Analysis of Time to the Hospital and Ambulance Use Following a Stroke Community Education Intervention in China

The Certification Ranking of Stroke Treatment Centers Is Unclear to the General Public

ABSTRACT

BACKGROUND: Certified stroke treatment centers are classified based on their available resources to treat stroke including an Acute Stroke Ready Hospital (ASRH), a primary stroke center (PSC), a Thrombectomy-Capable Stroke Center (TCSC), and comprehensive stroke centers (CSCs). These hospitals all provide varying levels of care with CSCs being the most able to treat all types and complexities of stroke. This undergraduate nursing-led study explored the public's preference for treatment at different certified stroke treatment centers. METHODS: This study was a prospective nonrandomized observational survey of English-speaking adults at a plasma donation center in the Southwest United States. Subjects completed a 2-minute survey asking whether they would drive to the hospital or call 911 during a suspected stroke, and at which type of hospital they would prefer to be treated. RESULTS: Of 249 respondents, 204 (81.9%) indicated that they would call 911 for hospital transport, and 45 (18.1%) would drive their family member to a hospital. Most respondents (95/248, 38.3%) would prefer treatment at a PSC, 90 (36.3%) preferred an ASRH, 52 (21.0%) preferred a CSC, and 11 (4.4%) preferred a TCSC. There was no association between transportation preference and hospital preference dichotomized as CSC or PSC versus ASRH or TCSC (χ 2 = 0.021, P = .885), nor CSC versus other (χ 2 = 0.944, P = .331). CONCLUSION : Most respondents did not select CSC as the preferred treatment site, and 1 in 5 would drive rather than call 911. This indicates a knowledge gap regarding stroke center classification that warrants increased education.

WSO Action Plan for Stroke Prehospital Care: Top Two Priorities

This editorial commentary describes the consensus reached by a group of experts from the World Stroke Organization regarding two top priorities to improve stroke prehospital care on the global stage. The first priority is effective stroke action awareness, and the second is the research and development of point-of-care prehospital diagnostic technologies.

Pre-hospital delay intention and its associated factors in the high-risk population of stroke: a latent profile analysis

AIMS

To explore the possible latent classifications of pre-hospital delayed intention at high risk of stroke and to analyse the characteristics of different profiles.

METHODS AND RESULTS

A cross-sectional study was conducted in one community in Shanghai, China. Four hundred and seventy individuals at high risk of stroke were recruited, and self-reported questionnaires (including socio-demographic, stroke knowledge, health belief, and pre-hospital delay behaviour intention scale) were distributed between April and June 2023. A latent profile analysis was employed to identify the delay intention clusters, and multinomial logistic regression was utilized to ascertain the factors influencing the latent classes of delay intention. Four hundred and fifty-seven high-risk populations with a response rate of 97.23% were finally enrolled in this study. Four distinct classes were identified: high warning signs-low delay intention (26.3%), low warning signs-low delay intention (17.7%), moderate level of delay intention (37.3%), and high level of delay intention (18.7%). The influencing factors included stroke knowledge, health belief, age, education background, the nearest distance to the medical institution, and household income.

CONCLUSION

The pre-hospital delay intention among high-risk populations of stroke was classified into four distinct classes. It is crucial for individuals at high risk to remain vigilant towards stroke symptoms and to take prompt action. Health promotion education may be explored as a strategy to bridge the gap between the recognition of stroke symptoms and the low pre-hospital delay intention.

Effectiveness of a home-based telesurveillance program in reducing hospital readmissions in older patients with chronic disease: The eCOBAHLT randomized controlled trial

INTRODUCTION

Given that chronic, long-term conditions are increasingly common in older patients, the impact of telesurveillance program on clinical outcomes is uncertain. This study aimed to evaluate the feasibility and effectiveness of a 12-month remote monitoring program in preventing rehospitalizations in older patients with two or more chronic diseases returning home after hospitalization.

