A Comprehensive Review of Prehospital and In-Hospital Delay Times in Acute Stroke Care

Abstract

The purpose of this study was to systematically review and summarize prehospital and in-hospital stroke evaluation and treatment delay times. We identified 123 unique peer-reviewed studies published from 1981 to 2007 of prehospital and in-hospital delay time for evaluation and treatment of patients with stroke, transient ischemic attack, or stroke-like symptoms. Based on studies of 65 different population groups, the weighted Poisson regression indicated a 6.0% annual decline (p<0.001) in hours/year for prehospital delay, defined from symptom onset to emergency department (ED) arrival. For in-hospital delay, the weighted Poisson regression models indicated no meaningful changes in delay time from ED arrival to ED evaluation (3.1%, p=0.49 based on 12 population groups). There was a 10.2% annual decline in hours/year from ED arrival to neurology evaluation or notification (p=0.23 based on 16 population groups) and a 10.7% annual decline in hours/year for delay time from ED arrival to initiation of computed tomography (p=0.11 based on 23 population groups). Only one study reported on times from arrival to computed tomography scan interpretation, two studies on arrival to drug administration, and no studies on arrival to transfer to an in-patient setting, precluding generalizations. Prehospital delay continues to contribute the largest proportion of delay time. The next decade provides opportunities to establish more effective community based interventions worldwide. It will be crucial to have effective stroke surveillance systems in place to better understand and improve both prehospital and in-hospital delays for acute stroke care.

Multimodal Imaging Does Not Delay Intravenous Thrombolytic Therapy in Acute Stroke

“…While prehospital delays have declined significantly from 1981 to 2007, no appreciable changes for in-hospital delay times were observed during the same period. 4 A recent systematic review reported that inhospital times are consistently longer than the recommended NINDS goals. 5 These goals, published in 1996, recommend the following: 10 minutes from door to ED evaluation, 15 minutes from door to neurologist notification, 25 minutes from door to initiation of CT scan, 45 minutes from door to CT interpretation, and 60 minutes from door to tPA administration.…”

Canadian Association of Emergency Physicians Position Statement on Acute Ischemic Stroke

“…15 The use of such strategies is likely one of the core reasons for the observed decline in prehospital delays to accessing thrombolytic therapy over the past decade. 13 Functional disability and mortality rates in telestroke treated patients are similar to those in patients treated at tertiary care centres. 29 Similarly, symptomatic hemorrhagic transformation rates are similar when comparing telestroke services with face-to-face stroke care by stroke neurologist.…”

“…Most of the time delay to administering thrombolysis elapses prior to the patient arriving in the Emergency Department. 13 Accordingly, a strong emphasis needs to be placed on identifying the factors contributing to prehospital delays in accessing definitive therapy. Finding ways to diminish or eliminate these factors represents a significant opportunity to improve the outcomes experienced by patients with acute ischemic stroke.…”

Prehospital Notification can Effectively Reduce In-Hospital Delay for Thrombolysis in Acute Stroke

“…The analysis was carried out for the remaining 379 patients, 180 with PHN and 199 without PHN (Figure 1). Median door-to-CT time for the PHN group was 6 min less than for the no-PHN group, which was statistically significant (median [interquartile range: IQR]; 14 [9][10][11][12][13][14][15][16][17][18][19][20][21][22] vs 20 ; p < 0.001).…”

“…Multiple factors have been identified for in-hospital delays including decision making process, laboratory tests, neurology service arrival and imaging [10][11][12]. Previously, we tried to identify and resolve the issues related to in-hospital latencies in our hospital in Tabriz, Iran.…”