Presentation Time to Hospital and Recognition of Stroke in Patients with Ischemic Stroke
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1 Presentation Time to Hospital and Recognition of Stroke in Patients with Ischemic Stroke Ji Hoe Heo, M.D., Hwa Young Cheon, M.D., Chung Mo Nam, Ph.D.*, Dong Chan Kim, R.N., Gyung Whan Kim, M.D., Byung In Lee, M.D. Department of Neurology and Preventive Medicine*, College of Medicine, Yonsei University B a c k g r o u n d : Recent advances in stroke therapies require patients to be treated very early after the onset of symptoms. To reduce the delay in time upon stroke and arriving at the hospital, we assessed the time delay, stroke recognition, and awareness before and after a public education program designed to increase recognition and awareness. M e t h o d s : Prospective standardized and structured interviews were performed in 155 patients with ischemic stroke who were admitted to the Severance hospital before and after the public education program. The educational program included local newspaper articles, distribution of pamphlets, and lectures to 119 emergency care teams. Time delay, variable factors, stroke recognition, and stroke awareness of patients were then assessed (75 pre-education and 80 post-education groups). R e s u l t s : 52% of the pre-education group and 52.5% of the post-education group arrived at the hospital within 24 hours. Those who arrived within 3 hours were only 21.3% and 15% respectively. A direct visit to the hospital and a cardioembolic infarction appeared to be associated with a shorter time delay. About half of the patients recognized their symptoms as a stroke before a diagnosis was made by a doctor. Most of them had known that a stroke should be treated urgently. However, the stroke recognition and awareness was not associated with an early arrival, which suggests that their knowledge was not solid. The efforts to inform the public using local newspaper articles and pamphlets geared towards the local residents for the limited time period was not effective in shortening arrival times. C o n c l u s i o n s : Many of the stroke patients did not arrive within the therapeutic time window. Our findings suggest that extensive and multidirectional campaigns should be performed to reduce the time delay. Our findings also suggest that educational aims should include the need for the rapid treatment of stroke and a therapeutic time window as well as stroke recognition. J Korean Neurol Assoc 18(2):125~131, 2000 Key Words : Presentation time, Arrival, Cerebrovascular disorders, Cerebral infarction, Education Ji Hoe Heo, M.D. Copyright 2000 by the Korean Neurological Association 125
2 126 J Korean Neurol Assoc / Volume 18 / March, 2000
3 Table 1. Demographic charateristics of patients Characteristics Pre-education Post-education Total Number of patients Sex men 43 (57.3) 49 (61.3) 92 (59.4) women 32 (42.7) 31 (38.8) 63 (40.6) Age (year) mean SD Occupation unemployed 21 (28.0) 37 (46.3) 58 (37.4) housewife 17 (22.7) 16 (20.0) 33 (21.3) office worker 6 (8.0) 10 (12.5) 16 (10.3) outdoor labor 7 (9.3) 2 (2.5) 9 (5.8) indoor labor 4 (5.3) 4 (5.0) 8 (5.2) expert 10 (13.3) 3 (3.8) 13 (8.4) others 10 (13.3) 8 (10.0) 18 (11.6) Education college 17 (22.7) 17 (21.3) 34 (21.9) high school 18 (24.0) 25 (31.3) 43 (27.7) middle school 13 (17.3) 9 (11.3) 22 (14.2) elementary school 19 (25.3) 19 (23.8) 38 (24.5) illiteracy 7 (9.3) 9 (11.3) 16 (10.3) unresponder 1 (1.3) 1 (1.3) 2 (1.3) Stroke type atherothrombotic 32 (42.7) 31 (38.8) 63 (40.6) cardioembolic 9 (12.0) 9 (11.3) 18 (11.6) lacunar 19 (25.3) 20 (25.0) 39 (25.2) undeterminate 11 (14.7) 15 (18.8) 26 (16.8) TIA 1 (1.3) 5 (6.3) 6 (3.9) SD : standard deviation, TIA; transient ischemic attack Numbers in parentheses are percentages. Figure 1. Cumulative line graph of the presentation time from stroke onset to arrival in the hospital. J Korean Neurol Assoc / Volume 18 / March,
4 Table 2. Clinical factors affecting on the time delay to hospital arrival Yes No Patients Time delay (hours) Patients Time dealy (hours) N mean (SD) N mean (SD) p-value Neurologic deficits weakness (119.5) (79.1) somatic sensory (121.4) (94.6) cortical sensory (85.4) (112.1) aphasia (82.0) (111.5) dementia (34.6) (109.1) neglect (106.8) (108.3) apraxia (135.4) (106.5) dysarthria (102.9) (111.5) visual field defect (62.4) (120.6) facial palsy (64.3) (109.8) EOM disturbance (63.3) (115.0) ataxia (92.8) (113.9) vertigo (149.4) (97.5) Past history stroke (114.2) (106.2) TIA (35.6) (108.7) DM (42.7) (110.8) Hypertension (66.5) (112.1) N : number of patients, EOM; extraocular movement, TIA : transient ischemic attack, DM : diabetes mellitus, SD : standard deviation Table 3. Multiple regression analysis of factors affecting on the time delay Variables Coefficient t-value p-value Neurologic deficits weakness cortical sensory neglect EOM disturbance Stroke type cardioembolic lacunar undeterminate TIA Referral way western medical facilities oriental medical facilities EOM : extraocular movement, TIA : transient ischemic attack Western medical facilities include clinics, general hospitals, and university hospitals. Oriental medical facilites include oriental medicine clinics and hospitals. The reference categories of stroke type and referral way were atherothrombotic and direct visit, respectively. R square of this model was 28.3%. 128 J Korean Neurol Assoc / Volume 18 / March, 2000