METHODS

We conducted a multicenter randomized controlled trial in two parallel groups to evaluate the remote monitoring system. Elderly patients with chronic diseases (at least two comorbidities) aged 65 years or older and discharged home after acute hospital care for a chronic disease were randomized to receive a home telemonitoring program (intervention group, n = 267) or conventional care (control group, n = 267). The remote home monitoring program was an online biometric home life analysis technology (e-COBAHLT) with tele-homecare/automation and biometric sensors. The eCOBALTH intervention group received the automation sensors containing chronic disease clinical factor trackers to monitor their biometric parameters and detect any abnormal prodromal disease decompensation by remote monitoring and providing geriatric expertise to general practitioners. The usual care group received no eCOBALTH program. In both groups, baseline visits were conducted at baseline and the final visit at 12 months. The primary outcome was the incidence of unplanned hospitalizations for decompensation during the 12-month period.

RESULTS

Among 534 randomized participants (mean [SD] age, 80.3 [8.1] years; 280 [52.4%] women), 492 (92.1%) completed the 12-month follow-up; 182 (34.1) had chronic heart failure, 115 (21.5%) had stroke, and 77 (14.4%) had diabetes. During the 12-month follow-up period, 238 patients had at least one unplanned hospitalization for decompensation of a chronic disease: 108 (40.4%) in the intervention group versus 130 (48.7%) in the control group (P = 0.04). The risk of rehospitalization was significantly reduced in the intervention group (age- and sex-adjusted relative risk: 0.72, 95% 95% confidence intervals 0.51-0.94).

CONCLUSION

A 12-month home telemonitoring program with online biometric analysis using Home life technology combining telecare and biometric sensors is feasible and effective in preventing unplanned hospitalizations for chronic disease decompensation in elderly patients with chronic diseases at high risk for hospitalizations.

Identification of Key Genes Mediated by N6-Methyladenosine Methyltransferase METTL3 in Ischemic Stroke via Bioinformatics Analysis and Experiments

The N6-methyladenosine (m6A) methyltransferase METTL3 has been demonstrated to function in mediating m6A modification, but its role in ischemic stroke (IS) has not been fully elucidated. This study aimed to explore the downstream mechanism of METTL3-mediated m6A modification in IS. GSE16561 and GSE22255 were downloaded from the Gene Expression Omnibus database for analysis of differentially expressed genes (DEGs), and it was found that METTL3 mRNA was downregulated in IS. Then quantitative real-time polymerase chain reaction was used to verify the downregulation of METTL3 mRNA in the peripheral blood of IS patients and the cortexes of transient middle cerebral artery occlusion mice. By combining DEGs with the m6A-downregulated genes in GSE142386 which performed methylated RNA immunoprecipitation sequencing (MeRIP-seq) on METTL3-deficient and control endothelial cells, a total of 131 genes were identified as the METTL3-mediated m6A-modified genes in IS. Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis showed that the genes were mainly involved in cytokine-cytokine receptor interaction, MAPK signaling pathway and NF-kappa B signaling pathway. CTSS and SBK1 were further screened as the key METTL3-mediated m6A-modified genes by random forest model and PCR validation. The ROC curve analysis showed that the combination with CTSS and SBK1 was of good diagnostic value for IS, with the AUC of 0.810, sensitivity of 0.780, and specificity of 0.773. Overall, we found that METTL3-mediated m6A modification may influence the occurrence and development of IS by participating in inflammation-related biological processes, and two key m6A-modified genes mediated by METTL3 (CTSS and SBK1) can be used as diagnostic biomarkers for IS.

Prevalence and determinants of prehospital delay among stroke patients in mainland China: A systematic review and meta-analysis of the study protocol

BACKGROUND

Prehospital delay is one of the most serious problems in the treatment of stroke patients. In China, although hospitals at all levels have promoted the construction of stroke centers, pre-hospital delays are still very common. As the primary cause of death and disability, stroke not only brings great harm to patients themselves, but also brings a heavy burden on social progress and economic development, it is important to understand the prevalence and determinants of prehospital delay among stroke patients. Therefore, this review aims to determine the pooled prevalence and determinants of prehospital delay in mainland China.

