Delay in Presentation After an Acute Stroke in a Multiethnic Population in South London: The South London Stroke Register

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Abstract

Background

Delayed presentation to hospital after an acute stroke is a major explanation given for low thrombolysis rates. This study aimed to investigate the factors associated with delays in presentation after an acute stroke and changes after a mass media campaign.

Methods and Results

Data were from a population-based study involving 1392 patients with first-ever strokes between 2002 and 2010 in a multiethnic South London population. Associations were determined between prehospital delay (≥3 hours) and variables of interest, including ethnicity, by using multivariate logistic regression analyses. Differences in prehospital delay and thrombolysis rates were determined for the period immediately before and after the FAST mass media campaign (2007/2008 versus 2009/2010).

The median (Q ₁ to Q ₃) time to presentation was 4.73 (1.55 to 12.70) hours, and 550 (39.5%) presented within 3 hours of symptom onset. In multivariate analysis, patients of black ethnicity had increased odds of delay (odds ratio: 1.63; 95% confidence interval, 1.11 to 2.38), whereas those with more severe strokes characterized by a higher National Institutes of Health Stroke Scale score (odds ratio: 0.35; 95% confidence interval, 0.20 to 0.61) had reduced odds of delay. There was no difference in the proportion of patients who arrived within 3 hours ( P=0.30) in the period immediately before and after the FAST campaign (40.7% in 2007/2008 versus 44.9% in 2009/2010). Among patients with ischemic stroke, 119 (11.0%) received thrombolysis between 2002 and 2010, with no difference observed between the pre- and postcampaign periods (16.9% versus 16.4%).

Conclusion

Significant delays in seeking care after stroke still occur in this population despite efforts to increase public awareness. Future educational programs must identify and specifically address factors that influence behavior and should target those at higher risk of delay. ( J Am Heart Assoc. 2012;1:e001685 doi: 10.1161/JAHA.112.001685.)

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Most cited references 21

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Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility.

P A Barber, J ZHANG, A M Demchuk … (2001)

Thrombolytic therapy for acute stroke (<3 hours) will not have a major impact on death and dependency unless it is accessible to more patients. To determine why patients with ischemic stroke did not receive IV TPA and assess the availability of this therapy to patients with ischemic stroke. Consecutive patients with acute ischemic stroke were prospectively identified at a university teaching hospital between October 1996 and December 1999. Additional patients with ischemic stroke were identified that were admitted to one of three other hospitals in the Calgary region during the study period. The Oxford Community Stroke Programme Classification was used to record type and side of stroke. Of 2165 stroke patients presenting to the university hospital, 1168 (53.9%) were diagnosed with ischemic stroke, 31.8% with intracranial hemorrhage (intracerebral, subarachnoid, or subdural), and 13.9% with TIA. Delay in presentation to emergency department beyond 3 hours excluded 73.1% (854/1168). Major reasons for delay included uncertain time of onset (24.2%), patients waited to see if symptoms would improve (29%), delay caused by transfer from an outlying hospital (8.9%), and inaccessibility of treating hospital (5.7%). Twenty-seven percent of patients with ischemic stroke (314/1168) were admitted within 3 hours of sympton onset and of these 84 (26.7%) patients received IV TPA. The major reasons for exclusion in this group of patients (<3 hours) were mild stroke (13.1%), clinical improvement (18.2%), perceived protocol exclusions (13.6%), emergency department referral delay (8.9%), and significant comorbidity (8.3%). Of those patients who were considered too mild or were documented to have had significant improvement, 32% either remained dependent at hospital discharge or died during hospital admission. Throughout the region there was a total of 1806 ischemic stroke patients (admitted to all four Calgary hospitals). During this study period, 4.7% received IV TPA. The majority of patients are unable to receive TPA for acute ischemic stroke because they do no not reach the hospital soon enough. Of those patients presenting within 3 hours, 27% received the therapy but a further 31% were excluded because their symptoms were either considered too mild or were rapidly improving. Subsequently, a third of these patients were left either dependent or dead, bringing into question the initial decision not to treat.

