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Magriço M, Serôdio M, Ramos JN, Ventura R, Sobral-Pinho A, Marto JP, Viana-Baptista M. Are we missing an opportunity? Prehospital delay in patients with acute ischemic stroke and known atrial fibrillation. Rev Port Cardiol 2024; 43:321-325. [PMID: 38395298 DOI: 10.1016/j.repc.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/07/2023] [Accepted: 11/17/2023] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION AND OBJECTIVES The follow-up of patients with atrial fibrillation (AF) presents an opportunity to alert patients and their families on how to recognize and act in the event of stroke. Our aim was to compare stroke recognition-to-door time and prehospital stroke code activation in patients with known AF (KAF) and AF detected after stroke (AFDAS). METHODS We performed a retrospective cohort study of consecutive patients receiving acute recanalization treatment for acute ischemic stroke between January 2016 and August 2022, with AF as a potential stroke cause. Patients were divided into KAF and AFDAS, and stroke recognition-to-door time and prehospital stroke code activation were compared. In the KAF subgroup, we assessed whether the use of preadmission anticoagulation was associated with the studied prehospital parameters. RESULTS We included 438 patients, 290 female (66.2%), mean age 79.3±9.4 years. In total, 238 patients had KAF (54.3%) and 200 (45.7%) had AFDAS. Of those with KAF, 114 (48.1%) were pretreated with anticoagulation. Patients with KAF and AFDAS had no differences in stroke recognition-to-door time (74.0 [55.0-101.0] vs. 78.0 [60.0-112.0] min; p=0.097) or prehospital stroke code activation [148 (64.6%) vs. 128 (65.3%); p=0.965]. In the KAF subgroup, preadmission anticoagulation did not influence stroke recognition-to-door time or mode of hospital admission. CONCLUSION Stroke recognition-to-door time and prehospital stroke code activation were similar between patients with known or newly diagnosed AF. Preadmission anticoagulation treatment also did not affect the studied parameters. Our findings highlight a missed opportunity to promote stroke knowledge in patients followed due to AF.
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Affiliation(s)
- Marta Magriço
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Miguel Serôdio
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.
| | - João Nuno Ramos
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Rita Ventura
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - André Sobral-Pinho
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal; Chronic Diseases Research Centre (CEDOC), Faculdade de Ciências Médicas|NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Miguel Viana-Baptista
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal; Chronic Diseases Research Centre (CEDOC), Faculdade de Ciências Médicas|NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
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Liao Y, Qi W, Li S, Shi X, Wu X, Chi F, Xia R, Qin L, Cao L, Ren L. Analysis of onset-to-door time and its influencing factors in Chinese patients with acute ischemic stroke during the 2020 COVID-19 epidemic: a preliminary, prospective, multicenter study. BMC Health Serv Res 2024; 24:615. [PMID: 38730381 PMCID: PMC11084012 DOI: 10.1186/s12913-024-11088-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 05/08/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Pre-hospital delay in China is a serious issue with unclear relevant reasons, seriously impeding the adoption of appropriate measures. Herein, we analyzed the onset-to-door time (ODT) in Chinese patients with acute ischemic stroke (AIS) and its influencing factors. METHODS We prospectively recruited 3,459 patients with AIS from nine representative tertiary general hospitals in China between January and June 2022. Patients were divided into ODT ≤ 3 h and ODT > 3 h groups. Following single-factor analysis, binary logistic regression analysis was performed to evaluate the risk factors leading to pre-hospital delay. RESULTS In total, 763 (21.83%) patients arrived at the hospital within 3 h of onset. After adjusting for confounding factors, the risk factors for ODT were residence in rural areas (odds ratio [OR]: 1.478, 95% credibility interval [CI]: 1.024-2.146) and hospital transfer (OR: 7.479, 95% CI: 2.548-32.337). The protective factors for ODT were location of onset ≤ 20 km from the first-visit hospital (OR: 0.355, 95% CI: 0.236-0.530), transportation by emergency medical services (OR: 0.346, 95% CI: 0.216-0.555), history of atrial fibrillation (OR: 0.375, 95% CI: 0.207-0.679), moderate stroke (OR: 0.644, 95% CI: 0.462-0.901), and severe stroke (OR: 0.506, 95% CI: 0.285-0.908). CONCLUSIONS Most patients with AIS fail to reach a hospital within the critical 3-h window. The following measures are recommended to reduce pre-hospital delays: reasonable distribution of hospitals accessible to nearby residents, minimizing interhospital transfer, paying attention to patients with mild stroke, and encouraging patients to use ambulance services. Pre-hospital delays for patients can be reduced by implementing these measures, ultimately improving the timeliness of treatment and enhancing patient prognosis. This study was carried out amid the COVID-19 pandemic, which presented challenges and constraints.
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Affiliation(s)
- Yuqi Liao
- School of Medicine, Shenzhen University, Shenzhen, China
| | - Wenwei Qi
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuting Li
- School of Statistics, Shandong Technology and Business University, Yantai, China
| | - Xin Shi
- School of Statistics, Shandong Technology and Business University, Yantai, China
- School of Health Management, China Medical University, Shenyang, China
| | - Xiaohong Wu
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Feng Chi
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Runyu Xia
- School of Medicine, Shenzhen University, Shenzhen, China
| | - Limin Qin
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Liming Cao
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China.
- Hunan Provincial Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, China.
| | - Lijie Ren
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
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3
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Shin J, Kim H, Kim Y, Moon J, Lee J, Jung S, Hwang R, Kim MY. Association between Prehospital Visits and Poor Health Outcomes in Korean Acute Stroke Patients: A National Health Insurance Claims Data Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2488. [PMID: 36767860 PMCID: PMC9915235 DOI: 10.3390/ijerph20032488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 06/18/2023]
Abstract
This study aimed to determine whether prehospital visits to other medical institutions before admission are associated with prolonged hospital stay, readmission, or mortality rates in acute stroke patients. Using the claims data from the Korean Health Insurance Service, a cross-sectional study was conducted on 58,418 newly diagnosed stroke patients aged ≥ 20 years from 1 January 2019 to 31 December 2019. Extended hospital stay (≥7 days; median value) following initial admission, readmission within 180 days after discharge, and all-cause mortality within 30 days were measured as health outcomes using multiple logistic regression analysis after adjusting for age, sex, income, residential area, and medical history. Stroke patients with a prehospital visit (10,992 patients, 18.8%) had a higher risk of long hospitalization (odds ratio = 1.06; 95% confidence interval = 1.02-1.10), readmission (1.19; 1.14-1.25), and mortality (1.23; 1.13-1.33) compared with patients without a prehospital visit. Female patients and those under 65 years of age had increased unfavorable outcomes (p < 0.05). Prehospital visits were associated with unfavorable health outcomes.
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Affiliation(s)
- Jinyoung Shin
- Department of Family Medicine, School of Medicine, Konkuk University, Seoul 05029, Republic of Korea
| | - Hyeongsu Kim
- Department of Preventive Medicine, School of Medicine, Konkuk University, Seoul 05029, Republic of Korea
| | - Youngtaek Kim
- Department of Preventive Medicine, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Jusun Moon
- Department of Neurology, National Medical Center, Seoul 04564, Republic of Korea
| | - Jeehye Lee
- National Emergency Medical Center, National Medical Center, Seoul 04564, Republic of Korea
| | - Sungwon Jung
- Department of Nursing, Fareast University, Eumseong 27601, Republic of Korea
| | - Rahil Hwang
- Department of Nursing, College of Nursing, Shinhan University, Uijeongbu 11644, Republic of Korea
| | - Mi Young Kim
- Department of Nursing, College of Nursing, Hanyang University, Seoul 15588, Republic of Korea
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Potisopha W, Vuckovic KM, DeVon HA, Park CG, Phutthikhamin N, Hershberger PE. Decision Delay Is a Significant Contributor to Prehospital Delay for Stroke Symptoms. West J Nurs Res 2023; 45:55-66. [PMID: 35711105 DOI: 10.1177/01939459221105827] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Prehospital delay after stroke symptom onset is a primary barrier to eligibility for reperfusion therapies. Decision delay is an understudied contributor to prehospital delay. We aimed to explore decision delay as a component of prehospital delay. For this correlational study, 170 Thai acute stroke patients were interviewed to explore their treatment-seeking decision factors: prior stroke knowledge, onset context, and cognitive, emotional, and behavioral factors. Participants' mean age was 61.2 years, and 46% were women. Median decision delay and prehospital delay times were 120 and 372 minutes. Decision delay represented 49% of prehospital delays. Factors shortening decision delay were atrial fibrillation, prior stroke knowledge, perceived cause of symptoms as stroke, perceived severity of symptoms, and advice from bystanders to seek treatment. In contrast, seeking support from others and self-treatment affected prolonged decision delay. Shortening decision delay, often under the patient or bystander control, can reduce overall prehospital delay.
