Factors Influencing Early Hospital Arrival of Patients with Acute Ischemic Stroke, Cross-Sectional Study at Teaching Hospital in Mogadishu Somalia

Background and Purpose

The low rates of thrombolysis for ischemic stroke in our country and other developing countries can be attributed to delays in arrival at the hospital. This study aims to investigate the factors that influence the early hospital arrival of patients with acute ischemic stroke to the hospital in Mogadishu, Somalia.

Methods

This is a cross-sectional study conducted at a teaching hospital in Mogadishu, Somalia. Adult patients with acute ischemic stroke admitted to the emergency department (ED) between June 2021 and May 2022 were included in the study. A questionnaire-based interview was administered to adult patients or their relatives to assess the factors contributing to hospital delay.

Results

Of the 212 patients in the study, 113 (53.3%) were male, while 99 (46.7%) were female. The mean age of the patients was 62±10. Hypertension was the most common risk factor among patients 121 (57%), followed by diabetes and hyperlipidemia. One hundred and forty (66%) patients lived in the city, while 72 (34%) lived outside of the city. About 53 (25%) of the patients were brought to the ED by ambulance, and only 32 (15%) reached the hospital in less than 4 hours. The majority of patients had no idea about stroke symptoms and thrombolytic treatment. In univariate and binary logistic regression analysis, delays in hospital arrivals were associated with a travel distance of more than 10 km, transportation via non-ambulance means, living alone, lack of recognition of stroke symptoms, night-time stroke onset, lack of knowledge about thrombolytic treatment, and non-hemiplegic presentation.

Conclusion

This study demonstrates factors delaying early hospital arrivals of patients with ischemic stroke. Improving the modifiable factors through public education will prevent delays in the early hospital arrival of stroke patients and will improve early thrombolytic intervention and the overall outcome of these patients.

Advancement of door-to-needle times in acute stroke treatment after repetitive process analysis: never give up!

Background:

In acute ischemic stroke, timely treatment is of utmost relevance. Identification of delaying factors and knowledge about challenges concerning hospital structures are crucial for continuous improvement of process times in stroke care.

Objective:

In this study, we report on our experience in optimizing the door-to-needle time (DNT) at our tertiary care center by continuous quality improvement.

Methods:

Five hundred forty patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) at Hannover Medical School were consecutively analyzed in two phases. In study phase I, including 292 patients, process times and delaying factors were collected prospectively from May 2015 until September 2017. In study phase II, process times of 248 patients were obtained from January 2019 until February 2021. In each study phase, a new clinical standard operation procedure (SOP) was implemented, considering previously identified delaying factors. Pre- and post-SOP treatment times and delaying factors were analyzed to evaluate the new protocols.

Results:

In study phase I, SOP I reduced the median DNT by 15 min. The probability to receive treatment within 30 min after admission increased by factor 5.35 [95% confidence interval (CI): 2.46–11.66]. Further development of the SOP with implementation of a mobile thrombolysis kit led to a further decrease of DNT by 5 min in median in study phase II. The median DNT was 29 (25th–75th percentiles: 18–44) min, and the probability to undergo IVT within 15 min after admission increased by factor 4.2 (95% CI: 1.63–10.83) compared with study phase I.

Conclusion:

Continuous process analysis and subsequent development of targeted workflow adjustments led to a substantial improvement of DNT. These results illustrate that with appropriate vigilance, there is constantly an opportunity for improvement in stroke care.