Hong Kong Journal of Emergency Medicine Delays in the presentation of stroke patients to hospital and possible ways of improvement KK Lau, KM Yeung, LH Chiu, B Sheng, KW Choi, YN Shih Objective: Stroke patients often came late to hospital and arrived beyond the therapeutic time window for thrombolytic therapy. We studied the time from stroke onset to arrival at Accident and Emergency (A&E) department and examined what barred them from early medical attendance. Methods: All acute stroke patients attending A&E between 15 March 1999 to 14 June 1999 were recruited. For those brought in by ambulance, their time intervals were divided into three: phase I was between stroke onset to call 999; phase II was between call 999 to A&E arrival; and phase III was between A&E arrival to being seen by doctor. For those who did not come by ambulance, they were divided into two groups: those who consulted other doctors and those who did not consult other doctors before coming to A&E. Their time lags from stroke onset to A&E consultation were compared. Results: One hundred and fifteen stroke patients were consecutively recruited. Sixty-five ambulance users had median time for phase I as 151 minutes, for phase II as 32 minutes, for phase III as 17 minutes. The total median time lag was 190 minutes. Fifty were ambulance non-users. For those who did not consult other doctors before A&E attendance, the median time lag was 641 minutes. For those who consulted others doctors before A&E attendance, their median time lag was 3,672 minutes. As a group their median time lag was 950 minutes. For the 65 ambulance users, we further studied the time intervals between A&E arrival and being seen by doctors; and the median waiting time for doctors was 17 (range 0 to 60) minutes. Conclusions: Public education was of paramount importance. Some common stroke signs could be widely propagated for recognition. Phase I should be less than 80 minutes. The median time for phase II would likely remain to be 32 minutes. Further shortening could be achieved in phase III. As category III & IV patients were most likely potential candidates for thrombolysis, they should be seen within 15 minutes. This would leave only 53 minutes for clinical assessment, CT brain and preparation of thrombolytic agent. These measures could increase the chance of providing thrombolytic treatment within the therapeutic time window. (Hong Kong j.emerg.med. 2003;10:76-80) Keywords: Cerebrovascular accident, emergency service, thrombolytic therapy, time factors Introduction Correspondence to: Lau Kwok Kwong, MRCP, FHKAM(Medicine) Princess Margaret Hospital, Department of Medicine and Recombinant tissue plasminogen activator (rtPA) can Geriatrics, Lai Chi Kok, Kowloon, Hong Kong improve morbidity of acute ischaemic stroke patients. Email: firstname.lastname@example.org The success of rtPA depends on a narrow therapeutic Yeung Kwan Mo, MRCP, FHKAM(Medicine) time window of less than three hours. When rtPA is Sheng Bun, MRCP, FHKAM(Medicine) given intravenously within the time window, patients Choi Kin Wing, MRCP, FHKAM(Medicine) can have better functional outcome and the effect is Princess Margaret Hospital, Accident and Emergency Department, sustained. 1,2 Despite all evidence, thrombolytic Lai Chi Kok, Kowloon, Hong Kong therapy has not been a general practice in most Chiu Lai Hong, FHKAM(Emergency Medicine, Medicine) Shih Yau Ngai, MRCP, FHKAM(Emergency Medicine) hospitals. The cautious attitude of some clinicians Lau et al./Delays in presentation of stroke patients 77 may cause some restriction, but the real limiting frame was divided into three phases after stroke onset. factor is time. Patients usually attend late after stroke Phase I was between stroke onset to call 999, phase and most of them come beyond the therapeutic time II was between call 999 to arrival at A&E, and phase window.3 To examine the problem of delay, we studied III was between arrival at A&E to medical attendance. the time from stroke onset to arrival at Accident and For the ambulance non-users, the time frame from Emergency (A&E) department. We looked for factors stroke onset to A&E arrival was recorded. In that barred them from early attendance and proposed particular they were asked whether they had visited some possible solutions. 