5 Figure 2. Time delay by stroke subtype. Patients with cardioembolic infarction showed a shorter presentation time to the hospital. Figure 3. Time delay by referral. Western medical facilities include clinics, general hospitals, and university hospitals while oriental medical facilities include oriental medicine clinics and hospitals. Patients who directly visited the hospital presented earlier than those who went through other medical facilities, especially oriental medicine. Figure 4. The path of referral routes. Table 4. The way of getting knowlege on the necessity of urgent stroke treatment Pre-education Post-education Total Common sense 47 (73.4) 57 (80.3) 104 (77.0) Doctor 8 (12.5) 9 (12.7) 17 (12.6) Neighbors or relatives 5 (7.8) 3 (4.2) 8 (5.9) Education 2 (3.1) 2 (1.5) Television 1 (1.4) 1 (0.7) Pamphlets 1 (1.4) 1 (0.7) Newspaper 0 (0.0) Magazine 0 (0.0) Radio 0 (0.0) Others 2 (3.1) 2 (1.5) Total 64 (100) 71 (100.0) 135 (100.0) Numbers are numbers of patients. Numbers in parentheses are percentages. J Korean Neurol Assoc / Volume 18 / March,
6 130 J Korean Neurol Assoc / Volume 18 / March, 2000
7 11. The National Institute of Neurological Disorders and Stroke rt-pa stroke study group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med ; : Camarata PJ, Heros RC, Latchaw RE. Brain attack : The rationale for treating stroke as a medical emergency. N e u r o s u r g e r y ; 3 4 : Jung K-Y, Chung C-S, Shin K-S, Lee H-B, Kim J-H, Lee A-Y, et al. Variables associated with delayed hospital arrival of stroke patients living in Taejon and its suburban areas. J Korean Neurol Assoc ; 1 3 : Ha JH, Kim JS, Lee JH, Im JH, Lee MC. Analysis of time delay between stroke onset and hospital visit in Korean patients. J Korean Neurol Assoc ; S u p p l : Menon SC, Pandey DK, Morgenstern LB. Critical factors determining access to acute stroke care. Neurology 1998; 51: Smith MA, Doliszny KM, Shahar E, McGovern PG, Arnett DK, Luepker RV. Delayed hospital arrival for acute stroke: the Minnesota Stroke Survey. Ann Intern Med ; : Harper GD, Haigh RA, Potter JF, Castleden CM. Factors delaying hospital admission after stroke in Leicestershire. Stroke 1992;23: Salisbury HR, Banks BJ, Footitt DR, Winner SJ, Reynolds DJ. Delay in presentation of patients with acute stroke to hospital in Oxford. QJM 1998;91: Jorgensen HS, Nakayama H, Reith J, Raaschou HO, Olsen TS. Factors delaying hospital admission in acute stroke: The Copenhagen Stroke Study. Neurology ; 4 7 : Streifler JY, Davidovitch S, Sendovski U. Factors associated with the time of presentation of acute stroke patients in an Israeli community hospital. Neuroepidemiology ; 1 7 : Morris AD, Grosset DG, Squire IB, Lees KR, Bone I, Reid JL. The experiences of an acute stroke unit--implications for multicentre acute stroke trials. J Neurol Neurosurg Psychiatry ; 5 6 : Foulkes MA, Wolf PA, Price TR, Mohr JP, Hier DB. The Stroke Data Bank: design, methods, and baseline characteristics. Stroke 1988;19: Kay R, Woo J, Poon S. Hospital arrival time after onset of stroke. J Neurol Neursurg Psychiatry 1992;55: Alberts MJ, Bertels C, Dawson DV. An analysis of time of presentation after stroke. JAMA 1990;263: Fogelholm R, Murros K, Rissanen A, Ilmavirta M. Factors delaying hospital admission after acute stroke. S t r o k e ; 2 7 : Wester P, Radberg J, Lundgren B, Peltonen M. Factors associated with delayed admission to hospital and in-hospital delays in acute stroke and TIA: a prospective, multicenter study. Seek- Medical-Attention-in-Time Study Group. Stroke 1999;30: Azzimondi G, Bassein L, Fiorani L, Nonino F, Montaguti U, Celin D, et al. Variables associated with hospital arrival time after stroke: effect of delay on the clinical efficiency of early treatment. Stroke ; 2 8 : Davalos A, Castillo J, Martinez-Vila E. Delay in neurological attention and stroke outcome. Cerebrovascular Diseases Study Group of the Spanish Society of Neurology. S t r o k e ; 2 6 : Rosamond WD, Gorton RA, Hinn AR, Hohenhaus SM, Morris DL. Rapid response to stroke symptoms: the Delay in Accessing Stroke Healthcare (DASH) study. Acad Emerg M e d ; 5 : Minn YK, Heo JH, Kim GW, Choi IS. The prognostic significance of infection in acute stroke -Preliminary study. J Korean Neurol Assoc ; 1 4 : J Korean Neurol Assoc / Volume 18 / March,
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