Factors delaying management of acute stroke: An Indian scenario

Prehospital Factors Associated with Delayed Hospital Arrival of Stroke Patients: A Regional Single-Center Study from India

Background

Only a small percentage of patients with acute stroke are currently eligible for thrombolysis, partly due to severe delays in hospital arrival. We had previously conducted the first regional study to assess the factors delaying acute stroke care in India. The present study aims to understand and describe in depth the variables associated with prehospital delay among patients admitted with an acute ischemic stroke.

Methods

Data were prospectively collected by conducting an in-depth interview of 470 acute ischemic stroke patients and their bystanders, aged above 18 years, presenting to the Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur. Patients who arrived within 4.5 h of symptom onset were considered as "early arrival" and those who arrived after 4.5 h were considered as "delayed arrival." Univariate and multivariate analyses were undertaken to determine associations between variables of interest and delays to hospital presentation.

Results

Of the 470 patients who met the inclusion criteria, 73 patients reached within 4.5 h (15.5%), whereas 397 patients arrived after 4.5 h. The mean age of acute stroke patients who reached within 4.5 h was 63 ± 13.7 years, whereas the mean age of those who reached after 4.5 h was 63 ± 12.1 years. Binary logistic regression performed to quantify the associations of prehospital factors showed an increased risk of prehospital delay among individuals with lack of awareness (odds ratio [OR] = 5.16 [3.040-8.757], P < 0.001), followed by those for whom a vehicle was not available at the site of event (OR = 3.745 [1.864-7.522], P < 0.001). Within the predefined socioeconomic strata, compared to lower class, upper middle class had less risk (OR = 0.135 [0.018-1.035], P = 0.054), whereas the distance from first medical contact to emergency department contributed moderate risk (OR = 1.071 [1.028-1.116], P < 0.001) for prehospital delay.

Conclusions

Health promotion techniques that increase public knowledge about the early signs of stroke, transferring patients directly to hospitals with thrombolysis capabilities, and making ambulance services more widely available are appropriate measures to reduce prehospital delay.

Stroke systems of care in South-East Asia Region (SEAR): commonalities and diversities

The Southeast Asia Region (SEAR) accounts for nearly 50% of the developing world's stroke burden. With various commonalities across its countries concerning health services, user awareness, and healthcare-seeking behavior, SEAR still presents profound diversities in stroke-related services across the continuum of care. This review highlights the numerous systems and challenges in access to stroke care, acute stroke care services, and health care systems, including rehabilitation. The paper has also attempted to compile information on the availability of stroke specialized centers, Intravenous thrombolysis (IVT) ready centers, Endovascular therapy (EVT) ready centers, rehabilitation centers, and workforce against a backdrop of each country's population. Lastly, the efforts of WHO (SEARO)-CMCL (World Health Organization-South East Asia region, Christian Medical College & Hospital Ludhiana) collaboration towards improving stroke services and capacity among the SEAR have been described.

Six years of the Angels Initiative: Aims, achievements, and future directions to improve stroke care worldwide

The rate of stroke-related death and disability is four times higher in low- and middle-income countries (LMICs) than in high-income countries (HICs), yet stroke units exist in only 18% of LMICs, compared with 91% of HICs. In order to ensure universal and equitable access to timely, guideline-recommended stroke care, multidisciplinary stroke-ready hospitals with coordinated teams of healthcare professionals and appropriate facilities are essential.Established in 2016, the Angels Initiative is an international, not-for-profit, public-private partnership. It is run in collaboration with the World Stroke Organization, European Stroke Organisation, and regional and national stroke societies in over 50 countries. The Angels Initiative aims to increase the global number of stroke-ready hospitals and to optimize the quality of existing stroke units. It does this through the work of dedicated consultants, who help to standardize care procedures and build coordinated, informed communities of stroke professionals. Angels consultants also establish quality monitoring frameworks using online audit platforms such as the Registry of Stroke Care Quality (RES-Q), which forms the basis of the Angels award system (gold/platinum/diamond) for all stroke-ready hospitals across the world.The Angels Initiative has supported over 1700 hospitals (>1000 in LMICs) that did not previously treat stroke patients to become "stroke ready." Since its inception in 2016, the Angels Initiative has impacted the health outcomes of an estimated 7.46 million stroke patients globally (including an estimated 4.68 million patients in LMICs). The Angels Initiative has increased the number of stroke-ready hospitals in many countries (e.g. in South Africa: 5 stroke-ready hospitals in 2015 vs 185 in 2021), reduced "door to treatment time" (e.g. in Egypt: 50% reduction vs baseline), and increased quality monitoring substantially.The focus of the work of the Angels Initiative has now expanded from the hyperacute phase of stroke treatment to the pre-hospital setting, as well as to the early post-acute setting. A continued and coordinated global effort is needed to achieve the target of the Angels Initiative of >10,000 stroke-ready hospitals by 2030, and >7500 of these in LMICs.

