Acute Stroke: Delays to Presentation and Emergency Department Evaluation

doi:10.1016/S0196-0644(99)70431-2

Annals of Emergency Medicine

Volume 33, Issue 1, January 1999, Pages 3-8

Presented as a poster at the International Joint Conference of Cerebrovascular Disease and Stroke, Orlando, FL, February 1998.

https://doi.org/10.1016/S0196-0644(99)70431-2 Get rights and content

Abstract

Study objective: To document prehospital and inhospital time intervals from stroke onset to emergency department evaluation and to identify factors associated with presentation to the ED within 3 hours of symptom onset, the current time window for thrombolytic therapy. Methods: Patients admitted through the ED with a diagnosis of stroke were identified through admitting logs. Time intervals were obtained from EMS runsheets and ED records. Information regarding first medical contact, education, and income was obtained by patient interview. Baseline variables were analyzed to assess association with ED arrival within 3 hours of symptom onset; variables significant on univariate analysis were placed in a multivariable model. Results: There were 151 stroke patients (59% white and 41% black). Time of stroke onset and time to ED arrival were documented for 119 patients (79%). The median time from stroke onset to ED arrival was 5.7 hours; 46 patients (30%) presenting within 3 hours. Of those with times recorded, the median time from stroke onset to EMS arrival was 1.7 hours. Multivariable logistic regression identified use of EMS (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.3 to 12.1) and white race (OR, 3.5; 95% CI, 1.3 to 10) as being independently associated with ED arrival within 3 hours of symptom onset. Median time from ED arrival to physician evaluation was 20 minutes. Median time from ED arrival to computed tomographic evaluation was 72 minutes. When patients were asked the main reason they sought medical attention, 40% (60/141) of those able to be interviewed said that they themselves did not decide to seek medical attention, but rather a friend or family member told them they should go to the hospital. Conclusion: The median time from stroke onset to ED evaluation was 5.7 hours, with almost a third of patients presenting within 3 hours. Use of EMS and white race were independently associated with arrival within 3 hours.

[Kothari R, Jauch E, Broderick J, Brott T, Sauerbeck L, Khoury J, Liu T: Acute stroke: Delays to presentation and emergency department evaluation. Ann Emerg Med January 1999;33:3-8.]

Section snippets

INTRODUCTION

Recombinant tissue plasminogen activator (tPA) has been shown to improve neurologic outcome if given within 3 hours after symptom onset in patients with acute ischemic stroke.¹ Delays to presentation continue to be the primary cause of patient exclusion from interventional thrombolytic stroke trials.2, 3 As in myocardial infarction,4, 5 the most significant delay to presentation, in patients with stroke, is the delay from symptom onset to decision to seek medical attention.6, 7, 8 In addition,

MATERIALS AND METHODS

This was a retrospective study of a convenience sample of patients admitted to the hospital with an ED diagnosis of stroke from July 1993 to April 1994. Patients were recruited from a single urban, university-based teaching hospital with an emergency medicine residency program (65,000 annual ED visits) and from 3 community-based hospitals (94,000 total annual ED visits; mean, 31,300 visits). The protocol was approved by the Institutional Review Boards of all 4 hospitals. Patients were

RESULTS

There were 174 eligible patients, 23 of whom were excluded because they had a final hospital discharge diagnosis other than stroke. Among the 151 stroke patients, 10 had intra-cerebral hemorrhage and 2 had subarachnoid hemorrhage. The mean age (±SD) for these 151 stroke patients was 66±13.4 years. There were 75 men and 76 women; 89 (59%) of the patients were whites and 62 (41%) were blacks. The majority of blacks (58/62, 94%) were evaluated at the urban teaching hospital. Of the 117 stroke

DISCUSSION

Presentation longer than 3 hours after symptom onset continues to be the primary cause of exclusion from thrombolytic therapy among patients with acute stroke.2, 18 Almost one third of our study population presented within 3 hours of symptom onset, and one quarter presented within 2 hours, which is a more realistic time frame for treatment according to the NINDS guidelines. Use of EMS, white race, and living with someone were associated with arrival at the ED within these time frames.

The use of

Acknowledgements

We thank Drs Scott Becker, James Farrell, Scott Heath, John Kelly, Todd Perkins, and Karen Thalinger for their assistance in this project.