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Affiliation(s)
- Wiphawadee Potisopha
- Faculty of Nursing, Khon Kaen University, Khon Kaen, Thailand.,North-Eastern Stroke Research Group, Khon Kaen University, Khon Kaen, Thailand
| | - Karen M Vuckovic
- College of Nursing, University of Illinois Chicago, Chicago, IL, USA.,College of Medicine, University of Illinois Chicago, Chicago, IL, USA
| | - Holli A DeVon
- School of Nursing, University of California Los Angeles, Los Angeles, CA, USA
| | - Chang G Park
- College of Nursing, University of Illinois Chicago, Chicago, IL, USA
| | | | - Patricia E Hershberger
- College of Nursing, University of Illinois Chicago, Chicago, IL, USA.,College of Medicine, University of Illinois Chicago, Chicago, IL, USA
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Ookeditse O, Ookeditse KK, Motswakadikgwa TR, Masilo G, Bogatsu Y, Lekobe BC, Mosepele M, Schirmer H, Johnsen SH. Public and outpatients’ awareness of calling emergency medical services immediately by acute stroke in an upper middle-income country: a cross-sectional questionnaire study in greater Gaborone, Botswana. BMC Neurol 2022; 22:347. [PMID: 36104670 PMCID: PMC9472421 DOI: 10.1186/s12883-022-02859-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives In this cross-sectional study from Botswana, we investigated awareness of calling emergency medical services (EMS) and seeking immediate medical assistance by acute stroke among stroke risk outpatients and public. Method Closed-ended questionnaires on awareness of calling EMS and seeking immediate medical assistance by acute stroke, were administered by research assistants to a representative selection of outpatients and public. Results The response rate was 96.0% (93.0% for public (2013) and 96.6% for outpatients (795)). Public respondents had mean age of 36.1 ± 14.5 years (age range 18–90 years) and 54.5% were females, while outpatients had mean age of 37.4 ± 12.7 years (age range 18–80 years) and 58.1% were females. Awareness of calling EMS (78.3%), and of seeking immediate medical assistance (93.1%) by stroke attack was adequate. For calling EMS by acute stroke, outpatients had higher awareness than the public (p < 0.05) among those with unhealthy diet (90.9% vs 71.1%), family history of both stroke and heart diseases (90.7% vs 61.2%), no history of psychiatric diseases (93.2% vs 76.0%) and sedentary lifestyle (87.5% vs 74.8%). Predictors of low awareness of both calling EMS and seeking immediate medical assistance were no medical insurance, residing/working together, history of psychiatric diseases, and normal weight. Male gender, ≥50 years age, primary education, family history of both stroke and heart diseases, current smoking, no history of HIV/AIDS, and light physical activity were predictors of low awareness of need for calling EMS. Conclusion Results call for educational campaigns on awareness of calling EMS and seeking immediate medical assistance among those with high risk factor levels. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02859-z. • This is the first study comparing awareness of calling EMS among outpatients and public in sub-Saharan Africa • Awareness of calling EMS or seeking immediate medical services by acute stroke was adequate among both outpatients and public • Predictors of low awareness of both calling EMS and seeking immediate medical assistance were no medical insurance, residing/working together, history of psychiatric diseases, and normal weight • Results call for educational campaigns on awareness of calling EMS/ seeking immediate medical assistance by stroke.
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Yoon CW, Oh H, Lee J, Rha J, Woo S, Lee WK, Jung H, Ban B, Kang J, Kim BJ, Kim W, Yoon C, Lee H, Kim S, Kim SH, Kang EK, Her A, Cha J, Kim D, Kim M, Lee JH, Park HS, Kim K, Kim RB, Choi N, Hwang J, Park H, Park KS, Yi S, Cho JY, Kim N, Choi K, Kim Y, Kim J, Han J, Choi JC, Kim S, Choi J, Kim J, Jee SJ, Sohn MK, Choi SW, Shin D, Lee SY, Bae J, Lee K, Bae H. Comparisons of Prehospital Delay and Related Factors Between Acute Ischemic Stroke and Acute Myocardial Infarction. J Am Heart Assoc 2022; 11:e023214. [PMID: 35491981 PMCID: PMC9238627 DOI: 10.1161/jaha.121.023214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Prehospital delay is an important contributor to poor outcomes in both acute ischemic stroke (AIS) and acute myocardial infarction (AMI). We aimed to compare the prehospital delay and related factors between AIS and AMI.
Methods and Results
We identified patients with AIS and AMI who were admitted to the 11 Korean Regional Cardiocerebrovascular Centers via the emergency room between July 2016 and December 2018. Delayed arrival was defined as a prehospital delay of >3 hours, and the generalized linear mixed‐effects model was applied to explore the effects of potential predictors on delayed arrival. This study included 17 895 and 8322 patients with AIS and AMI, respectively. The median value of prehospital delay was 6.05 hours in AIS and 3.00 hours in AMI. The use of emergency medical services was the key determinant of delayed arrival in both groups. Previous history, 1‐person household, weekday presentation, and interhospital transfer had higher odds of delayed arrival in both groups. Age and sex had no or minimal effects on delayed arrival in AIS; however, age and female sex were associated with higher odds of delayed arrival in AMI. More severe symptoms had lower odds of delayed arrival in AIS, whereas no significant effect was observed in AMI. Off‐hour presentation had higher and prehospital awareness had lower odds of delayed arrival; however, the magnitude of their effects differed quantitatively between AIS and AMI.
Conclusions
The effects of some nonmodifiable and modifiable factors on prehospital delay differed between AIS and AMI. A differentiated strategy might be required to reduce prehospital delay.
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7
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Identification and analysis of key risk factors for prehospital delay in patients with stroke. Int Emerg Nurs 2022; 62:101156. [DOI: 10.1016/j.ienj.2022.101156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 01/27/2022] [Accepted: 02/11/2022] [Indexed: 01/18/2023]
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Kharbach A, Obtel M, Achbani A, Aasfara J, Hassouni K, Lahlou L, Razine R. Ischemic stroke in Morocco: Prehospital delay and associated factors. Rev Epidemiol Sante Publique 2021; 69:345-359. [PMID: 34148762 DOI: 10.1016/j.respe.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES This study aimed to estimate prehospital delay and to identify the factors associated with the late arrival of patients with ischemic stroke at the Souss Massa Regional Hospital Center in Morocco. PATIENTS AND METHODS An observational, prospective, cross-sectional study was conducted from March 2019 to September 2019 in the Souss Massa regional hospital center, which is a public hospital structure. A questionnaire was administered to patients with ischemic stroke and to bystanders (family or others), while clinical and paraclinical data were collected from medical records. Univariate and multivariate logistic regression analyses were used to identify the factors associated with delayed arrival at emergency department. RESULTS A total of 197 patients and 197 bystanders who fulfilled the criteria for the study were included. The median time from symptom onset to hospital arrival was 6hours (IQR, 4-16). Multiple regression analysis showed that illiteracy (OR 38.58; CI95%: 3.40-437.27), waiting for symptoms to disappear (patient behavior) (OR 11.24; CI95%: 1.57-80.45), deciding to go directly to the hospital (patient behavior) (OR 0.07; CI95%: 0.01-0.57), bystander's knowledge that stroke is a disease requiring urgent care within a limited therapeutic window (OR 0.005; CI95%: 0.00-0.36), and direct admission without reference (OR 0.005; CI95%: 0.00-0.07), were independently associated with late arrival (>4.5hours) of patients with acute ischemic stroke. In addition, illiteracy (OR 24.62; CI95%: 4.37-138.69), vertigo and disturbance of balance or coordination (OR 0.14; CI95%: 0.03-0.73), the relative's knowledge that stroke is a disease requiring urgent care and within a limited therapeutic window (OR 0.03; CI95%: 0.00-0.22), calling for an ambulance (relative's behavior) (OR 0.16; CI95%: 0.03-0.80), distance between 50 and 100km (OR 10.16; CI95%: 1.16-89.33), and direct admission without reference (OR 0.03; CI95%: 0.00-0.14), were independently associated with late arrival (>6hours) of patients with acute ischemic stroke. CONCLUSION Patient behavior, bystander knowledge and direct admission to the competent hospital for stroke care are modifiable factors potentially useful for reducing onset-to-door time, and thereby increasing the implementation rates of acute stroke therapies.