METHODS

A systematic review of eligible articles will be conducted using preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. A comprehensive literature search will be conducted in PubMed, Embase, Cochrane, web of science, China National Knowledge Infrastructure (CNKI), Wanfang, Weipu (VIP) and Chinese Biomedicine Iiterature databas (CBM) databases. The quality of the articles included in the review will be evaluated using the Newcastle-Ottawa Scale (NOS). The pooled prevalence of prehospital delay, and odds ratio and their 95% confidence intervals for relevant influencing factors, will be calculated using RevMan 5.3 software. The existence of heterogeneity among studies will be assessed by computing p-values of Higgins's I2 test statistics and Cochran's Q-statistics. Sensitivity analysis and subgroup analysis will be conducted based on study quality to investigate the possible sources of heterogeneity. Publication bias will be evaluated by funnel chart and by Egger's regression test. This review protocol has been registered PROSPERO (CRD42023484580).

DISCUSSION

By collecting and summarizing information on prehospital delay among stroke patients can be a step towards a better understanding of the prevalence of prehospital delay among stroke patients in mainland China and how the associated factors influence the prevalence of prehospital delay. Therefore, a rapid, accurate diagnosis Stroke, timely pre-hospital first aid, the treatment process forward, for the patient It has great significance. This summarized finding at the national level will provide new clues for intervention to reduce the rate of pre-hospital delay of stroke patients, and is expected to further improve the treatment effect of stroke patients.

Epidemiological profile of stroke in Qatar: Insights from a seven-year observational study

OBJECTIVES

Stroke prevalence is progressively increasing in developing countries due to increased vascular risk factors. This study aims to describe the epidemiology, prevalent risk factors, and outcomes of stroke in a multi-ethnic society of Qatar.

MATERIALS AND METHODS

We conducted a retrospective analysis of all patients with suspected stroke admitted to stroke services between January 2014 and September 2020.

RESULTS

A total of 11,892 patients were admitted during this period with suspected stroke. Of these, the diagnosis was ischemic stroke (48.8 %), transient ischemic attack (10.3 %), intracerebral hemorrhage (10.9 %), cerebral venous sinus thrombosis (1.3 %), and stroke mimics (28.6 %). The median age was 52 (43-62), with a male-female ratio of 3:1. The study population was predominantly Asian (56.8 %) and Arab (36 %). The majority of the patients were hypertensive (66.8 %), diabetic (47.9 %), and dyslipidemic (45.9 %). A history of prior stroke was observed in 11.7 %, while 0.9 % had prior transient ischemic attack. Among ischemic strokes, 31.7 % arrived within 4.5 h, 12.5 % received thrombolysis, and 4.6 % underwent thrombectomy. Median Door-to-Needle time was 51 (33-72) minutes. The average length of stay was 5.2 ± 9.0 days, with 71.5 % discharged home, 13.8 % transferred to rehabilitation, 9.3 % to other specialties, 3 % to long-term care, and 2.4 % suffered in-hospital mortality.

CONCLUSION

Stroke in Qatar is characterized by a younger, expatriate-dominant cohort, with notable prevalence of ischemic and hemorrhagic stroke and a distinct risk factor profile. Further analysis of epidemiological differences among different population groups can inform targeted policies for prevention and management to reduce the burden of disease.

Value of the stroke 1-2-0 prehospital stroke education system: the experience of a general practitioner team

BACKGROUND

Stroke is one of the leading causes of death worldwide, especially in developing countries. In China, there is an urgent need to educate people about stroke awareness and the importance of using emergency medical services (EMS) quickly after a stroke has occurred.

OBJECTIVE

We sought to explore the effects of the Stroke 1-2-0 Prehospital Stroke Education System based on the experience of a general practitioner team.

METHOD

We prospectively enrolled 119 community general practitioners to be trained in the procedures advocated by the Stroke 1-2-0 Prehospital Stroke Education System. The training content included early detection of ischemic stroke, first aid for stroke, and intravenous thrombolysis; The effects of the training were later evaluated via a before-and-after comparison. The 119 enrolled physicians formed a Stroke 1-2-0 lecturer group and taught stroke knowledge to community residents. The group remained active for 6 months, during which the medical treatment data of stroke patients (i.e., stroke onset time, prehospital delay, whether an ambulance was called, and whether thrombolytic therapy was performed) in each of 5 jurisdictions were recorded for the month before (January 2021) and that after (August 2021) the 6-month community education program. Finally, the effects of the community education program were evaluated.