Stumbling Blocks to Stroke Thrombolysis: An Indian Perspective

Background and purpose

Stroke is a leading cause of morbidity and mortality worldwide. Developing countries, however, still lag behind in providing timely thrombolytic therapy (TLT) to many eligible patients owing to various reasons. This study aims to identify such factors.

Materials and methods

This was a descriptive observational study undertaken over a period of 18 months at a tertiary care teaching hospital and included 252 acute ischemic stroke patients of which 200 were not thrombolyzed. The reasons for nonthrombolysis were recorded and analyzed.

Results

The study included 252 acute ischemic stroke patients of which only 20% were thrombolyzed. Of the 200 nonthrombolyzed patients, 55% arrived out of the window period while patient-related factors were the second biggest factor preventing thrombolysis. Hospital factors at 14% and financial constraints at 4.5% contributed significantly. Delayed consent emerged as an important factor making 6% of the delays.

Conclusion

Stroke thrombolysis still faces various pre- and intrahospital barriers in India. There is an urgent need to improve infrastructure and organizational streamlining to enable eligible patients to receive prompt treatment.

How to cite this article

Shah A, Diwan A. Stumbling Blocks to Stroke Thrombolysis: An Indian Perspective. Indian J Crit Care Med 2023;27(9):616-619.

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.

Factors Affecting the Delay of intravenous Thrombolysis in Hyperacute Ischemic Stroke Patients: A Single Centre Study

Introduction

Intravenous thrombolysis with r-tPA is the gold standard procedure in managing acute ischemic stroke recommended by the World Stroke Association, which is performed by injecting the drug r-tPA (Alteplase) intravenously. Generally, the preparation time to achieve thrombolysis is divided into pre-hospital and in-hospital. If this time can be shortened, the efficacy of thrombolysis can be increased. This study aims to determine the factors that can affect the delay in thrombolysis.

Methods

This is an analytic observational study with a retrospective cohort design in ischemic stroke confirmed by a neurologist at the neurology emergency unit of Hasan Sadikin Hospital (RSHS) from January 2021 to December 2021 and divided into two groups, delay and non-delay thrombolysis. A logistic regression test was performed to determine the independent predictor of delayed thrombolysis.

Results

There were 141 patients with an ischemic stroke diagnosis confirmed by a neurologist at the neurological emergency unit at Hasan Sadikin Hospital (RSHS) from January 2021 to December 2021. A total of 118 (83.69%) patients were included in the "delay" category, while 23 (16.31%) patients were included in the "non-delay" category. Patients included in the "delay" category had an average age of 58.29+11.19 years with a male-to-female sex ratio of 57%, while patients included in the "non-delay" category had an average age of 55.57+15.55 years with a male-to-female sex ratio of 66%. The NIHSS admission score was a significant risk factor for delayed thrombolysis. Through multiple logistic regression, it was found that age, onset, female gender, NIHSS admission score, and NIHSS discharge score were independent predictors of delayed thrombolysis. However, all of them were not statistically significant.

Conclusion

Gender, risk factors for dyslipidemia, and arrival onset are independent predictors of delayed thrombolysis. Prehospital factors contribute relatively more to the delay in thrombolytic action.

If Time is Neuron, What Are We Waiting for?

How to cite this article: Samavedam S. If Time is Neuron, What Are We Waiting for? Indian J Crit Care Med 2023;27(2):87-88.