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Affiliation(s)
- A Kharbach
- Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco.
| | - M Obtel
- Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco; Laboratory of Social Medicine (Public Health, Hygiene and Preventive Medicine), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco.
| | - A Achbani
- Laboratory of Cell Biology and Molecular Genetics (LBCGM), Department of Biology, Faculty of Sciences, University Ibn Zohr Agadir, Rabat, Morocco.
| | - J Aasfara
- Department of Neurology, International Cheikh Khalifa University Hospital, Mohammed VI University of Health Sciences (UM6SS) Casablanca, Rabat, Morocco.
| | - K Hassouni
- International School of Public Health, Mohammed VI University of Health Sciences (UM6SS) Casablanca, Rabat, Morocco.
| | - L Lahlou
- Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco; Faculty of Medicine and Pharmacy of Agadir, University Ibn Zohr, Agadir, Morocco.
| | - R Razine
- Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco; Laboratory of Social Medicine (Public Health, Hygiene and Preventive Medicine), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco.
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Uivarosan D, Tit DM, Iovan C, Nistor-Cseppento DC, Endres L, Lazar L, Sava C, Sabau AM, Buhas C, Moleriu LC, Bungau S, Aleya L. Effects of combining modern recovery techniques with neurotrophic medication and standard treatment in stroke patients. THE SCIENCE OF THE TOTAL ENVIRONMENT 2019; 679:80-87. [PMID: 31100563 DOI: 10.1016/j.scitotenv.2019.05.070] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 05/06/2019] [Accepted: 05/06/2019] [Indexed: 06/09/2023]
Abstract
Stroke is the main cause of disability after age 65, leaving survivors with sequels that require care and recovery treatment lasting years. It is estimated that by the year 2030 this pathology will be leading cause of mortality. To determine the efficacy of Lokomat training combined with neurotrophic medication and balneo-physiotherapeutic treatment in rehabilitation of post-stroke patients, a prospective study of 3 parallel groups was conducted: Group I (n = 22) - Lokomat, balneo-physiotherapy, and Cerebrolysin; Group II (n = 18) - Lokomat associated with balneo-physiotherapy; and Group III (n = 30) - balneo-physiotherapy alone (Control group). Patients were evaluated physically, neurologically, and functionally, according to the evolution of their motor deficiency, spasticity, functional independence and health-related quality of life. Patient improvement is significantly better (p < 0.05) in the group with associated therapies, especially during the first 6 months. Evolution was significantly better in all groups at 12 months than initially (p < 0.05), for all studied parameters and with the best effects in Group I (the three therapies combined). Association of Lokomat training with neurotrophic factors and classic recovery techniques improves the rehabilitation process in stroke patients.
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Affiliation(s)
- Diana Uivarosan
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania
| | - Delia Mirela Tit
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania
| | - Ciprian Iovan
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania
| | - Delia Carmen Nistor-Cseppento
- Department of Psycho-Neuroscience and Recovery, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania
| | - Laura Endres
- Department of Psycho-Neuroscience and Recovery, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania
| | - Liviu Lazar
- Department of Psycho-Neuroscience and Recovery, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania
| | - Cristian Sava
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania
| | - Anca Maria Sabau
- Department of Physical Education, Sport and Physical Therapy, Faculty of Geography, Tourism and Sport, University of Oradea, Oradea 410028, Romania
| | - Camelia Buhas
- Department of Morphological Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania
| | - Lavinia Cristina Moleriu
- Department III Functional Sciences, Faculty of Medicine, University of Medicine and Pharmacy "Victor Babes", Timisoara, Romania
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania
| | - Lotfi Aleya
- Laboratoire Chrono-environnement, Université de Franche-Comté, Besançon, France.
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Drenck N, Viereck S, Bækgaard JS, Christensen KB, Lippert F, Folke F. Pre-hospital management of acute stroke patients eligible for thrombolysis - an evaluation of ambulance on-scene time. Scand J Trauma Resusc Emerg Med 2019; 27:3. [PMID: 30626404 PMCID: PMC6327613 DOI: 10.1186/s13049-018-0580-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/20/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Stroke is a leading cause of death and disability with effective treatment, including thrombolysis or thrombectomy, being time-critical for favourable outcomes. While door-to-needle time in hospital has been optimized for many years, little is known about the ambulance on-scene time (OST). OST has been reported to account for 44% of total alarm-to-door time, thereby being a major time component. We aimed to analyse ambulance OST in stroke patients eligible for thrombolysis and identify potential areas of time optimization. METHODS A study-specific registration form was developed to record detailed information about OST consumption in cases where the Emergency Medical Services (EMS) suspected a stroke from July 2014-May 2015. Registration forms were completed by ambulance personnel and included details on estimated time spent: 1) localising patient, 2) clinical examination, 3) consulting with the on-call neurologist, 4) mobilising patient to the ambulance, 5) treatment in ambulance before departure. Additionally, estimated total OST was noted. For patients found eligible for further evaluation at a stroke centre, time points were analysed using multivariate Poisson regressions. RESULTS A total of 520 cases were included. The median OST was 21 min (Interquartile Range (IQR) 16-27). Time consumption was significantly lower (17 vs 21 min, p = 0.0015) when electrocardiography (ECG) was obtained in-hospital instead of on-scene, when intravenous (IV) access was established during transportation instead of before transportation (17 vs 21 min, p < 0.0001), and when the quality of communication with the stroke centres was rated as "good" as opposed to "acceptable/poor" (21 vs 23 min, p = 0.014). Neither the presence of relatives nor ambulance trainees had a significant effect on OST. CONCLUSIONS In-hospital ECG recording and IV cannulation during transport were found to reduce OST, while "acceptable/poor" communication was found to prolong OST relative to "good" communication. These components of pre-hospital stroke management represent potential opportunities for lowering OST with relatively simple changes, which could ultimately lead to earlier treatment and better patient outcome. TRIAL REGISTRATION Unique identifier: NCT02191514 .
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Affiliation(s)
- Nicolas Drenck
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark.
| | - Søren Viereck
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Freddy Lippert
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Fredrik Folke
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark.,Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark
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Pulvers JN, Watson JDG. If Time Is Brain Where Is the Improvement in Prehospital Time after Stroke? Front Neurol 2017. [PMID: 29209269 DOI: 10.3389/fneur.2017.00617/full] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Despite the availability of thrombolytic and endovascular therapy for acute ischemic stroke, many patients are ineligible due to delayed hospital arrival. The identification of factors related to either early or delayed hospital arrival may reveal potential targets of intervention to reduce prehospital delay and improve access to time-critical thrombolysis and clot retrieval therapy. Here, we have reviewed studies reporting on factors associated with either early or delayed hospital arrival after stroke, together with an analysis of stroke onset to hospital arrival times. Much effort in the stroke treatment community has been devoted to reducing door-to-needle times with encouraging improvements. However, this review has revealed that the median onset-to-door times and the percentage of stroke patients arriving before the logistically critical 3 h have shown little improvement in the past two decades. Major factors affecting prehospital time were related to emergency medical pathways, stroke symptomatology, patient and bystander behavior, patient health characteristics, and stroke treatment awareness. Interventions addressing these factors may prove effective in reducing prehospital delay, allowing prompt diagnosis, which in turn may increase the rates and/or efficacy of acute treatments such as thrombolysis and clot retrieval therapy and thereby improve stroke outcomes.
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Affiliation(s)
- Jeremy N Pulvers
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
| | - John D G Watson
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
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12
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Pulvers JN, Watson JDG. If Time Is Brain Where Is the Improvement in Prehospital Time after Stroke? Front Neurol 2017; 8:617. [PMID: 29209269 PMCID: PMC5701972 DOI: 10.3389/fneur.2017.00617] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/06/2017] [Indexed: 01/19/2023] Open
Abstract
Despite the availability of thrombolytic and endovascular therapy for acute ischemic stroke, many patients are ineligible due to delayed hospital arrival. The identification of factors related to either early or delayed hospital arrival may reveal potential targets of intervention to reduce prehospital delay and improve access to time-critical thrombolysis and clot retrieval therapy. Here, we have reviewed studies reporting on factors associated with either early or delayed hospital arrival after stroke, together with an analysis of stroke onset to hospital arrival times. Much effort in the stroke treatment community has been devoted to reducing door-to-needle times with encouraging improvements. However, this review has revealed that the median onset-to-door times and the percentage of stroke patients arriving before the logistically critical 3 h have shown little improvement in the past two decades. Major factors affecting prehospital time were related to emergency medical pathways, stroke symptomatology, patient and bystander behavior, patient health characteristics, and stroke treatment awareness. Interventions addressing these factors may prove effective in reducing prehospital delay, allowing prompt diagnosis, which in turn may increase the rates and/or efficacy of acute treatments such as thrombolysis and clot retrieval therapy and thereby improve stroke outcomes.
