early stroke recurrence were presenting late, they would present with stroke rather than TIA and could not be captured and included in very early stroke risk calculation.…”

Acute Ischaemic Stroke: Management, Recent Advances and Controversies

“…Delay in presentation within the strict 3-hour window is often the major underlying cause for not being able to institute thrombolysis. [83][84][85][86][87][88] Moreover, only 1% of the enrolled patients in the NINDS Trial were Asian by race. The risk-benefit ratio of t-PA as well as the possible need for dosage adjustment in Asian populations remain to be confirmed.…”