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Time to hospital presentation following intracerebral haemorrhage: Proportion of patients presenting within eight hours and factors associated with delayed presentation
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Prolonged time to diagnosis of primary intracerebral haemorrhage (ICH) can result in delays in obtaining appropriate blood pressure control, reversal of coagulopathy or surgical intervention in select cases. We sought to characterise the time to diagnosis in a cohort of patients with ICH and identify factors associated with delayed diagnosis.
The stroke database of our hospital was retrospectively reviewed to identify patients presenting to our hospitals emergency department with ICH over two years (January 2017-December 2018.) Data collected included demographics (age and sex), comorbidities, anticoagulation status, clinical scores (NIHSS, GCS, ICH score), and imaging (anatomical site, haematoma size). Time from symptom onset to diagnosis and hospital presentation were recorded. Factors associated with diagnosis >8 h post ictus were assessed using a univariate and then multivariable analysis.
235 patients were identified with 125 males (53%) and a median age of 76 (range 40-98). For the 200 patients that initially presented to our hospital, median time to presentation was 179 min (IQR 77-584 min), and median time from ictus to imaging diagnosis was 268 min (IQR 114-717 min). 139 (70%) presented within 8 h of symptom onset, and 129 (65%) patients had imaging of the brain performed within 8 h of symptom onset. Factors associated with presentation >8 h post symptom onset included wake up stroke (OR 5.31, 95% confidence interval (CI) 2.36-11.96, p < 0.0001) and age (OR 1.04, 95% CI 1.01-1.08, p = 0.01). Patients with hemiplegia were less likely to present >8 h following ictus (OR 0.41, 95% CI 0.21-0.84, p = 0.01).
The majority of patients with ICH presented within 8 h of ictus. Cases of delayed diagnosis involved patients who had not incurred hemiplegia.
An integrated spatio-temporal analysis of emergency medical service response characteristics for stroke events across Alabama
2021, Journal of Transport and Health
Stroke treatment must be given within the first few hours of symptom onset, so rapid Emergency Medical Services (EMS) response is essential for positive patient outcomes. Examining EMS response characteristics across temporal and geographical perspectives is critical for improving Alabama's stroke death rate from its current 49th place in the U.S.
We examined EMS delay characteristics for patients with suspected strokes from 2018-2019 across Alabama, with particular attention paid to rural and urban differences. We used EMS call data from the Alabama Department of Public Health and defined possible stroke cases as calls where a stroke scale completed by EMS was positive or indeterminate. We coded the time between EMS dispatch and destination arrival as EMS delay. This study incorporates global and local spatio-temporal weighted ordered logistic regression models to evaluate significant non-stationary correlations of factors with EMS delay by accounting for unobserved heterogeneity.
We examined 17,088 possible stroke cases and found that 74% of these calls had total response times within 60 min. The longest EMS delay occurred in rural counties. EMS response characteristics, such as pre-arrival instructions and advanced vehicle navigation, were associated with shorter delays, while long travel distance and on-scene/transport times were associated with longer EMS delays. The impact of response characteristics on stroke-event-based EMS delay varied significantly across rural and urban counties and time (i.e., between 2018 and 2019).
The revealed spatio-temporal correlations are useful for EMS personnel in applying effective localized rural and urban EMS response improvement strategies.
Prehospital supplemental oxygen for acute stroke – A retrospective analysis
2020, American Journal of Emergency Medicine
Brief early administration of supplemental oxygen (sO₂) to create hyperoxia may increase oxygenation to penumbral tissue and improve stroke outcomes. Hyperoxia may also result in respiratory compromise and vasoconstriction leading to worse outcomes. This study examines the effects of prehospital sO₂ in stroke.
This is a retrospective analysis of adult acute stroke patients (aged ≥18 years) presenting via EMS to an academic Comprehensive Stroke Center between January 1, 2013 and December 31, 2017. Demographic and clinical characteristics obtained from Get with the Guidelines-Stroke registry and subjects’ medical records were compared across three groups based on prehospital oxygen saturation and sO₂ administration. Chi-square, ANOVA, and multivariate logistic regression were used to determine if sO₂ status was associated with neurological outcomes or respiratory complications.
1352 eligible patients were identified. 62.7% (n = 848) did not receive sO₂ (“controls”), 10.7% (n = 144) received sO₂ due to hypoxia (“hypoxia”), and 26.6% (n = 360) received sO₂ despite normoxia (“hyperoxia”). The groups represented a continuum from more severe deficits (hypoxia) to less severe deficits (controls): mean prehospital GCS (hypoxia -12, hyperoxia - 2, controls - 14 p ≤ 0.001), mean initial NIHSS (hypoxia - 15, hyperoxia - 13, controls - 8 p < 0.001). After controlling for potential confounders, all groups had similar rates of respiratory complications and favorable neurological outcomes.
Hyperoxic subjects had no significant increase in respiratory complications, nor did they differ in neurologic outcomes at discharge when controlling for confounders. While limited by the retrospective nature, this suggests brief, early sO₂ for stroke may be safe to evaluate prospectively.
Preventable delays to intravenous furosemide administration in the emergency department prolong hospitalization for patients with acute heart failure
2018, International Journal of Cardiology
We sought to examine whether factors impacting the time to emergency department (ED) administration of intravenous (IV) furosemide were associated with the duration of hospital admission for patients with acute heart failure (AHF).