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Affiliation(s)
- Jeremy N Pulvers
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
| | - John D G Watson
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
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13
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Subic A, Cermakova P, Norrving B, Winblad B, von Euler M, Kramberger MG, Eriksdotter M, Garcia-Ptacek S. Management of acute ischaemic stroke in patients with dementia. J Intern Med 2017; 281:348-364. [PMID: 28150348 DOI: 10.1111/joim.12588] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
An estimated 10% of stroke patients have an underlying dementia. As a consequence, health professionals often face the challenge of managing patients with dementia presenting with an acute stroke. Patients with dementia are less likely to receive thrombolysis (0.56-10% vs. 1-16% thrombolysis rates in the general population), be admitted to a stroke unit or receive some types of care. Anticoagulation for secondary stroke prevention is sometimes withheld, despite dementia not being listed as an exclusion criterion in current guidelines. Studies in this population are scarce, and results have been contradictory. Three observational studies have examined intravenous thrombolysis for treatment of acute ischaemic stroke in patients with dementia. In the two largest matched case-control studies, there were no significant differences between patients with and without dementia in the risks of intracerebral haemorrhage or mortality. The risk of intracerebral haemorrhage ranged between 14% and 19% for patients with dementia. Studies of other interventions for stroke are lacking for this population. Patients with dementia are less likely to be discharged home compared with controls (19% vs. 41%) and more likely to be disabled (64% vs. 59%) or die during hospitalization (22% vs. 11%). The aim of this review was to summarize current knowledge about the management of ischaemic stroke in patients with pre-existing dementia, including organizational aspects of stroke care, intravenous thrombolysis, access to stroke unit care and use of supportive treatment. Evidence to support anticoagulation for secondary prevention of stroke in patients with atrial fibrillation and antiplatelet therapy in nonembolic stroke will be discussed, as well as rehabilitation and how these factors influence patient outcomes. Finally, ethical issues, knowledge gaps and pathways for future research will be considered.
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Affiliation(s)
- A Subic
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Stockholm, Sweden.,Department of Neurology, University Medical Center, Ljubljana, Slovenia
| | - P Cermakova
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Stockholm, Sweden.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - B Norrving
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - B Winblad
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Stockholm, Sweden
| | - M von Euler
- Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.,Karolinska University Hospital, Department of Clinical Pharmacology, Stockholm, Sweden
| | - M G Kramberger
- Department of Neurology, University Medical Center, Ljubljana, Slovenia
| | - M Eriksdotter
- Department of Geriatric Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.,Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Stockholm, Sweden
| | - S Garcia-Ptacek
- Department of Geriatric Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.,Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Stockholm, Sweden
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14
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Marto JP, Borbinha C, Filipe R, Calado S, Viana-Baptista M. Impact of stroke education on middle school students and their parents: A cluster randomized trial. Int J Stroke 2016; 12:401-411. [PMID: 27799456 DOI: 10.1177/1747493016677980] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background School students are an attractive target for stroke education due to the potential impact on stroke prevention and recognition. Additionally, these students can drive behavioral changes in their families. Aim To evaluate the impact of stroke education on school students, in terms of students' and parents' acquired stroke knowledge. Methods A structured questionnaire on knowledge of stroke was filled out by eighth-grade students and one of their parents in seven public schools. In four of these schools, students attended a stroke lecture; educational flyers and magnetic posters were distributed and parent education was encouraged. Students and parents of the other three schools were included in a control group. Students and parents, of both intervention and control groups, were resubmitted to the initial structured questionnaire within one week of the stroke lecture and three months later. Results We included 764 students and 344 parents, 383 (50.1%) and 210 (61.0%) in the intervention group. Correct test scores for students before, within one week, and three months after the intervention were 54.49% versus 55.03% (p = 0.418), 98.69% versus 60.89% (p < 0.001), and 95.58% versus 75.7% (p < 0.001) in the intervention and control groups, respectively. Correct test scores for parents at the same time points were 68.78% versus 64.47% (p = 0.107), 96.89% versus 71.42% (p < 0.001), and 94.58% versus 76.54% (p < 0.001) in the intervention and control groups, respectively. Conclusions School-based interventions may improve stroke knowledge in middle school students and their parents.
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Affiliation(s)
- João Pedro Marto
- 1 Department of Neurology, Egas Moniz Hospital, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Cláudia Borbinha
- 1 Department of Neurology, Egas Moniz Hospital, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Rita Filipe
- 2 Public Health Unit, Agrupamento de Centros de Saúde (ACES), Lisboa Ocidental e Oeiras, Lisbon, Portugal
| | - Sofia Calado
- 1 Department of Neurology, Egas Moniz Hospital, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.,3 Chronic Diseases Research Centre (CEDOC)-Nova Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Miguel Viana-Baptista
- 1 Department of Neurology, Egas Moniz Hospital, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.,3 Chronic Diseases Research Centre (CEDOC)-Nova Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
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Ramírez-Moreno J, Alonso-González R, Peral Pacheco D, Millán-Nuñez M, Roa-Montero A, Constantino-Silva A, Aguirre-Sánchez J. Effect of socioeconomic level on knowledge of stroke in the general population: A social inequality gradient. NEUROLOGÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.nrleng.2015.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Masztalewicz M, Nowacki P, Kotlęga D, Bajer-Czajkowska A. Early Emergency Medical Service Calls for Stroke: Was the Long-Term Education Program Based on the Experience of West Pomerania Successful? J Stroke Cerebrovasc Dis 2015; 25:254-8. [PMID: 26706444 DOI: 10.1016/j.jstrokecerebrovasdis.2015.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 09/16/2015] [Accepted: 09/21/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Our objectives are to investigate whether the percentage of early emergency calls for stroke had increased and to assess current factors determining the time of deciding to seek medical help in the event of early stroke symptoms. MATERIALS AND METHODS We analyzed data concerning the decision to call for medical help in relation to observed stroke symptoms. Group I comprised 287 people who made the decision to call emergency medical service (EMS) in the first 10 minutes after observing stroke symptoms. Group II included 275 people who called EMS after that time. Data from the current database (2013-2014) were compared with relevant data from the period 2003-2005. RESULTS In 2013-2014, awareness of stroke signs was 2.5 times greater than in 2003-2005. Among the groups of early and delayed EMS calls during 2003-2005 and 2013-2014, there were no significant differences in the number of people who suspected stroke. Advanced patient age, young caller age, hemiparesis, facial weakness, and the severity of neurological deficit were independent factors that correlated strongly with an early EMS call, whereas feelings of numbness and dizziness correlated significantly with delayed EMS calls. CONCLUSIONS In the West Pomeranian community, general knowledge of stroke is not a significant factor when making appropriate decisions at the onset of stroke symptoms. The education campaign regarding the initial symptoms of stroke and the possible fatal consequences appears to have been ineffective.
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Affiliation(s)
- Marta Masztalewicz
- Department of Neurology, Pomeranian Medical Unversity in Szczecin, Szczecin, Poland.
| | - Przemysław Nowacki
- Department of Neurology, Pomeranian Medical Unversity in Szczecin, Szczecin, Poland
| | - Dariusz Kotlęga
- Department of Neurology, Pomeranian Medical Unversity in Szczecin, Szczecin, Poland
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Wireklint Sundström B, Herlitz J, Hansson PO, Brink P. Comparison of the university hospital and county hospitals in western Sweden to identify potential weak links in the early chain of care for acute stroke: results of an observational study. BMJ Open 2015; 5:e008228. [PMID: 26351184 PMCID: PMC4563274 DOI: 10.1136/bmjopen-2015-008228] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To identify weak links in the early chain of care for acute stroke. SETTING 9 emergency hospitals in western Sweden, each with a stroke unit, and the emergency medical services (EMS). PARTICIPANTS All patients hospitalised with a first and a final diagnosis of stroke-between 15 December 2010 and 15 April 2011. The university hospital in the city of Gothenburg was compared with 6 county hospitals. PRIMARY AND SECONDARY MEASURES: (1) The system delay, that is, median delay time from call to the EMS until diagnosis was designated as the primary end point. Secondary end points were: (2) the system delay time from call to the EMS until arrival in a hospital ward, (3) the use of the EMS, (4) priority at the dispatch centre and (5) suspicion of stroke by the EMS nurse. RESULTS In all, 1376 acute patients with stroke (median age 79 years; 49% women) were included. The median system delay from call to the EMS until (1) diagnosis (CT scan) and (2) arrival in a hospital ward was 3 h and 52 min and 4 h and 22 min, respectively. The system delay (1) was significantly shorter in county hospitals. (3) The study showed that 76% used the EMS (Gothenburg 71%; the county 79%; p<0.0001). (4) Priority 1 was given at the dispatch centre in 54% of cases. (5) Stroke was suspected in 65% of cases. A prenotification was sent in 32% (Gothenburg 52%; the county 20%; p<0.0001). CONCLUSIONS System delay is still long and only a small fraction of patients received thrombolysis. Three of four used the EMS (more frequent in the county). They were given the highest priority at the dispatch centre in half of the cases. Stroke was suspected in two-thirds of the cases, but a prenotification was seldom sent to the hospital.