RESULTS

The participants' understanding of intravenous thrombolysis in the treatment of acute ischemic stroke improved significantly after the training as compared with their earlier understanding (96% vs. 78.99%; P < .001), and their understanding of the time window for intravenous thrombolysis increased from 26.05% before to 72% (P < .001) after the training. Most of the participants (90% vs. 67.23%; P < .001) said that they would immediately call the 120 emergency number of China's emergency phone system if they encountered individuals who appeared to be victims of acute stroke. A total of 82 stroke patients were seen before and 67 after the community education program. As for the use of the emergency call system, more patients with stroke activated that system after the program versus before (21.95% vs. 37.31%; P = .04). The 3-hour arrival rate after the program was nearly three times higher than that before the program (62.69% vs. 19.51%; P < .001). Also, regarding receiving thrombolysis after the occurrence of a stroke, the program triggered a substantial increase compared with the total earlier (19.4% vs. 6.1%; P = .013).

CONCLUSION

We found that the Stroke 1-2-0 Prehospital Stroke Education System significantly improved community residents' knowledge regarding stroke.

Results of an international survey on the status of prehospital care

BACKGROUND

Prehospital care including recognition of stroke symptoms by the public and professionals combined with an efficient and effective emergency medical service (EMS) is essential to increase access to effective acute stroke care. We undertook a survey to document the status of stroke prehospital care globally.

METHODS

A survey was distributed via email to the World Stroke Organization (WSO) members. Information was sought on the current status of stroke prehospital delay globally, including (1) ambulance availability and whether payment for use is required, (2) ambulance response times and the proportion of patients arriving at hospital by ambulance, (3) the proportion of patients arriving within 3 h and more than 24 h after symptom, (4) whether stroke care training of paramedics, call handlers, and primary care staff, (5) availability of specialist centers, and (6) the proportion of patients taken to specialist centers. Respondents were also asked to identify the top three changes in prehospital care that would benefit their population. Data were analyzed descriptively at both country and continent level.

RESULTS

Responses were received from 116 individuals in 43 countries, with a response rate of 4.7%. Most respondents (90%) reported access to ambulances, but 40% of respondents reported payment was required by the patient. Where an ambulance service was available (105 respondents) 37% of respondents reported that less than 50% of patients used an ambulance and 12% less than 20% of patients used an ambulance. Large variations in ambulance response times were reported both within and between countries. Most of the participating high-income countries (HIC) offered a service used by patients, but this was rarely the case for the low- and middle-income countries (LMIC). Time to admission was often much longer in LMIC, and there was less access to stroke training for EMS and primary care staff.

CONCLUSIONS

Significant deficiencies in stroke prehospital care exist globally especially in LMIC. In all countries, there are opportunities to improve the quality of the service in ways that would likely result in improved outcomes after acute stroke.

Prevalence and determinants of delays in care among premature deaths due to acute cardiac conditions and stroke in residents of a district in India

Background

Lack of timely care is a predictor of poor outcomes in acute cardiovascular emergencies including stroke. We assessed the presence of delay in seeking appropriate care among those who died due to cardiac/stroke emergencies in a community in northern India and identified the reasons and determinants of this delay.

Methods

We conducted a social audit among all civil-registered premature (30-69 years) deaths due to acute cardiac event or stroke in the district. The three-delays model was used to qualitatively classify the delays in care-seeking-deciding to seek care, reaching the appropriate health facility (AHF) and initiating definitive treatment. Based on the estimated time from symptom onset to reaching AHF, we classified patients as early (reached within one hour) or delayed arrivers. We used mixed-effect logistic regression with postal code as a random effect to identify determinants of delayed arrival.

Findings

Only 10.8% of the deceased reached an AHF within one hour. We noted level-1 delay in 38.4% (60% due to non-recognition of seriousness); level-2 delay in 20% (40% due to going to an inappropriate facility) and level-3 delay in 10.8% (57% due to lack of affordability). Patients with a monthly family income of >270US$ (aOR 0.44; 95% CI 0.21-0.93) were less and those staying farther from AHF (aOR 1.12; 95% CI 1.01-1.25 for each Km) were more likely to have delayed arrival in AHF.