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Systematic review of mass media interventions designed to improve public recognition of stroke symptoms, emergency response and early treatment

Jan Lecouturier, Helen Rodgers, Madeleine Murtagh … (2010)

Background Mass media interventions have been implemented to improve emergency response to stroke given the emergence of effective acute treatments, but their impact is unclear. Methods Systematic review of mass media interventions aimed at improving emergency response to stroke, with narrative synthesis and review of intervention development. Results Ten studies were included (six targeted the public, four both public and professionals) published between 1992 and 2010. Only three were controlled before and after studies, and only one had reported how the intervention was developed. Campaigns aimed only at the public reported significant increase in awareness of symptoms/signs, but little impact on awareness of need for emergency response. Of the two controlled before and after studies, one reported no impact on those over 65 years, the age group at increased risk of stroke and most likely to witness a stroke, and the other found a significant increase in awareness of two or more warning signs of stroke in the same group post-intervention. One campaign targeted at public and professionals did not reduce time to presentation at hospital to within two hours, but increased and sustained thrombolysis rates. This suggests the campaign had a primary impact on professionals and improved the way that services for stroke were organised. Conclusions Campaigns aimed at the public may raise awareness of symptoms/signs of stroke, but have limited impact on behaviour. Campaigns aimed at both public and professionals may have more impact on professionals than the public. New campaigns should follow the principles of good design and be robustly evaluated.

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Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.).

C R Lacy, D C Suh, M Bueno … (2001)

Early treatment is a critical determinant of successful intervention in acute stroke. The study was designed to find current patterns of stroke care by determining delays in time from onset of signs or symptoms to arrival at the emergency department and to initial evaluation by physicians and by identifying factors associated with these delays. Data were prospectively collected by nurses and physicians from patients, patients' family members, and medical records from 10 hospitals of the Robert Wood Johnson Health System in New Jersey. A total of 553 patients who presented with signs or symptoms of acute stroke were studied. Thirty-two percent of patients arrived at the emergency department within 1.5 hours of stroke onset. Forty-six percent of patients arrived within 3 hours and 61% within 6 hours. Delays in arrival time were significantly associated with sex, race, transportation mode, and history of cardiovascular disease. Patients arriving by ambulance were more likely to present earlier (odds ratio [OR] 3.7 for arrival within 3 hours; OR 4.5 for arrival within 6 hours). Patients arriving by ambulance (OR 2.3 within 15 minutes; OR 1.7 within 30 minutes) and those requiring admission to intensive care units (OR 4.5 within 15 minutes and OR 5.2 within 30 minutes) were examined sooner by physicians. Despite national efforts to promote prompt stroke evaluation and treatment, significant delays still exist. The lack of improvement throughout the past decade underscores the need for implementation of effective public health programs designed to minimize the time to evaluation and treatment of stroke.

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Author and article information

Journal

Journal ID (nlm-ta): J Am Heart Assoc

Journal ID (iso-abbrev): J Am Heart Assoc

Journal ID (hwp): ahaoa

Journal ID (publisher-id): jah3

Title: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease

Publisher: Blackwell Publishing Ltd

ISSN (Electronic): 2047-9980

Publication date Collection: June 2012

Publication date (Electronic): 22 June 2012

Volume: 1

Issue: 3

Electronic Location Identifier: e001685

Affiliations

King's College London, Division of Health and Social Care Research, London, United Kingdom (J.A., S.A., J.L., A.G.R., C.M., C.D.A.W.)

Stroke Unit, Guy's and St. Thomas' NHS Foundation Trust, St. Thomas' Hospital, London, United Kingdom (A.G.R.)

National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom (J.A., C.D.A.W.)

Author notes

Correspondence to: Juliet Addo, King's College London, Division of Health and Social Care Research, 7th Floor Capital House, 42 Weston Street, London SE1 3QD, United Kingdom. E-mail Juliet.addo@ 123456kcl.ac.uk

Article

Publisher ID: jah324

DOI: 10.1161/JAHA.112.001685

PMC ID: 3487318

PubMed ID: 23130144

SO-VID: b1f19295-c000-4753-b68b-6ea7834d07b6

License:

This is an Open Access article under the terms of the Creative Commons Attribution Noncommercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

History

Date received : 02 March 2012

Date accepted : 29 March 2012

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Delay in Presentation After an Acute Stroke in a Multiethnic Population in South London: The South London Stroke Register

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Abstract

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Stroke MRI

Most cited references 21

Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility.

Systematic review of mass media interventions designed to improve public recognition of stroke symptoms, emergency response and early treatment

Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.).

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