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Affiliation(s)
- Birgitta Wireklint Sundström
- Faculty of Caring Science, Work Life and Social Welfare, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, Borås, Sweden
| | - Johan Herlitz
- Faculty of Caring Science, Work Life and Social Welfare, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, Borås, Sweden
| | - Per Olof Hansson
- Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Peter Brink
- Emergency Medical Service System, NU-Hospital Organisation,Trollhättan, Sweden
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18
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Ramírez-Moreno JM, Alonso-González R, Peral-Pacheco D, Millán-Núñez MV, Aguirre-Sánchez JJ. Stroke Awareness Is Worse among the Old and Poorly Educated: A Population-Based Survey. J Stroke Cerebrovasc Dis 2015; 24:1038-46. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.12.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/10/2014] [Accepted: 12/29/2014] [Indexed: 10/23/2022] Open
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19
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Simonsen SA, Andresen M, Michelsen L, Viereck S, Lippert FK, Iversen HK. Evaluation of pre-hospital transport time of stroke patients to thrombolytic treatment. Scand J Trauma Resusc Emerg Med 2014; 22:65. [PMID: 25391354 PMCID: PMC4233232 DOI: 10.1186/s13049-014-0065-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 10/22/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Effective treatment of stroke is time dependent. Pre-hospital management is an important link in reducing the time from occurrence of stroke symptoms to effective treatment. The aim of this study was to evaluate time used by emergency medical services (EMS) for stroke patients during a five-year period in order to identify potential delays and evaluate the reorganization of EMS in Copenhagen in 2009. METHODS We performed a retrospective analysis of ambulance records from stroke patients suitable for thrombolysis from 1 January 2006 to 7 July 2011. We noted response time from dispatch of the ambulance to arrival at the scene, on-scene time and transport time to the hospital-in total, alarm-to-door time. In addition, we noted baseline characteristics. RESULTS We reviewed 481 records (58% male, median age 66 years). The median (IQR) alarm-to-door time in minutes was 41 (33-52), of which 18 (12-24) minutes were spent on scene. Response time was reduced from the period before to the period after reorganization (7 vs. 5 minutes, p <0.001). In a linear multiple regression model, higher patient age and longer distance to the hospital correlated with significantly longer transportation time (p <0.001). CONCLUSIONS This study shows an unchanged alarm-to-door time of 41 minutes over a five-year period. Response time, but not total alarm-to-door time, was reduced during the five years. On-scene time constituted nearly half of the total alarm-to-door time and is thus a point of focus for improvement.
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Affiliation(s)
- Sofie Amalie Simonsen
- Glostrup Stroke Centre, Department of Neurology, Glostrup Hospital, Copenhagen University Hospital, Nordre ringvej 57, Glostrup, 2600, Denmark.
| | - Morten Andresen
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen East, 2100, Denmark.
| | - Lene Michelsen
- Glostrup Stroke Centre, Department of Neurology, Glostrup Hospital, Copenhagen University Hospital, Nordre ringvej 57, Glostrup, 2600, Denmark.
| | - Søren Viereck
- Emergency Medical Services, Copenhagen, Capital Region of Denmark, Telegrafvej 5, Ballerup, 2750, Denmark.
| | - Freddy K Lippert
- Emergency Medical Services, Copenhagen, Capital Region of Denmark, Telegrafvej 5, Ballerup, 2750, Denmark.
| | - Helle Klingenberg Iversen
- Glostrup Stroke Centre, Department of Neurology, Glostrup Hospital, Copenhagen University Hospital, Nordre ringvej 57, Glostrup, 2600, Denmark.
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Ramírez-Moreno JM, Alonso-González R, Peral Pacheco D, Millán-Nuñez MV, Roa-Montero A, Constantino-Silva AB, Aguirre-Sánchez JJ. Effect of socioeconomic level on knowledge of stroke in the general population: A social inequality gradient. Neurologia 2014; 31:24-32. [PMID: 25124671 DOI: 10.1016/j.nrl.2014.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 06/11/2014] [Accepted: 06/18/2014] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES Socioeconomic status is a factor that influences health-related behaviour in individuals as well as health conditions in entire populations. The objective of the present study was to analyse the sociodemographic factors that may influence knowledge of stroke. METHOD Cross-sectional study. A representative sample was selected by double randomisation. Face-to-face interviews were carried out by previously trained medical students using a structured questionnaire with open- and closed-ended questions. Adequate knowledge was previously defined. The Mantel-Haenszel test and adjusted logistic regression analysis were used to assess the association between knowledge of stroke and the study variables. RESULTS 2411 subjects were interviewed (59.9% women; mean age 49.0 [SD 17.3] years) Seventy-three per cent were residents of urban areas, 24.7% had a university education, and 15.2% had a low level of schooling. Only 2.1% reported earning more than 40 000 euros/year, with 29.9% earning less than 10 000. Nearly 74% reported having an excellent or good state of health. The unemployment rate was 17.0%. Prevalence of "adequate knowledge" was 39.7% (95% CI: 37.7%-41.6%). Trend analysis showed an association between knowledge of stroke and income (z=10.14, P<0.0001); educational level (z=15.95, P<0.0001); state of health (z=7.92, P<0.0001); and employment status (z=8.98, P<0.0001). CONCLUSIONS Educational level, income, employment status, and state of health are independent factors for adequate knowledge of stroke. Public awareness campaigns should present material using simple language and efforts should be directed toward the most disadvantaged social strata in particular.
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Affiliation(s)
- J M Ramírez-Moreno
- Sección de Neurología, Hospital Universitario Infanta Cristina, Badajoz, España; Departamento de Ciencias Biomédicas, Facultad de Medicina, Universidad de Extremadura, Badajoz, España.
| | - R Alonso-González
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Londres, Reino Unido
| | - D Peral Pacheco
- Departamento de Historia de la Medicina y Bioética, Facultad de Medicina, Universidad de Extremadura, Badajoz, España
| | - M V Millán-Nuñez
- Servicio de Cardiología, Hospital Universitario Infanta Cristina, Badajoz, España
| | - A Roa-Montero
- Sección de Neurología, Hospital Universitario Infanta Cristina, Badajoz, España
| | | | - J J Aguirre-Sánchez
- Sección de Neurología, Hospital Universitario Infanta Cristina, Badajoz, España; Departamento de Ciencias Biomédicas, Facultad de Medicina, Universidad de Extremadura, Badajoz, España
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Koksal EK, Gazioglu S, Boz C, Can G, Alioglu Z. Factors associated with early hospital arrival in acute ischemic stroke patients. Neurol Sci 2014; 35:1567-72. [PMID: 24744194 DOI: 10.1007/s10072-014-1796-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 04/07/2014] [Indexed: 11/26/2022]
Abstract
Early diagnosis and treatment in acute ischemic stroke are crucial in terms of survival and disability. Many stroke patients remain disabled because of the treatment delay. The purpose of this study was to investigate the factors associated with the early hospital arrival in acute ischemic stroke patients. 113 patients diagnosed with acute ischemic stroke were included in this prospective study performed at the Karadeniz Technical University Medical Faculty Hospital. Patients' characteristics and patients' and relatives' emotional and behavioral reactions were compared between early (within 3 h) and late (after 3 h) arrival groups. 72.6 % of patients arrived at hospital within 3 h from symptoms onset. Univariate analysis revealed that history of atrial fibrillation (p = 0.04) and coronary heart disease (p = 0.02), sudden onset of symptoms (p = 0.001), loss of consciousness (p = 0.03), recognizing symptoms as stroke (p = 0.01), seeking immediate medical attention (p < 0.001), feelings of fear and panic (p = 0.001), arriving at hospital by ambulance having called the emergency medical services (p = 0.04) and National Institute of Health Stroke Scale (NIHSS) score (p = 0.001) were associated with hospital arrival within 3 h. A multivariate regression model demonstrated that recognizing symptoms as stroke (OR, 3.4; 95 % CI, 1.2-9.3) and atrial fibrillation (OR, 4.3; 95 % CI, 1.1-15.7) were independent factors associated with early arrival. The role in early arrival at hospital of recognizing symptoms as stroke and seeking immediate medical attention with transportation by ambulance emphasize the importance of public awareness concerning recognizing the symptoms of stroke and accessing emergency medical assistance.
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Affiliation(s)
- Esin Kulein Koksal
- Department of Neurology, Karadeniz Technical University Medical Faculty, 61080, Trabzon, Turkey
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Abstract
Stroke is one of the most common causes of morbidity and mortality in hospitalized patients in the United States. A proper understanding of stroke mechanisms helps to guide specific case management. The only therapy approved by the US Food and Drug Administration for the management of acute ischemic stroke is initiation of intravenous recombinant tissue plasminogen activator within 3 hours of symptom onset. Other treatment options include intra-arterial recombinant tissue plasminogen activator, mechanical thrombectomy, clot retrieval, or a combination of these approaches. In this article, we provide an evidence-based review of the diagnostic approach for acute ischemic stroke, including recognizing common stroke mimics. We detail the initial medical management of acute stroke and the medical and surgical therapeutic interventions for patients who have sustained acute ischemic stroke.