Interpretation

A small proportion of patients with cardiac and stroke emergencies reach health facility early with delays at multiple levels. Addressing the reasons for delay could prevent these deaths.

Funding

: Indian Council of Medical Research, New Delhi, India.

Association of the Stroke Ready Community-Based Participatory Research Intervention With Incidence of Acute Stroke Thrombolysis in Flint, Michigan

Importance

Acute stroke treatment rates in the US lag behind those in other high-income nations.

Objective

To assess whether a hospital emergency department (ED) and community intervention was associated with an increased proportion of patients with stroke receiving thrombolysis.

Design, Setting, and Participants

This nonrandomized controlled trial of the Stroke Ready intervention took place in Flint, Michigan, from October 2017 to March 2020. Participants included adults living in the community. Data analysis was completed from July 2022 to May 2023.

Intervention

Stroke Ready combined implementation science and community-based participatory research approaches. Acute stroke care was optimized in a safety-net ED, and then a community-wide, theory-based health behavior intervention, including peer-led workshops, mailers, and social media, was conducted.

Main Outcomes and Measures

The prespecified primary outcome was the proportion of patients hospitalized with ischemic stroke or transient ischemic attack from Flint who received thrombolysis before and after the intervention. The association between thrombolysis and the Stroke Ready combined intervention, including the ED and community components, was estimated using logistic regression models, clustering at the hospital level and adjusting for time and stroke type. In prespecified secondary analyses, the ED and community intervention were explored separately, adjusting for hospital, time, and stroke type.

Results

In total, 5970 people received in-person stroke preparedness workshops, corresponding to 9.7% of the adult population in Flint. There were 3327 ischemic stroke and TIA visits (1848 women [55.6%]; 1747 Black individuals [52.5%]; mean [SD] age, 67.8 [14.5] years) among patients from Flint seen in the relevant EDs, including 2305 in the preintervention period from July 2010 to September 2017 and 1022 in the postintervention period from October 2017 to March 2020. The proportion of thrombolysis usage increased from 4% in 2010 to 14% in 2020. The combined Stroke Ready intervention was not associated with thrombolysis use (adjusted odds ratio [OR], 1.13; 95% CI, 0.74-1.70; P = .58). The ED component was associated with an increase in thrombolysis use (adjusted OR, 1.63; 95% CI, 1.04-2.56; P = .03), but the community component was not (adjusted OR, 0.99; 95% CI, 0.96-1.01; P = .30).

Conclusions and Relevance

This nonrandomized controlled trial found that a multilevel ED and community stroke preparedness intervention was not associated with increased thrombolysis treatments. The ED intervention was associated with increased thrombolysis usage, suggesting that implementation strategies in partnership with safety-net hospitals may increase thrombolysis usage.

Trial Registration

ClinicalTrials.gov Identifier: NCT036455900.

Impact of bilingual face, arm, speech, time (FAST) public awareness campaigns on emergency medical services (EMS) activation in a large Canadian metropolitan area

BACKGROUND AND AIMS

Face, arm, speech, time (FAST) public awareness campaigns improve stroke recognition in the general population. Whether this translates into improved emergency medical services (EMS) activation remains unclear. We assessed the association of five consecutive FAST campaigns with EMS calls for suspected strokes in a large urban area of Quebec, Canada.

METHODS

We conducted an observational study to assess data collected between June 2015 and December 2019 by the public EMS agency covering the cities of Laval and Montreal (Quebec, Canada). Five FAST campaigns were held over this period (mean duration: 9 weeks). We compared daily EMS calls before and after all FAST campaigns (2015 vs 2019) with t tests and Mann-Whitney U tests. We used single-group, univariate interrupted time series to measure changes in daily EMS calls for suspected strokes following each FAST campaign (stroke categories: any, symptom onset < 5 h, Cincinnati Prehospital Stroke Scale [CPSS] 3/3). Calls for headache served as negative control.

