Factors delaying management of acute stroke: An Indian scenario

Abstract

Background and purpose: The purpose of this study was to assess factors causing delay in treatment of acute stroke in a tertiary care institute in South India.

Methods: All clinically suspected cases of acute stroke presenting to the emergency department over a period of 1 year were prospectively followed up and data collected as per a preset pro forma. The various time intervals from stroke onset to definitive management and other pertinent data were collected. The time delays have been evaluated in the decision tree model: Chi-squared Automatic Interaction Detection. Significance was assessed at 5% level of significance (P < 0.05).

Results: The mean prehospital time delay for all clinically suspected stroke (n = 361) in our institute was 716 min and the median time 190 min. The mean total in-hospital delay was 94.17 ± 54.5 min and median time being 82 min. The onset of symptoms to first medical contact was the main interval that influenced the prehospital delay. Computed tomographic (CT) diagnosis to stroke unit admission influenced the in-hospital delay the most.

Conclusions: Lack of awareness regarding stroke leads to delayed seeking of treatment for the same. The factors that contribute to the in-hospital delay included patient admission procedure delay, lack of staff to transport the patient, and the distance between the stroke unit and CT room. Educating the community with regard to "stroke" and implementation of a better pre- and in-hospital stroke care system is a need of the hour in the country.

Keywords: Decision tree analysis; in-hospital; prehospital; stroke; thrombolysis; time delays.

Figure 1

Stroke to therapy time frames: onset - Stroke onset time; onset to first medical contact - time of onset of symptoms to first medical contact time; first medical contact to emergency department - time taken from first medical contact to the emergency department door; emergency department door to detection - time taken for detection of stroke; detection to diagnosis - detection of stroke to computed tomographic interpretation; diagnosis to stroke unit - computed tomographic interpretation to admission to neurology Intensive Care Unit/stroke unit; stroke unit to consent - Time taken to obtain consent; consent to drug - time taken for administering the drug. AIS: Acute ischemic stroke

Figure 2

Flow diagram illustrating the subgroups, in which the data were analyzed. TIA: Transient Ischemic Attack, mins: Minutes, hrs: Hours

Figure 3

Gain summary for nodes in decision tree analysis of prehospital delay in all stroke decision tree analysis of the prehospital time of all clinically suspected stroke (n = 361) with onset to first medical contact, first medical contact to door as independent variables revealed that onset to first medical contact was the most influential factor with node 4, 30% with a mean 2002.95 min influencing the onset to first medical contact the most

Figure 4

Gain and summary for nodes of decision tree analysis of in-hospital delay in all ischemic stroke. (n = 273). Decision tree analysis of the total in-hospital time for all ischemic stroke. (n = 273), with first medical contact to emergency department, emergency department door to detection, detection to diagnosis, diagnosis to stroke unit, stroke unit to consent, consent to drug, and onset of symptoms to first medical contact as the independent variables revealed that diagnosis to stroke unit was the most influential factor, with node 3, 28.9% with mean 134.7. min influencing diagnosis to stroke unit the most