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23
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Kurz MW, Kurz KD, Farbu E. Acute ischemic stroke--from symptom recognition to thrombolysis. Acta Neurol Scand 2012. [PMID: 23190293 DOI: 10.1111/ane.12051] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The understanding of stroke has changed in the recent years from rehabilitation to an emergency approach. We review existing data from symptom recognition to thrombolysis and identify challenges in the different phases of patient treatment. RESULTS Implementation of treatment in dedicated stroke units with a multidisciplinary team exclusively treating stroke patients has led to significant reduction of stroke morbidity and mortality. Yet, first the introduction of treatment with intravenous rtPA (IVT) has led to the 'time is brain' concept where stroke is conceived as an emergency. As neuronal death in stroke is time dependent, all effort should be laid on immediate symptom recognition, rapid transport to the nearest hospital with a stroke treatment facility and diagnosis and treatment as soon as possible. The main cause of prehospital delay is that patients do not recognize that they suffered a stroke or out of other reasons do not call the Emergency Medical Services immediately. Educational stroke awareness campaigns may have an impact in increasing the number of patients eligible for rtPA treatment and can decrease the prehospital times if they are directed both to the public and to the medical divisions treating stroke. Stroke transport times can be shortened by the use of helicopter and a stroke mobile--an ambulance equipped with a CT scanner--may be helpful to decrease time from onset to treatment start in the future. Yet, IVT has several limitations such as a narrow time window and a weak effect in ischemic strokes caused by large vessel occlusions. In these cases, interventional procedures and the concept of bridging therapy, a combined approach of IVT and intraarterial thrombolysis or mechanical thrombectomy, might improve recanalization rates and patient outcome. CONCLUSIONS As neuronal death in stroke patients occurs in a time-dependent fashion, all effort should be made to decrease time from symptom onset to treatment start with rtPA: major challenges are stroke recognition in the public, transport times to hospital and an efficient stroke triage in the hospital.
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Affiliation(s)
| | - K. D. Kurz
- Department of Radiology; Stavanger University Hospital; Stavanger; Norway
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Kue R, Steck A. Prehospital Diagnosis and Management of Patients with Acute Stroke. Emerg Med Clin North Am 2012; 30:617-35. [DOI: 10.1016/j.emc.2012.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ünlüer EE, Yaka E, Akhan G, Limon Ö, Kara PH, Yavaşi Ö, Vandenberk N, Nazli YE, Kutluk K. Ability of emergency physicians to detect early ischemic changes of acute ischemic stroke on cranial computed tomography. Med Princ Pract 2012; 21:534-7. [PMID: 22653221 DOI: 10.1159/000339116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 04/12/2012] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the ability of emergency physicians (EPs) to diagnose early ischemic changes due acute ischemic stroke on cranial computed tomography (CT). SUBJECTS AND METHODS Three EPs interpreted CT scans obtained within 3 h of symptom onset in 50 patients with acute stroke. The CT scans were interpreted by the EPs and compared to official neuroradiologist reports as a gold standard. ĸ statistics were calculated to determine agreement among the three readers. Sensitivities and specificities were analyzed for each reader. RESULTS The EPs' sensitivities were 50, 45.5, and 45.5%, and specificities were 64.3, 82.1, and 64.3%, respectively. Focal parenchymal hypodensity was the criterion for which the EPs were the most sensitive (77.3%). The ability of EPs to recognize early ischemic changes on CT scans in acute ischemic stroke was moderate based on sensitivities. CONCLUSION Based on this study, EPs must be trained especially for recognizing early ischemic changes in acute ischemic stroke to improve their accuracy of interpretation.
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Affiliation(s)
- Erden Erol Ünlüer
- Department of Emergency Medicine, Izmir Ataturk Research and Training Hospital, Izmir, Turkey. erolerdenun @ yahoo.com
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Teuschl Y, Brainin M. Stroke education: discrepancies among factors influencing prehospital delay and stroke knowledge. Int J Stroke 2010; 5:187-208. [PMID: 20536616 DOI: 10.1111/j.1747-4949.2010.00428.x] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Time is essential for the treatment of acute stroke. Much time is lost outside the hospital, either due to failure in identifying stroke symptoms or due to a delay in notification or transport. We review studies reporting factors associated with better stroke knowledge and shorter time delays. We summarise the evidences for the effect of stroke knowledge and education on people's reaction in the acute situation of stroke. METHODS We searched MEDLINE for studies reporting factors associated with prehospital time of stroke patients, or knowledge of stroke symptoms. Further, we searched for studies reporting educational interventions aimed at increasing stroke symptom knowledge in the population. FINDINGS We included a total of 182 studies. Surprisingly, those factors associated with better stroke knowledge such as education and sociodemographic variables were not related to shorter time delays. Few studies report shorter time delays or better stroke knowledge in persons having suffered a previous stroke. Factors associated with shorter time delays were more severe stroke and symptoms regarded as serious, but not better knowledge about the most frequent symptoms such as hemiparesis or disorders of speech. Only 25-56% of patients recognised their own symptoms as stroke. While stroke education increases the knowledge of warning signs, a few population studies measured the impact of education on time delays; in such studies, time delays decreased after education. This may partly be mediated by better organisation of EMS and hospitals. INTERPRETATION There is a discrepancy between theoretical stroke knowledge and the reaction in an acute situation. Help-seeking behaviour is more dependent on the perceived severity of symptoms than on symptom knowledge. Bystanders play an important role in the decision to call for help and should be included in stroke education. Education is effective and should be culturally adapted and presented in a social context. It is unclear which educational concept is best suited to enhance symptom recognition in the acute situation of stroke, especially in view of discrepancies between knowledge and action.
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Affiliation(s)
- Yvonne Teuschl
- Department of Clinical Medicine and Preventive Medicine, Danube University, Krems, Austria
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Herlitz J, Wireklintsundström B, Bång A, Berglund A, Svensson L, Blomstrand C. Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities. Scand J Trauma Resusc Emerg Med 2010; 18:48. [PMID: 20815939 PMCID: PMC2944143 DOI: 10.1186/1757-7241-18-48] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 09/06/2010] [Indexed: 12/20/2022] Open
Abstract
Background The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably. In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count. This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase. Method A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases. Results In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women). With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably. In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke. Conclusion Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.
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Affiliation(s)
- Johan Herlitz
- Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden.
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Puolakka T, Väyrynen T, Häppölä O, Soinne L, Kuisma M, Lindsberg PJ. Sequential analysis of pretreatment delays in stroke thrombolysis. Acad Emerg Med 2010; 17:965-9. [PMID: 20836777 DOI: 10.1111/j.1553-2712.2010.00828.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim was to determine if an intensive restructuring of the approach to acute stroke improved time to thrombolysis over a 3-year study period and to determine whether delay modifications correlated with increased thrombolytic intervention or functional outcome. METHODS The study examined the pretreatment process to define specific time intervals (delays) of interest in the acute management of 289 consecutive ischemic stroke patients who were transported by the emergency medical services (EMS) and received intravenous (IV) thrombolytic therapy in the emergency department (ED) of Helsinki University Central Hospital. Time interval changes of the 3-year period and use of thrombolytics was measured. Functional outcome, measured with the modified Rankin Scale (mRS) at 3 months, was assessed with multivariable statistical analysis. RESULTS During implementation of the restructuring program from 2003 to 2005, the median total time delay from symptom onset to drug administration dropped from 149 to 112 minutes (p < 0.0001). Prehospital delays did not change significantly during the study period. The median delay in calling an ambulance remained at 13 minutes, and the total median prehospital delay stayed at 71 minutes. In-hospital delays decreased from 67 to 34 minutes (p < 0.0001). The median call delay was 25 minutes in patients with mild symptoms (National Institute of Health Stroke Scale [NIHSS] score < 7) and 8 minutes with severe symptoms (NIHSS > 15). In the multivariate model, stroke severity (odds ratio [OR] = 0.83, 95% confidence interval [CI] = 0.78 to 0.88, p < 0.0001), age (OR = 0.57, 95% CI = 0.42 to 0.77, p < 0.0001), and in-hospital delay (OR = 0.47, 95% CI = 0.22 to 0.97, p = 0.04) were suggesting a good outcome. CONCLUSIONS Restructuring of the teamwork between the EMS personnel and the reorganized ED significantly reduced in-hospital, but not prehospital, delays. The present data suggest that a decreased in-hospital delay improves the accessibility of the benefits of thrombolysis.