4 All these measures aimed general practitioners before they came to A&E. at making thrombolytic therapy feasible as the Exclusion criteria were stroke patients who had treatment had been proved to reduce morbidity and attended other hospitals for the same episode, or mortality. stroke occurring during hospitalization. The stroke onset time was specifically asked. If a patient was found to have stroke upon awakening, then the time Methods patient went to bed was counted as the possible stroke onset time. Time records were up to the minute, This prospective observational study was carried out which were checked with patients and their relatives at the Accident and Emergency Department of and also with the time records in the Ambulance Princess Margaret Hospital (PMH) from 15 March Service. 1999 to 14 June 1999 inclusively. We consecutively recruited all acute stroke patients attending A&E By the time of this study, it had already been a PMH within this period. 5,6 The inclusion criteria practice that an experienced nurse would triage most included all acute stroke patients. They were divided (more than 90% of all) A&E attendance within ten into two groups by whether they used 999 emergency minutes after registration. Patients were prioritized ambulance or not. For the ambulance users, the time according to a triage system. (Table 1) Patients with Table 1. Triage Guideline for Accident & Emergency Departments, Hospital Authority 1999 Edition and Results Triage Category I II III IV V Vital signs Unstable vital Borderline vital Stable vital Stable vital Stable vital signs signs signs signs signs Terminology Critical Emergency Urgent Semi-urgent Non-urgent Definition • Life threatening • Potential life • Suffer from major • Suffer from • Suffer from a condition threatening condition with an acute but minor and stable • With unstable condition relatively stable stable condition condition condition • Require emergency signs with stable vital • Require immediate treatment and • Require treatment signs resuscitation close, immediate, as early as possible and continuous monitoring Neurological deficit • Inadequate • Respond to verbal • Acute onset of • Bell's palsy respiratory effort command focal neurological • Respond to pain deficit e.g. limb or below weakness, numbness or slurring of speech Total Number of patients 3 3 56 3 0 65 Time interval 0 4 19 16 - 17 (median) between arrival to being seen by A&E doctor (min) Time range (min) 0 2~7 0~60 9~20 - 0~60 78 Hong Kong j. emerg. med. Vol. 10(2) Apr 2003 unstable vital signs would be given a higher priority. median time interval between call 999 to arrival at A&E Under this system, patients in category I, II, III and Department (phase II) was 32 minutes. In A&E, patients IV would expect to be seen by A&E doctors within were triaged into different categories. Three patients the time frame of immediate, less than 15 minutes, were in category I, and A&E doctors attended them less than 30 minutes and less than 90 minutes immediately. Three patients were in category II, and respectively. We measured the time intervals between A&E doctors attended them after a median time of registration and medical attendance. four minutes (range 2 to 7 minutes). Fifty-six patients were in category III, and A&E doctors attended them after a median time of 19 minutes (range 0 to 60 Results minutes). Three patients were in category IV, and A&E doctors attended them after a median time of 16 One hundred and fifteen patients were recruited, 65 minutes (range 9 to 20 minutes). No patient was in used ambulance and 50 arrived by other means of category V. As a whole group, A&E doctors attended transportation. Two stroke patients who had attended these patients after a median time of 17 minutes (range other hospitals for the same episode, and two other 0 to 60 minutes). patients who had stroke during their hospitalization were excluded. Patients' demography and CT results Fifty patients did not use ambulance to attend A&E were recorded in Table 2. For the 65 ambulance users, and 36 of them did not consult private practitioners their stroke onset time and time lag were recorded before their A&E attendance. Their median time lag in Table 3. between stroke onset to A&E consultation was 641 minutes. Four teen of them consulted private For the 65 patients who used ambulance, the median practitioners before attending A&E. Their median time interval between stroke onset to call 999 (phase I) time lag was 3,672 minutes. As a whole group, their was 151 minutes (ranged 0 to 10,751 minutes). The median time lag was 950 minutes. (Table 4) Table 2. Patients' demography and CT results Male: Female 61: 54 Age (mean; median; range) (yr) 69; 70; 35~94 CT results: Haemorrhage (%) 22 (19.1%) Ischaemia (%) 88 (76.5%) Subarachnoid haemorrhage (%) 3 (2.6%) Undefined (no imaging) 2 (1.7%) Table 3. Time interval for 65 ambulance users from stroke onset to A&E arrival Stroke onset time mn- 3a.m.