RESULTS

After five FAST campaigns, mean daily EMS calls increased by 28% (p < 0.001) for any suspected stroke and by 61% (p < 0.001) for stroke with symptom onset < 5 h, compared to 10.1% for headache (p = 0.012). Significant increases in daily EMS calls were observed after three campaigns (highest OR = 1.26; 95% CI 1.11, 1.43; p < 0.001). There were no significant changes in calls after individual campaigns for suspected stroke with symptom onset < 5 h, or suspected stroke with CPSS 3/3.

CONCLUSIONS

We observed an inconsistent impact of individual FAST campaigns on EMS calls for any suspected stroke, and did not observe significant EMS call changes after individual campaigns for acute (< 5 h) and severe (CPSS 3/3) strokes. These results may help stakeholders identify potential benefits and limitations of public awareness campaigns using the FAST acronym.

Age and geographic disparities in acute ischaemic stroke prehospital delays in China: a cross-sectional study using national stroke registry data

Background

Stroke has been the leading cause of death in China for decades. The extremely low intravenous thrombolysis rate is largely due to the prehospital delays that make patients ineligible for the time-sensitive therapy. Limited studies evaluated prehospital delays across China. We investigated prehospital delays in the stroke population across China and the associated age, rurality, and geographic disparities.

Methods

A cross-sectional study design was employed using the Bigdata Observatory platform for Stroke of China in 2020, the nationwide, prospective, multicentre registry of patients with acute ischaemic stroke (AIS). Mixed-effect regression models were used to account for the clustered data.

Findings

The sample contained 78,389 AIS patients. The median onset-to-door (OTD) time was 24 h, with only 11.79% (95% confidence interval [CI]: 11.56-12.02%) patients arriving at hospitals within 3 h. About 12.43% (95% CI: 12.11-12.74%) of patients 65 years or older arrived at hospitals within 3 h, which was significantly higher than the young and middle-aged patients (11.03%; 95% CI: 10.71-11.36%). After controlling for potential confounders, young and middle-aged patients were less likely to present to hospitals within 3 h (adjusted odds ratio: 0.95; 95% CI: 0.90-0.99) compared to patients 65 years or older. The 3-h hospital arrival rate was the highest in Beijing (18.40%, 95% CI: 16.01-20.79%), which was almost 5 times higher than that in Gansu (3.45%, 95% CI: 2.69-4.20%). The arrival rate in urban areas was almost 2 times higher than that in rural areas (13.35% versus. 7.66%).

Interpretation

We found that the low rates of timely arrival at hospitals after a stroke is more salient in the younger population, rural settings, or those residing in less developed geographic regions. This study calls for more tailored interventions focusing on younger people, rural areas, and less developed geographic regions.

Funding

The National Natural Science Foundation of China; CIHR, Grant/Award Number: 81973157, PI: JZ. Natural Science Foundation of Shanghai; CIHR, Grant/Award Number: 17dz2308400, PI: JZ. Funding from the University of Pennsylvania; Grant/Award Number: CREF-030, PI: RL.

Prehospital stroke management and mobile stroke units

PURPOSE OF REVIEW

Delayed presentation at the hospital contributes to poorer patient outcomes and undertreatment of acute stroke patients. This review will discuss recent developments in prehospital stroke management and mobile stroke units aimed to improve timely access to treatment within the past 2 years and will point towards future directions.

RECENT FINDINGS

Recent progress in research into prehospital stroke management and mobile stroke units ranges from interventions aimed at improving patients' help-seeking behaviour, to the education of emergency medical services team members, to the use of innovative referral methods, such as diagnostic scales, and finally to evidence of improved outcomes by the use of mobile stroke units.

SUMMARY

Understanding is increasing about the need for optimizing stroke management over the entire stroke rescue chain with the goal of improving access to highly effective time-sensitive treatment. In the future, we can expect that novel digital technologies and artificial intelligence will become relevant in effective interaction between prehospital and in-hospital stroke-treating teams, with beneficial effects on patients' outcomes.