We conducted a single-center, retrospective analysis of patients presenting to the ED and admitted between January 1, 2007 and December 31, 2014 who received a dose of IV furosemide. A Cox proportional hazards model was used to examine the likelihood that a patient would be discharged home alive, adjusting for patient demographics, AHF severity (low, moderate, high), laboratory result timing, and known AHF confounders. We identified 695 patients who met study criteria with 430 (61.9%) in the low-severity group. In the overall model, every 60-minute delay in IV furosemide administration was associated with an 8% lower chance of successful discharge home relative to someone who received early furosemide (aHR 0.93, 95%CI 0.87, 0.98, P = 0.012). Subgroup analysis suggests this association was most impactful in low-acuity patients. Our adjusted analysis suggests delaying furosemide administration until after serum creatinine results resulted in a 41% lower chance of successful discharge home relative to someone who had furosemide administered prior to creatinine results (aHR 1.41, 95%CI 1.07, 1,84).
AHF patients, particularly those with lower severity, may benefit from rapid administration of IV furosemide in the ED. This suggests that a key determinant of hospital visit duration in this low-risk cohort is decongestion, which occurs sooner when IV therapy is begun early in the ED stay regardless of serum creatinine.
Differences in and Determinants of Prehospital Delay Times among Stroke Patients—1994 Versus 2012
2018, Journal of Stroke and Cerebrovascular Diseases
Prehospital delay is a challenge for stroke treatment and the delivery of time-critical treatments. Few studies have examined secular trends in prehospital delay, and results vary. This study investigates how prehospital delay among Norwegian stroke patients has changed over the last 2 decades.
We compared time from symptom onset to admission in 2 cohorts of stroke patients admitted to Akershus University Hospital, Norway, in 1994 (n = 550) and 2012 (n = 522), and constructed predictive models for arrival within 3 hours for each cohort.
More patients arrived within 3 hours of symptom onset in 2012 compared to 1994 (proportion, 47.1% versus 19.3%, P < .001), also after adjusting for age, sex, and baseline differences; odds ratio (OR) was 5.14 (95% confidence interval [CI] 3.69-7.15). Stroke severity was the only predictor examined that was independently associated with early arrival during both periods. For patients with moderate strokes the overall OR was 2.06 (95% CI 1.41-3.00) and for severe strokes 4.52 (95% CI 2.97-6.87), compared to those with mild strokes. In the 1994 cohort additional predictors of early arrival were living with others and not being admitted from nursing home.
Prehospital delay in Norway has decreased considerably over the last 2 decades and since the availability of time-critical treatments. However, there is still an urgent need to reduce the number of delayed admissions as a large proportion of patients continue to arrive too late to benefit from these treatments. Patients with severer strokes were predicted to have earlier arrival.
The Effect of Being Found with Stroke Symptoms on Predictors of Hospital Arrival
2018, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Being found with stroke symptoms is a confounder of the association between clinical and demographic variables and time of hospital arrival. Prior studies have shown that African-American race, transportation to the hospital by means other than EMS, and low SES are associated with delay in hospital arrival after stroke symptom onset.1-5,11-15 We have shown that these sociodemographic and clinical characteristics differ in patients who are found down compared with patients with other acute ischemic stroke.
Studies examining predictors of delay in hospital arrival after stroke symptom onset have not accounted for patients who are found with their symptoms and cannot seek help independently. Our objective is to show that inclusion of patients who are “found down” in studies of prehospital delay biases the estimated association of sociodemographic and clinical variables with time of hospital arrival.
We performed a retrospective analysis of sociodemographic and clinical characteristics of patients with acute ischemic stroke presenting to a tertiary care hospital in the Bronx, New York.
Compared with all other patients with acute ischemic stroke (N = 1784), patients who were found down (N = 120) were more likely to be older (75 ± 13 years versus 68 ± 14 years, P < .0001), female (68% versus 53%, P = .003), Caucasian race (P < .001), have higher socioeconomic status (P = .001), more severe stroke deficits (P < .0001), use emergency medical services (P < .001), and arrive to the hospital more than 3 hours after symptom onset (P < .001). Inclusion of patients who were found down in a model predicting delay in hospital arrival decreased the strength of the association between the predictors and the outcome.
Being found with stroke symptoms confounds the association of sociodemographic and clinical variables with time of hospital arrival. Studies of predictors of prehospital delay should therefore exclude patients who are found down.

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^☆: Supported by a Young Investigators Award from the American Heart Association, Ohio Affiliate (SW-93944-YI).

^☆☆: Address for reprints: Rashmi Kothari, MD, Department of Emergency Medicine, University of Cincinnati, PO Box 670769,Cincinnati, OH 45267-0769;E-mail [email protected].

^★: 0196-0644/99/$8.00 + 0

^★★: 47/1/94119

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Acute Stroke: Delays to Presentation and Emergency Department Evaluation☆,☆☆,★,★★

Abstract

Section snippets

INTRODUCTION

MATERIALS AND METHODS

RESULTS

DISCUSSION

Acknowledgements

Am J Med

Lancet

Ann Emerg Med

Am J Cardiol

Tissue plasminogen activator for acute ischemic stroke

N Engl J Med

The importance of patient and public education in acute ischemic stroke

Strategies for early treatment of acute cerebral infarction

Delay time in suspected acute myocardial infarction and the importance of its modification

Clin Cardiol

An analysis of the admission delay of acute strokes

Cerebrovasc Dis

An analysis of time of presentation after stroke

JAMA

Current emergency department management of stroke in Houston, Texas

Stroke

Bethesda

MD: The National Institute of Neurological Disorders and Stroke