- 6 a.m.- 9 a.m.- 12 noon- 3 p.m.- 6 p.m.- 9 p.m.- Total 3 a.m. 6 a.m. 9 a.m. 12 noon 3 p.m. 6 p.m. 9 p.m. 12 mn Number of patients 5 4 15 11 7 9 7 7 65 Ambulance call time mn- 3a.m.- 6 a.m.- 9 a.m.- 12 noon- 3 p.m.- 6 p.m.- 9 p.m.- Total 3 a.m. 6 a.m. 9 a.m. 12 noon 3 p.m. 6 p.m. 9 p.m. 12 mn Number of calls 3 5 8 15 10 13 8 3 65 Time lapse from <1 <2 <3 <6 <9 <12 <15 <18 <21 <24 ≧ 24 stroke, from onset to ambulance call (hr) Cumulative no. of 23 28 35 45 51 52 54 56 58 59 65 patients (%) 35 43 54 69 78 80 83 86 89 91 100 Lau et al./Delays in presentation of stroke patients 79 Table 4. PMH A&E department arrival time for stroke patients Ambulance users (n=65) All strokes median time lag = 190 min Not visit GP before PMH (n=115) (n=36) Ambulance non-users median time lag = 641 min (n=50) median time lag = 950 min Visit GP before PMH (n=14) median time lag = 3,672 min Discussion stroke and they all died within the first seven days and 30 days respectively. Among the ambulance users, 44 Why did patients wait for more than two and a half out of 65 patients (67.7%) had ischaemic stroke. They hours before they decided to call 999 for emergency belonged to category III and IV, and they were seen ambulance? We believed that they could not recognize after a median time of 19 minutes and 16 minutes the signs and symptoms of acute strokes. They were respectively. It is important to note that they are not aware of the possibility that the patient had an acute potential candidates for rtPA treatment and they belong medical problem; hence they did not call 999. The lack to category III and IV. We therefore suggest that of knowledge was also seen in patients who did not use suspected stroke patients should be upgraded to a status emergency ambulance. The 36 ambulance non-users of category II, and be seen by doctor within 15 minutes.9 who did not visit their general practitioners had been Even with these arrangements, the doctor can only have waiting for more than ten hours before they came to about 53 minutes to take the history, perform A&E. Presumably the hemiplegia did not improve, or examination, arrange CT brain and prepare the had further deteriorated while they were waiting. The thrombolytic agent. The success of stroke treatment 14 ambulance non-users who visited their general depends on streamline arrangement as well as providing practitioners had waited even longer. They waited for effective treatment within the therapeutic window. two and a half days before they attended A&E. Our first important message was to emphasize the PMH is a general hospital with 1,130 acute beds that importance of public education to recognize the signs serves about 800,000 people. The 999 emergency of stroke and to encourage the use of emergency ambulance service has provided a high standard of ambulance service properly. While the ambulance service with no charge. In 1999 more than 93% of service will most likely remain as efficient as before, all 999 emergency ambulance requests could be met the interval between stroke onset to call 999 (phase I) within 12 minutes.10 should be within 80 minutes if not shorter. The reason is that triage, physical examination, CT brain and With the success of rtPA treatment in acute ischaemic preparation of thrombolytic agent will require another stroke, reasons for late admission were carefully 60 minutes. We conclude that patient delay is the main searched. Possibilities included: low awareness, lack obstacle in providing early therapeutic treatment to of knowledge, lack of supporting relatives, stroke patients and changes can be done in phase I. geographical reason, means of transportation, time of onset, age, availability of insurance cover and The triage system in our A&E department was the same transportation.8,11 In our study, the lack of knowledge as the standard practice for all A&E departments in and prompt responses were the essential hurdles. We Hong Kong and also in many hospitals overseas. Patients put much emphasis on stroke onset time. It had been with worse symptoms and poor outcomes tended to arbitrarily recorded as the midpoint between going come early.7,8 Nevertheless when we examined the result, to bed and waking up. 8 Our study used the earliest all category I and II stroke patients had haemorrhagic possible time because the actual time of stroke onset 80 Hong Kong j. emerg. med. Vol. 10(2) Apr 2003 could be as early as the beginning of sleep. In future References when rtPA is contemplated as the therapeutic agent, the earliest possible onset time must be taken.1 In other 1. Tissue plasminogen activator for acute ischemic stroke. studies, poor outcome was associated with late admission The National Institute of Neurological Disorders and of the day and also nocturnal onset of stroke.8 We could Stroke rt-PA Stroke Study Group. N Engl J Med 1995; 333(24):1581-7. not demonstrate these phenomena in our study. 