Impact of the COVID-19 pandemic on acute stroke care: An analysis of the 24-month data from a comprehensive stroke center in Shanghai, China

INTRODUCTION

Whether the coronavirus disease-2019 (COVID-19) pandemic is associated with a long-term negative impact on acute stroke care remains uncertain. This study aims to compare the timing of key aspects of stroke codes between patients before and after the COVID-19 pandemic.

METHODS

This retrospective cohort study was conducted at an academic hospital in Shanghai, China and included all adult patients with acute ischemic stroke hospitalized via the emergency department (ED) stroke pathway during the 24 months since the COVID-19 outbreak (COVID-19: January 1, 2020-December 31, 2021). The comparison cohort included patients with ED stroke pathway visits and hospitalizations during the same period (pre-COVID-19: January 1, 2018-December 31, 2019). We compared critical time points of prehospital and intrahospital acute stroke care between patients during the COVID-19 era and patients during the pre-COVID-19 era using t test, χ² , and Mann-Whitney U test where appropriate.

RESULTS

A total of 1194 acute ischemic stroke cases were enrolled, including 606 patients in COVID-19 and 588 patients in pre-COVID-19. During the COVID-19 pandemic, the median onset-to-hospital time was about 108 min longer compared with the same period of pre-COVID-19 (300 vs 192 min, p = 0.01). Accordingly, the median onset-to-needle time was 169 min in COVID-19 and 113 min in pre-COVID-19 (p = 0.0001), and the proportion of patients with onset-to-hospital time within 4.5 h was lower (292/606 [48.2%] vs 328/558 [58.8%], p = 0.0003) during the pandemic period. Furthermore, the median door-to-inpatient admission and door-to-inpatient rehabilitation times increased from 28 to 37 h and from 3 to 4 days (p = 0.014 and 0.0001).

CONCLUSIONS

During the 24 months of COVID-19, a prolongation of stroke onset to hospital arrival and to intravenous rt-PA administration times were noted. Meanwhile, acute stroke patients needed to stay in the ED for a longer time before hospitalization. Educational system support and process optimization should be pursued in order to acquire timely delivery of stroke care during the pandemic.

Pre- and in-hospital delays in the use of thrombolytic therapy for patients with acute ischemic stroke in rural and urban Egypt

Background

Reducing pre- and in-hospital delays plays an important role in increasing the rate of intravenous thrombolysis (IVT) in patients with acute ischemic stroke. In Egypt, the IVT rate has increased steadily but is still far away from an ideal rate.

Aim

The study aimed to investigate the factors associated with pre- and in-hospital delays of IVT among patients with acute ischemic stroke coming from urban and rural communities.

Methods

This prospective, multicenter, observational cohort study was conducted from January 2018 to January 2019. Patients with acute ischemic stroke, who did not receive IVT, were included in the study. Patients were recruited from three large university stroke centers in Egypt, Assiut (south of Egypt), Tanta (north of Egypt), both serving urban and rural patients, and the University Hospital in Cairo (capital city), only serving an urban community. All participants underwent the National Institutes of Health Stroke Scale and full neurological assessment, urgent laboratory investigations, and computed tomography or magnetic resonance imaging to confirm the stroke diagnosis. The patients were subjected to a structured questionnaire that was designed to determine the parameters and time metrics for the pre- and in-hospital delays among patients from rural and urban regions.

Results

A total of 618 patients were included in the study, of which 364 patients (58.9%) lived in rural regions and 254 (41.1%) in urban regions. General demographic characteristics were similar between both groups. Approximately 73.3% of patients who arrived within the therapeutic time window were urban patients. The time from symptom onset till hospital arrival (onset to door time, ODT) was significantly longer among rural patients (738 ± 690 min) than urban patients (360 ± 342 min). Delayed onset to alarm time (OAT), initial misdiagnosis, and presentation to non-stroke-ready hospitals were the most common causes of pre-hospital delay and were significantly higher in rural patients. For patients arriving within the time window, the most common causes of in-hospital delays were prolonged laboratory investigations and imaging duration.

Conclusion

The limited availability of stroke-ready hospitals in rural Egypt leads to delays in stroke management, with subsequent treatment inequality of rural patients with acute stroke.