Temporal Trends and Associated Factors for Pre-Hospital and In-Hospital Delays of Stroke Patients over a 16-Year Period: The Athens Study

Abstract

Background: The management and outcome of acute ischemic stroke changed dramatically after the introduction of intravenous thrombolysis. However, relatively few patients have received thrombolytic treatment, mainly due to pre-hospital and/or in-hospital delays. Although the causes of these delays have been adequately studied, their change over a long period has not. Methods: All acute first-ever stroke patients (n = 2,746) presenting to our academic center from 1993 to 2008 were prospectively documented in a computerized stroke data bank. The time from symptoms onset to presentation at the emergency room and to acquisition of a brain CT was calculated. Time trends over this period as well as the factors affecting them were analyzed. Results: The final study cohort consisted of 2,326 acute stroke patients after excluding 302 patients with an unknown time of stroke onset and 118 who suffered a stroke during hospitalization for another illness. Over the 16-year period, the median time from stroke onset to presentation at the emergency room decreased significantly from 3.15 h (interquartile range 1.30–10.30) to 2.00 h (range 1.00–4.00) (p < 0.001). The median time from emergency room presentation to CT scan completion also decreased significantly (p < 0.001) from 12.3 h (range 4.1–29.8) to 1.0 h (range 0.31–2.77). As a result, the proportion of patients having a CT scan within 4 h of stroke onset increased significantly from 8.6% in 1993–1994 to 53.6% in 2007–2008 (p < 0.001). Thrombolytic treatment was applied in 4.15% of all ischemic stroke patients in the period from 2003 to 2008. Along with other significant factors, use of an emergency medical service was associated with a 57% greater chance of presenting within 3 h after symptoms onset. Conclusions: These results suggest a continued improvement in pre-hospital and in-hospital delays for stroke management. Public awareness and education regarding medical and paramedical services are necessary for the best early management of acute stroke patients.

Development of an education campaign to reduce delays in pre-hospital response to stroke

“…This finding is consistent with one previous report [60] and further supports the need for the educational message to focus on the patient acting promptly without referring to anyone else. It also suggests the need for educational interventions about stroke that specifically target health professionals, most of all general practitioners, who emerged as the source of health information considered most reliable in our context.…”

Time to Hospital Admission and Start of Treatment in Patients with Ischemic Stroke in Northern Italy and Predictors of Delay

“…These findings are in keeping with other reports [10,21,40]. In a study done in 20,234 patients enrolled in the North Carolina Stroke Registry, only about one third of cases arrived to the hospital within 2 h. Independent predictors of delayed arrival to initial brain imaging included, among others, pre-hospital time, mode of transport, time of day, weekday versus weekend, and hospital type [24].…”

“…In light of the present and previous studies [40,41,42], increasing the use of EMS by proper education of the local population (public information campaigns), applying appropriate EMS and triage codes by continuous hospital personnel education (high level urgency codes) and increasing the number of equipped hospitals could help increase the number of stroke patients with a timely diagnosis and early assignment to the appropriate treatment.…”

Knowledge of Stroke Warning Symptoms and Intended Action in Response to Stroke in Spain: A Nationwide Population-Based Study

“…The American Heart Association advises that calling an ambulance should be the first and only response to suspected stroke symptoms [8], because the use of emergency medical services is consistently associated with earlier arrival and greater use of recombinant tissue plasminogen activator [9,10,11,12,13]. …”

“…Although it has been recognized that increased knowledge of symptoms may be insufficient and that behavioral change interventions focusing on motivation are needed to promote rapid calling of emergency services [10,11,12,13,14,15], information on public awareness of stroke symptoms remains important for planning effective future educational programs [12]. …”