2. Kwiatkowski TG, Libman RB, Frankel M, et al. Effects of tissue plasminogen activator for acute ischemic stroke We did not have a standard questionnaire for why at one year. National Institute of Neurological Disorders patients were late to hospital. A close examination of and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group. N Engl J Med 1999;340(23): the possible reasons would require another study. But 1781-7. when some patients or their relatives were interviewed 3. A system approach to immediate evaluation and later, they often expressed their inability in recognizing management of hyperacute stroke. Experience at eight early signs and symptoms of stroke. We had to reiterate centers and implications for community practice and the importance of public education as clinical features patient care. The National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Study such as sudden onset of hemiplegia, hemiparesis, Group. Stroke 1997;28(8):1530-40. dysphasia, weakness of facial muscles, ataxia, double 4. Adams HP Jr, Brott TG, Furlan AJ, et al. Guidelines vision, stupor, confusion or coma could be the first for Thrombolytic Therapy for Acute Stroke: a symptoms of stroke, no matter how simple and straight Supplement to the Guidelines for the Management of Patients with Acute Ischemic Stroke. A statement for forward they might seem to be. Unfortunately their healthcare professionals from a Special Writing Group knowledge, attitude and subsequent responses were not of the Stroke Council, American Heart Association. systematically studied in this study. Probably another Stroke 1996;27(9):1711-8. study would be necessary to identify the significance of 5. Huang CY, Chan FL, Yu YL, Woo E, Chin D. these factors.7,10,12 Cerebrovascular disease in Hong Kong Chinese. Stroke 1990;21(2):230-5. 6. Kay R, Woo J, Kreel L, Wong HY, Teoh R, Nicholls The main obstacle in providing timely treatment to acute MG. Stroke subtypes among Chinese living in Hong stroke patients is low public awareness of the symptoms Kong: the Shatin Stroke Registry. Neurology 1992; and signs of stroke. Patients and their relatives often 42(5):985-7. wait for several hours, if not days, to recognize that it is 7. Alberts MJ, Perry A, Dawson DV, Bertels C. Effects of public and professional education on reducing the a medical emergency, and then decide to call 999. Some delay in presentation and referral of stroke patients. would even visit their family doctors before they were Stroke 1992;23(3):352-6. referred to A&E. This practice has been proved to cause 8. Harper GD, Haigh RA, Potter JF, Castleden CM. further delay.9 Our suggestions are: educate the public Factors delaying hospital admission after stroke in Leicestershire. Stroke 1992;23(6):835-8. to recognize the symptoms and signs of acute stroke 9. Harraf F, Sharma AK, Brown MM, Lees KR, Vass RI, and then come to A&E by ambulance. In A&E triage, Kalra L. A multicentre observational study of stroke patients should be upgraded to category II even presentation and early assessment of acute stroke. BMJ if they appear stable, because these groups of patients 2002;324(7354):17. can benefit from thrombolytic therapy in the narrow 10. Lo CB, Lai KK, Mak KP. Prehospital care in Hong Kong. Hong Kong Med J 2000;6(3):283-7. time window. 11. Esagunde RU, Navarro JC, Conde BL, Marasigan SM, Javier RS. Reasons for the delay in hospital admissions among stroke patients seen at JRRMMC [Abstract]. Acknowledgement 4th Biennial Convention of the ASEAN Neurological Association (ASNA) 2001:91. 12. Jorgensen HS, Nakayama H, Reith J, Raaschou HO, We would like to acknowledge the Emergency Olsen TS. Factors delaying hospital admission in acute Ambulance Service of Fire Services Department for stroke: the Copenhagen Stroke Study. Neurology their contribution in this study. 1996;47(2):383-7.
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