Temporal Trends and Risk Factors for Delayed Hospital Admission in Suspected Stroke Patients

Abstract

(1) Background: The benefit of acute ischemic stroke (AIS) treatment declines with any time delay until treatment. Hence, factors influencing the time from symptom onset to admission (TTA) are of utmost importance. This study aimed to assess temporal trends and risk factors for delays in TTA. (2) Methods: We included 1244 consecutive patients from 2015 to 2018 with suspected stroke presenting within 24 h after symptom onset registered in our prospective, pre-specified hospital database. Temporal trends were assessed by comparing with a cohort of a previous study in 2006. Factors associated with TTA were assessed by univariable and multivariable regression analysis. (3) Results: In 1244 patients (median [IQR] age 73 [60–82] years; 44% women), the median TTA was 96 min (IQR 66–164). The prehospital time delay reduced by 27% in the last 12 years and the rate of patients referred by Emergency medical services (EMS) increased from 17% to 51% and the TTA for admissions by General Practitioner (GP) declined from 244 to 207 min. Factors associated with a delay in TTA were stroke severity (beta−1.9; 95% CI–3.6 to −0.2 min per point NIHSS score), referral by General Practitioner (GP, beta +140 min, 95% CI 100–179), self-admission (+92 min, 95% CI 57–128) as compared to admission by emergency medical services (EMS) and symptom onset during nighttime (+57 min, 95% CI 30–85). Conclusions: Although TTA improved markedly since 2006, our data indicates that continuous efforts are mandatory to raise public awareness on the importance of fast hospital referral in patients with suspected stroke by directly informing EMS, avoiding contact of a GP, and maintaining high effort for fast transportation also in patients with milder symptoms.

Access to acute stroke care: A retrospective descriptive analysis of stroke patients’ journey to a district hospital

“…This was also demonstrated in numerous international studies where referrals from other medical facilities as well as awakening with symptoms lead to longer delays to hospital presentation. [ 28 , 31 , 32 ] Patients who arrived at the hospital via primary EMS calls had the shortest delays from symptom onset to hospital arrival, congruent with international data. [ 4 , 13 , 14 , 27 ] Considering the relatively quick median EMS call-to-hospital-arrival time of 1 hour and 31 minutes, it is evident that the longest delays occurred before EMS was activated.…”

“…This is in contrast to other studies in HIC where time of symptom onset and weekday presentation are associated with shorter delays. [ 27 , 32 , 33 ] Anecdotally, this could be due to better access to transport or improved stroke symptom recognition with the rest of the family or support structure at home, rather than at work. Our study also demonstrated shorter symptom onset-to-hospital-arrival times in patients in the highest income category, where 80% using private transport.…”

Help‐seeking behaviour and subsequent patient and system delays in stroke

“…Our findings of a median patient delay of 280 min was longer than that reported in other studies 8,19,29 . This could be explained by different registrations of symptom onset for wake‐up strokes and patients with reduced consciousness found by others 30 . Additionally, we included patients with minor to severe stroke.…”

“…Several studies have reported that the system delay (and the total prehospital delay) was shorter if the EMS was the first to be contacted and that the system delay was prolonged if the first contact was directed to the GP 17,19,29–31 . We used a patient delay of up to 3 h as cut‐off, as this makes arrival within the time window for reperfusion therapy reachable for the early group.…”

Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review

“…We identified 67 studies addressing pre-hospital organizational factors associated with delay or access to ART ( Appendix A - Table A3 ). Activation of stroke code, pre-hospital notification and use of pre-hospital emergency services [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ], mobile stroke units [ 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ], implementation of specific electronic apps to insert and share clinical data with the hospital stuff [ 33 ], use of ambulance [ 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ], telestroke [ 47 , 48 ], implementation of specific pre-hospital protocols [ 49 , 50 ], education campaigns […”