Emergency department delays in acute stroke – analysis of time between ED arrival and imaging

Abstract

We determined the factors leading to emergency department (ED) delays in patients with acute stroke. Data were collected prospectively in four Berlin inner-city hospitals by ED documentation, medical records, imaging files and patient interviews. An extended Cox proportional hazards model was fitted to the data. Analyses were performed in 558 patients with confirmed diagnosis of stroke. Median time from admission at ED to beginning of computed tomography/magnetic resonance imaging (CT/MRI) was 108 min. In a subgroup of patients potentially eligible for thrombolysis with a pre-hospital delay <120 min and a National Institutes of Health Stroke Scale (NIHSS) >4 (n = 74), the median interval to imaging was 68 min. Multivariable analysis revealed that a more severe initial NIHSS, a pre-hospital delay <3 h, admission at two specific hospitals, admission at weekends, and private health insurance were significantly associated with reduced delays. In stroke patients, the time interval between ED admission and imaging depends both on factors that emerge from clinical needs and on factors independent of clinical necessities. Considering the urgency of therapeutic measures in acute stroke, there is necessity and room for both improvement of in-hospital management and of medical and non-medical factors influencing pre-hospital delays.

Emergency Department Crowding and Time to Care in Patients With Acute Stroke

“…In another study, hospital-level differences explained differences in time to imaging. 6 Further study is needed to investigate what other factors may lead to subsets of patients experiencing delays. Certainly, clinical issues (eg, airway management) can lead to unavoidable delays, but only 10% of the Ͻ3-hour cohort was intubated indicating that other factors likely contribute.…”

“…2 Rapid coordination of ED services for patients with stroke is challenging because of competing demands in the ED, delays in specialist availability, prehospital transport, and recognition. [3][4][5][6][7] ED crowding occurs when demands for care exceed resource supply, and this may play a role in delays in stroke care. 8 ED crowding delays critical ED services, including time to antibiotics in pneumonia, time to analgesia in severe pain, and time to CT readings in abdominal pain.…”

Predictors of Time From Hospital Arrival to Initial Brain-Imaging Among Suspected Stroke Patients

“…This is consistent with another study reporting longer time to treatment among those with longer prehospital delays. 27 Despite a shorter CT delay among those arriving at the hospital within 2 hours of symptom onset, only 23% received a CT scan within 25 minutes per NINDS guidelines. 28 To our knowledge, compliance with this NINDS guideline has not previously been reported.…”

Do Presenting Symptoms Explain Sex Differences in Emergency Department Delays Among Patients With Acute Stroke?

“…[21][22][23] A study conducted in 4 Berlin hospitals used proportional hazard models to evaluate door-to-image times among 558 patients with stroke hospitalized in 2000 to 2001. 22 Women had significantly longer median door-to-image times in univariate analyses (120 versus 102 minutes; hazard ratio, 0.83). This result was attenuated slightly after adjusting for age, health insurance, National Institutes of Health Stroke Scale, prehospital delay, weekend admission, and hospital (adjusted hazard ratio, 0.87; 95% CI, 0.74 to 1.04).…”