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Gargano JW, Wehner S, Reeves MJ. Presenting symptoms and onset-to-arrival time in patients with acute stroke and transient ischemic attack. J Stroke Cerebrovasc Dis 2010; 20:494-502. [PMID: 20719538 DOI: 10.1016/j.jstrokecerebrovasdis.2010.02.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Revised: 12/23/2009] [Accepted: 02/05/2010] [Indexed: 11/19/2022] Open
Abstract
Delayed arrival to the emergency department (ED) precludes most stroke patients from receiving thrombolytic treatment. Our objective in this study was to examine the association between presenting symptoms and onset-to-arrival time (ie, time between onset of symptoms to arrival at the ED) in a statewide stroke registry. Demographics, clinical data, and presenting symptoms were collected for patients with acute stroke or symptomatic transient ischemic attack (TIA) admitted to 15 Michigan hospitals (n = 1922). Polytomous logistic regression models were developed to test the association between presenting symptoms and onset-to-arrival time (classified as <2 hours, 2-6 hours, or >6 hours/unknown). Onset-to-arrival time was <2 hours in 19% of the patients, 2-6 hours in 22%, and >6 hours/unknown in 59%. Unilateral symptoms (reported by 40%) and speech difficulties (reported by 22%) were associated with increased likelihood of arriving within 2 hours (unilateral: adjusted odds ratio [aOR], 1.5; 95% confidence interval [CI], 1.1-1.9; speech: aOR, 1.6; 95% CI, 1.2-2.2). Difficulty with walking, balance, or dizziness (12%), confusion (9%), loss of consciousness (6.7%) and falls (3.4%) were associated with lower likelihood of arriving within 2 hours (walking: aOR, 0.7; 95% CI, 0.4-1.0; confusion: aOR, 0.5; 95% CI, 0.3-0.8; consciousness: aOR, 0.5; 95% CI, 0.1-0.9; falls: aOR, 0.4; 95% CI, 0.3-0.9). Presenting symptoms were strongly associated with time of arrival; patients with unilateral symptoms and speech difficulties were more likely to seek care early. Future studies should consider including more specific patient-level data to identify psychosocial and behavioral aspects of recognition and action to stroke symptoms.
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Affiliation(s)
- Julia Warner Gargano
- Department of Epidemiology, Michigan State University, East Lansing, MI 48824, USA
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Kim HJ, Ahn JH, Kim SH, Hong ES. Factors associated with prehospital delay for acute stroke in Ulsan, Korea. J Emerg Med 2010; 41:59-63. [PMID: 20466504 DOI: 10.1016/j.jemermed.2010.04.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 12/24/2009] [Accepted: 04/04/2010] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early hospital presentation is critical in the treatment of acute ischemic stroke with thrombolysis. OBJECTIVES The aim of this study was to investigate the factors associated with prehospital delay in acute ischemic stroke. METHODS Data were retrospectively collected over a 1-year period from 247 acute ischemic stroke patients who presented to the emergency department (ED) within 7 days after symptom onset. To investigate the factors associated with prehospital delay, sociodemographic data, initial symptoms, risk factor, National Institutes of Stroke Scale in the ED, and use of emergency medical services (EMS) were evaluated. Univariate and multivariate analysis were used to evaluate delay factors. RESULTS Of 247 patients (mean age 64.4 ± 12.6 years, 149 male patients), the non-delay group (≤ 2 h after symptom onset) included 45 patients (mean age 60.0 ± 13.1 years, 31 male patients) and the delay group (> 2 h after symptom onset) included 202 patients (mean age 65.4 ± 12.3 years, 118 male patients). Advanced age (odds ratio [OR] 1.056, 95% confidence interval [CI] 1.024-1.089), no consciousness disturbance at symptom onset (OR 2.938, 95% CI 1.066-8.104), presentation to ED by self (OR 3.826, 95% CI 1.580-9.624), referral from other hospital (OR 16.787, 95% CI 5.445-51.750), and worsened symptoms at the ED compared to symptom onset (OR 7.708, 95% CI 1.557-38.151) were associated with a prehospital delay. CONCLUSION Elderly patients with progressive symptom worsening had delayed arrival, but those who used EMS or had disturbed consciousness at symptom onset had early arrival.
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Affiliation(s)
- Hyung Ju Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Ramanujam P, Castillo E, Patel E, Vilke G, Wilson MP, Dunford JV. Prehospital Transport Time Intervals for Acute Stroke Patients. J Emerg Med 2009; 37:40-5. [DOI: 10.1016/j.jemermed.2007.11.092] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Revised: 11/20/2007] [Accepted: 11/26/2007] [Indexed: 11/25/2022]
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Evenson KR, Foraker RE, Morris DL, Rosamond WD. A comprehensive review of prehospital and in-hospital delay times in acute stroke care. Int J Stroke 2009; 4:187-99. [PMID: 19659821 PMCID: PMC2825147 DOI: 10.1111/j.1747-4949.2009.00276.x] [Citation(s) in RCA: 195] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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 arrival. For in-hospital delay, the weighted Poisson regression models indicated no meaningful changes in delay time from emergency department arrival to emergency department evaluation (3.1%, P=0.49 based on 12 population groups). There was a 10.2% annual decline in hours/year from emergency department 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 emergency department 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.
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Affiliation(s)
- K R Evenson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27514, USA.
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Nakajima M, Hirano T, Uchino M. Patients with acute stroke admitted on the second visit. J Stroke Cerebrovasc Dis 2009; 17:382-7. [PMID: 18984432 DOI: 10.1016/j.jstrokecerebrovasdis.2008.05.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Revised: 04/15/2008] [Accepted: 05/19/2008] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The aim of this study was to identify the characteristics of patients with stroke who were discharged home despite their need for acute hospital treatment. METHODS This study included 611 consecutive patients with ischemic stroke who were admitted to our hospital within 7 days of stroke onset. The patients were divided into two groups: those directly admitted and those readmitted after having previously been seen at our hospital or other facilities. The patients' characteristics and symptoms at the time of their initial visit were analyzed. RESULTS In all, 61 patients (10.0%) were initially discharged. The presence of hypertension, a summer admission, ambulance transport, and evaluation by neurologists were more frequent in the direct admission group than in the nondirect admission group. There was a lower incidence of consciousness disturbance and motor deficits in the nondirect admission group than in the direct admission group. The incidence of visual disturbance, gait disturbance, vertigo or dizziness, nausea, and sensory disturbance was higher in the nondirect admission group than in the direct admission group. On logistic regression model analysis, evaluation by nonneurologists (odds 33.0), hypertension (3.14), absence of consciousness disturbance (5.26), absence of paralysis (2.27), and presence of sensory disturbance (3.45) were independently associated with being initially discharged. CONCLUSION Physicians tend to consider that a patient has no need to be admitted into hospital if the patient is alert, has a sensory disturbance, or has no paralysis.
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Affiliation(s)
- Makoto Nakajima
- Department of Medicine, Kumamoto Rosai Hospital, Yatsushiro, Japan.
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Gargano JW, Wehner S, Reeves MJ. Do presenting symptoms explain sex differences in emergency department delays among patients with acute stroke? Stroke 2009; 40:1114-20. [PMID: 19211483 DOI: 10.1161/strokeaha.108.543116] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies report that women with stroke may experience longer delays in diagnostic workup than men after arriving at the emergency department. We hypothesized that presenting symptom differences could explain these delays. METHODS Data were collected on 1922 acute stroke cases who presented to 15 hospitals participating in a statewide stroke registry. We evaluated 2 in-hospital time intervals: emergency department arrival to physician examination ("door-to-doctor") and emergency department arrival to brain imaging ("door-to-image"). We used parametric survival models to estimate time ratios, which represent the ratio of average times comparing women to men, after adjusting for symptom presentation and other confounders. RESULTS Women were significantly less likely than men to present with any stroke warning sign or suspected stroke (87.5% versus 91.4%) or to report trouble with walking, balance, or dizziness (9.5% versus 13.7%). Difficulty speaking and loss of consciousness were associated with shorter door-to-doctor times. Weakness, facial droop, difficulty speaking, and loss of consciousness were associated with shorter door-to-image times, whereas difficulty with walking/balance was associated with longer door-to-image times. In adjusted analyses, women had 11% longer door-to-doctor intervals (time ratio, 1.11; 95%, CI 1.02 to 1.22) and 15% longer door-to-image intervals (time ratio, 1.15; 95% CI, 1.08 to 1.25) after accounting for presenting symptoms, age, and other confounders. Furthermore, these sex differences remained evident after restricting to patients who arrived within 6 or within 2 hours of symptom onset. CONCLUSIONS Women with acute stroke experienced greater emergency department delays than men, which were not attributable to differences in presenting symptoms, time of arrival, age, or other confounders.
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Affiliation(s)
- Julia Warner Gargano
- Department of Epidemiology, Michigan State University, East Lansing, MI 48824, USA.
