Predictors of delays in the care of acute stroke patients.

BACKGROUND AND OBJECTIVES: Early admission to hospital followed by correct diagnosis with minimum delay is necessary for successful intervention in acute stroke. By looking at times of presentation and referral patterns among our stroke population, reasons for delay can be pinpointed and targeted for specific intervention. Our study aimed to identify reasons for delays in the care of acute stroke patients

STUDY DESIGN: Prospective, cross-sectional

METHODS: Data were obtained on all stroke patients consecutively admitted to St. Lukes Medical Center and enrolled in the Stroke Data Bank over a six month period from May 1 to October 31, 2000. Using structured questionnaires and chart review, time interval from symptom onset/awareness to initial presentation, time to neurology assessment, time to performance of cranial CT scan, as well as factors associated with any delay were recorded. Logistic regression analysis was performed to determine factors that may significantly predict consultation within three hours and performance of a CT scan within one hour.

RESULTS: Two hundred fifty-nine patients (mean age 61.6 years, 43 percent females) were included in the analysis. Cerebral infarction occurred in 163 cases (63 percent), intracerebral hemorrhage in 82 (32 percent), and subarachnoid hemorrhage in 14(5 percent) One hundred fifty-three patients (59 percent) presented for consultation within three hours of symptom onset/awareness, and 73 percent within 6 hrs (median time: 2 hours). Patients with intracerebral hemorrhage presented earlier compared to those with infarction (median 1 hr vs. 3 hrs; p0.001). Initial medical contact was with a physician (non-neurologist) in 97 percent of cases and in a hospital setting in 81 percent. Median delay from initial presentation to neurology evaluation was 7.5 hours. Failure to recognize the seriousness of symptoms and to identify them as stroke-related were common reasons for delaying consultation Median time from initial presentation, to brain imaging was 5.5 hours. This was significantly shorter for patients brought immediately to hospitals equipped with neuroimaging facilities compared to those transferred to other institutions because of unavailability of scans (median: 2 hrs vs. 11.5 hrs; p0.001). Presence of signs and symptoms of increased intracranial pressure was associated with presentation within 3 hours of symptoms onset/awareness, but not with earlier performance of CT scan.

CONCLUSIONS AND RECOMMENDATION: Patient delay in seeking medical consultation is not the only cause of delays in early intervention among our stroke patients. Longer delays can be attributed to healthcare-related factors including delays in physician/neurology referral and neuroradiological diagnosis. Measures to shorten existing timeframes in the care of acute stroke patients should include not only comprehensive education of the public but of physicians as well. In addition, strategies that would allow earlier neurological evaluation and faster patient transport to CT-equipped hospital or designated "Stroke Centers" must be developed. (Author)