Sources and reasons for delays in the care of acute stroke patients

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Abstract

Objective: This study aimed to identify sources and reasons for delays in the care of our acute stroke patients. Methods: Data on time interval from symptom onset or awareness to initial presentation, to neurology assessment, to performance of cranial CT scan, and demographic and medical factors associated with delays among stroke patients admitted at St. Luke's Medical Center from May to October 2000 were obtained by interview and record review. Results: Of 259 patients (mean age 61.5±13.6 years, 43% females), 63% had infarction (INF), 32% intracerebral hemorrhage (ICH) and 5% subarachnoid hemorrhage (SAH). Fifty-nine percent presented within 3 h of symptom onset or awareness, 73% within 6 h (median=2 h). Patients with ICH presented earlier than those with infarction. Reasons for delayed consultation included failure to recognize symptoms as serious and stroke-related. A non-neurologist was initially consulted in 97% of cases. Median delay from presentation to neurology evaluation was 7.5 h. Median time from presentation to brain imaging was significantly shorter for patients brought to CT-equipped facilities (2 h) than for those needing transfer to other hospitals (11.5 h). Conclusions and Recommendations: Patient delay in presentation is only one cause of delay in acute stroke care. Longer delays arise from healthcare-related factors such as delays in neurologist referral and neuroradiologic diagnosis. Professional and public education on the necessity of early neurologic evaluation and patient transport to CT-equipped “Stroke Centers” is recommended.

Introduction

Recent advances have been made in the treatment of acute stroke, but the effectiveness of these new therapies is highly time-dependent. Recombinant human tissue plasminogen activator (rtPA), for example, has been documented to improve functional outcome or even reverse neurological deficits among stroke patients if given within the first few hours of stroke onset [1]. Despite these observations, patients with stroke symptoms often delay many hours before seeking medical attention. Median time from stroke onset to presentation from previous studies range from 4 to 24 h (overall median 5.9 h) [2], [3], [4], [5], [6], [7], [8], [9], [10]. Another major source of delay is in the time required to evaluate and accurately diagnose the patient and begin therapy [11], [12]. This includes delays in hospital admission, physician/neurological referral, and further in-hospital delays before neuroradiological diagnosis. If intervention in acute stroke is to be successful, early admission to hospital followed by correct diagnosis with minimum delay is therefore necessary.

Efforts to reduce delay time of therapy for acute stroke may be more effective if the time of presentation and referral after a stroke as well as factors associated with their delay are thoroughly investigated. Time is a key variable in treating stroke. By analyzing the patterns of presentation and referral among our own stroke population, sources of delay in the acute care of stroke patients can be identified and targeted for specific intervention.

There have been several published foreign studies that have addressed this issue [2], [3], [4], [5], [6], [7], [8], [9], [10], [12], [13]. However, differences in geographic areas, ethnic characteristics, culture, demographic profile, and healthcare organization among different countries make it difficult to generalize the results.

Our study aimed to identify sources of delays in the care of our acute stroke patients.

Section snippets

Subjects

Included in this study were all patients consecutively admitted at the St. Luke's Medical Center and enrolled in the Stroke Data Bank from May 1 to October 31, 2000. The Stroke Data Bank project is an observational, prospective, non-interventional study on all stroke patients admitted at St. Luke's Medical Center since January 1999. This hospital-based registry contains information on demographics, risk factors, mini-mental status and neurological examination, in-hospital treatment, results of

Results

From May 1 to October 31, 2000, a total of 292 patients were enrolled in the Stroke Data Bank. Thirty-three patients were excluded because the time of stroke onset or symptom awareness could not be accurately identified in 13 patients, 17 patients had strokes while already in the hospital for other reasons, while three patients presented more than 48 h after symptom onset. Analyses were performed on the remaining 259 patients.

Discussion

In the past, the acute treatment of strokes has been relatively neglected, with more emphasis being placed on prevention and rehabilitation. In recent years, however, with the greater understanding of the pathophysiology of stroke and the development of promising new treatments, efforts are now concentrated at cerebral revascularization and neuronal protection during the first few hours of a “brain attack.” Four years after the publication of the landmark NINDS study on the role of rtPA in

Conclusion

Half of patients with strokes generally present after a period of delay before seeking medical attention. The first medical contact was with a non-neurologist physician and in a hospital setting in the majority of cases. Presence of signs and symptoms of increased intracranial pressure was the only predictor of early consultation.

Misjudging the seriousness of symptoms was the predominant reason for delaying consult. However, significant delays in the initiation of care for acute stroke patients

Recommendations

The results of this study support recommendations for the identification and establishment of “Stroke Centers” for collaborative efforts among different subspecialties particularly emergency physicians, neurologists, neurosurgeons, radiologists, as well as clinical laboratories to facilitate rapid stroke diagnosis and management.

Comprehensive community education is necessary and must focus on improving recognition of stroke symptoms and increasing public awareness on the need to seek urgent

Acknowledgements

We would like to thank the following people for their support in this project: Dr. Joven R. Cuanang—Director, Institute for Neurosciences; Dr. Filipinas F. Natividad—Director, Research and Biotechnology Division; Dr. Abdias V. Aquino, Dr. Alejandro F. Diaz, Dr. Conrad C. Nievera, and Dr. Joey C. Boiser, Stroke Data Bank co-investigators.

The Stroke Data Bank Project is being funded by the Research and Biotechnology Division, St. Luke's Medical Center.

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