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Rafay MF, Pontigon AM, Chiang J, Adams M, Jarvis DA, Silver F, MacGregor D, deVeber GA. Delay to Diagnosis in Acute Pediatric Arterial Ischemic Stroke. Stroke 2009; 40:58-64. [PMID: 18802206 DOI: 10.1161/strokeaha.108.519066] [Citation(s) in RCA: 184] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
For the clinician, the diagnosis of arterial ischemic stroke (AIS) in children is a challenge. Prompt diagnosis of pediatric AIS within 6 hours enables stroke-specific thrombolytic and neuroprotective strategies.
Methods—
We conducted a retrospective study of prospectively enrolled consecutive cohort of children with AIS, admitted to The Hospital for Sick Children, Toronto, from January 1992 to December 2004. The data on clinical presentation, symptom onset, emergency department arrival, neuroimaging and stroke diagnosis were recorded. The putative predictors of delayed diagnosis were selected a priori for analysis.
Results—
A total of 209 children with AIS were studied. The median interval from symptom onset to AIS diagnosis was 22.7 hours (interquartile range: 7.1 to 57.7 hours), prehospital delay (symptom onset to hospital arrival) was 1.7 hours (interquartile range: 49 minutes to 8.1 hours), and the in-hospital delay (presentation to diagnosis) was 12.7 hours (interquartile range: 4.5 to 33.5 hours). The initial assessment was completed in 16 minutes and initial neuroimaging in 8.8 hours. The diagnosis of AIS was suspected on initial assessment in 79 (38%) children and the initial neuroimaging diagnosed AIS in 47%. The parent’s help seeking action, nonabrupt onset of symptoms, altered consciousness, milder stroke severity, posterior circulation infarction and lack of initial neuroimaging at a tertiary hospital were predictive delayed AIS diagnosis.
Conclusion—
In the diagnosis of AIS, significant prehospital and in-hospital delays exist in children. Several predictors of the delayed AIS diagnosis were identified in the present study. Efforts to target these predictors can reduce diagnostic delays and optimize the management of AIS in children.
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Affiliation(s)
- Mubeen F. Rafay
- From the Section of Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, the Population Health Sciences Program (M.F.R., A.-M.P., J.C., M.A., G.A.d.V.), the Division of Emergency Medicine (D.A.J.), and the Division of Neurology (D.M., G.A.d.V.), The Hospital for Sick Children, Toronto, Ontario, Canada; and the Division of Neurology (F.S.), University Health Network, Toronto, Ontario, Canada
| | - Ann-Marie Pontigon
- From the Section of Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, the Population Health Sciences Program (M.F.R., A.-M.P., J.C., M.A., G.A.d.V.), the Division of Emergency Medicine (D.A.J.), and the Division of Neurology (D.M., G.A.d.V.), The Hospital for Sick Children, Toronto, Ontario, Canada; and the Division of Neurology (F.S.), University Health Network, Toronto, Ontario, Canada
| | - Jackie Chiang
- From the Section of Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, the Population Health Sciences Program (M.F.R., A.-M.P., J.C., M.A., G.A.d.V.), the Division of Emergency Medicine (D.A.J.), and the Division of Neurology (D.M., G.A.d.V.), The Hospital for Sick Children, Toronto, Ontario, Canada; and the Division of Neurology (F.S.), University Health Network, Toronto, Ontario, Canada
| | - Margaret Adams
- From the Section of Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, the Population Health Sciences Program (M.F.R., A.-M.P., J.C., M.A., G.A.d.V.), the Division of Emergency Medicine (D.A.J.), and the Division of Neurology (D.M., G.A.d.V.), The Hospital for Sick Children, Toronto, Ontario, Canada; and the Division of Neurology (F.S.), University Health Network, Toronto, Ontario, Canada
| | - D. Anna Jarvis
- From the Section of Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, the Population Health Sciences Program (M.F.R., A.-M.P., J.C., M.A., G.A.d.V.), the Division of Emergency Medicine (D.A.J.), and the Division of Neurology (D.M., G.A.d.V.), The Hospital for Sick Children, Toronto, Ontario, Canada; and the Division of Neurology (F.S.), University Health Network, Toronto, Ontario, Canada
| | - Frank Silver
- From the Section of Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, the Population Health Sciences Program (M.F.R., A.-M.P., J.C., M.A., G.A.d.V.), the Division of Emergency Medicine (D.A.J.), and the Division of Neurology (D.M., G.A.d.V.), The Hospital for Sick Children, Toronto, Ontario, Canada; and the Division of Neurology (F.S.), University Health Network, Toronto, Ontario, Canada
| | - Daune MacGregor
- From the Section of Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, the Population Health Sciences Program (M.F.R., A.-M.P., J.C., M.A., G.A.d.V.), the Division of Emergency Medicine (D.A.J.), and the Division of Neurology (D.M., G.A.d.V.), The Hospital for Sick Children, Toronto, Ontario, Canada; and the Division of Neurology (F.S.), University Health Network, Toronto, Ontario, Canada
| | - Gabrielle A. deVeber
- From the Section of Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, the Population Health Sciences Program (M.F.R., A.-M.P., J.C., M.A., G.A.d.V.), the Division of Emergency Medicine (D.A.J.), and the Division of Neurology (D.M., G.A.d.V.), The Hospital for Sick Children, Toronto, Ontario, Canada; and the Division of Neurology (F.S.), University Health Network, Toronto, Ontario, Canada
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Reeves MJ, Bushnell CD, Howard G, Gargano JW, Duncan PW, Lynch G, Khatiwoda A, Lisabeth L. Sex differences in stroke: epidemiology, clinical presentation, medical care, and outcomes. Lancet Neurol 2008; 7:915-26. [PMID: 18722812 DOI: 10.1016/s1474-4422(08)70193-5] [Citation(s) in RCA: 833] [Impact Index Per Article: 52.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Stroke has a greater effect on women than men because women have more events and are less likely to recover. Age-specific stroke rates are higher in men, but, because of their longer life expectancy and much higher incidence at older ages, women have more stroke events than men. With the exception of subarachnoid haemorrhage, there is little evidence of sex differences in stroke subtype or severity. Although several reports found that women are less likely to receive some in-hospital interventions, most differences disappear after age and comorbidities are accounted for. However, sex disparities persist in the use of thrombolytic treatment (with alteplase) and lipid testing. Functional outcomes and quality of life after stroke are consistently poorer in women, despite adjustment for baseline differences in age, prestroke function, and comorbidities. Here, we comprehensively review the epidemiology, clinical presentation, medical care, and outcomes of stroke in women.
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Affiliation(s)
- Mathew J Reeves
- Department of Epidemiology, College of Human Medicine, Michigan State University, East Lansing, MI 48824, USA.
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Leitlinien zum Management von Patienten mit akutem Hirninfarkt oder TIA der Europäischen Schlaganfallorganisation 2008. DER NERVENARZT 2008; 79:936-57. [DOI: 10.1007/s00115-008-2531-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25:457-507. [PMID: 18477843 DOI: 10.1159/000131083] [Citation(s) in RCA: 1671] [Impact Index Per Article: 104.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 03/27/2008] [Indexed: 12/13/2022] Open
Abstract
This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.
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Chen CH, Huang P, Yang YH, Liu CK, Lin TJ, Lin RT. Pre-hospital and in-hospital delays after onset of acute ischemic stroke: a hospital-based study in southern Taiwan. Kaohsiung J Med Sci 2008; 23:552-9. [PMID: 18055303 DOI: 10.1016/s1607-551x(08)70002-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The biggest hurdle for early hospital presentation is the narrow therapeutic window after stroke. The aims of our study were to investigate the time lags and the factors causing pre-hospital and emergency department (ED) delay during acute ischemic stroke attack. Between June 2004 and October 2005, we prospectively studied 129 acute ischemic stroke patients who presented to the ED of the study hospital within 4 hours after symptom onset. Chi-square testing for trend, univariate and multiple logistic regression analyses was performed to evaluate the factors influencing delays in the ED presentation of acute ischemic stroke patients. The median time from symptom onset to ED arrival was 71 (mean +/- SD, 82.7 +/- 57.7) minutes. The median times from ED arrival to neurologic consultation, computed tomography scan, electrocardiogram, and laboratory data completion were 10 (11.3 +/- 9.9) minutes, 17 (9.6 +/- 11.3) minutes, 14 (23.3 +/- 55) minutes, and 39 (44.4 +/- 24.5) minutes, respectively. Univariate and multiple logistic regression models revealed that age < 65 years, illiteracy and awakening with symptoms were the most significant factors related to a delay in ED presentation. This study indicates that 2 hours of pre-hospital delay is the cutoff point for thrombolytic therapy. Organization of a stroke team and standardized stroke pathways may help to shorten in-hospital time consumption. Educational efforts should not only focus on the public, but also on the training of ED physicians and other medical personnel.
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Affiliation(s)
- Chun-Hung Chen
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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