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.

In-Hospital Emergency Treatment Delay Among Chinese Patients with Acute Ischaemic Stroke: Relation to Hospital Arrivals and Implications for Triage Pathways

Introduction

Timely access to emergency treatment during in-hospital care phase is critical for managing the onset of acute ischaemic stroke (AIS), particularly in developing countries. We aimed to explore in-hospital emergency treatment delay and the relation of door-to-needle (DTN) time to ambulance arrivals vs walk-in arrivals.

Methods

Data were collected from 1276 Chinese AIS patients admitted to a general, tertiary-level hospital for intravenous thrombolysis. Information on patients' characteristics and time taken during in-hospital emergency treatment was retrieved from the hospital registry data and medical records. Ambulance arrival was defined as being transported by emergency ambulance services, while walk-in arrival was defined as arriving at hospital by regular vehicle. In-hospital emergency treatment delay occurred when the DTN time exceeded 60 minutes. We performed multivariable logistic regression analysis to explore the association between hospital arrivals (by ambulance vs by walk-in) and treatment delay after adjustment for age, sex, education, marital status, residence, medical insurance, number of symptoms, clinical severity and survival outcome.

Results

Over half (53.76%) of patients aged over 60 years. Around one-fifth (20.61%) of patients admitted to hospital through emergency ambulance services, while their counterparts arrived by regular vehicle. Overall, the median time taken from the hospital door to treatment initiation was 86.0 minutes. Patients arrived by ambulance (adjusted odds ratio [aOR] = 1.744, 95% confidence interval [CI] = 1.185-2.566, p = 0.005), had higher socio-economic status (aOR = 1.821, 95% CI = 1.251-2.650; p = 0.002), or paid out-of-pocket (aOR = 2.323, 95% CI = 1.764-3.060; p < 0.001) had an increased likelihood of in-hospital emergency treatment delays.

Conclusion

In-hospital emergency treatment delay is common in China, and occurs throughout the entire emergency treatment journey. Having a triage pathway involving hospital arrival by ambulance seems to be more likely to experience in-hospital emergency treatment delay. Further efforts to improve triage pathways may require qualitative evidence on provider- and institutional-level factors associated with in-hospital emergency treatment delay.

Factors Associated with Prehospital Delay in Patients with Acute Stroke in South India

Background

Early hospital presentation is critical in the management of acute ischemic stroke. The effectiveness of stroke treatment is highly dependent on the amount of time lapsed between onset of symptoms and treatment. This study was aimed to identify the factors associated with prehospital delay in patients with acute stroke.

Material and Methods

A cross-sectional descriptive study was conducted in Sri Ramachandra University Hospital, India. A total of 210 patients hospitalized in the stroke unit were included. Patients' data were obtained by interviewing the patient and/or accompanying family member and by reviewing their medical records using a standard questionnaire. Associations were determined between prehospital delay (≥4.5 h) and variables of interest by using univariate and multivariate logistic regression analyses.

Results

The prehospital delay was observed in 154 patients (73.3%) and the median prehospital delay was 11.30 h. The following are the factors significantly (P < 0.05) attributed for the delay in presenting to the hospital: contextual factors like using public transport (bus), taxi, time of onset of symptoms, 7 pm-3 am; family history of stroke, perceived cognitive and behavioral factors like, wishing or praying for the symptoms to subside on its own, hesitation to travel due to long distance, delay in arranging transport, and arranging money for admission and wasting time by shopping for general practitioners, nursing homes, and hospitals. The presence of stroke symptom, headache, significantly decreased the prehospital delay.

Conclusions

Prehospital delay is high in South India and influenced by clinical, contextual, and cognitive/behavioral factors.

Ischemic stroke in Morocco: Prehospital delay and associated factors

OBJECTIVES

This study aimed to estimate prehospital delay and to identify the factors associated with the late arrival of patients with ischemic stroke at the Souss Massa Regional Hospital Center in Morocco.

PATIENTS AND METHODS

An observational, prospective, cross-sectional study was conducted from March 2019 to September 2019 in the Souss Massa regional hospital center, which is a public hospital structure. A questionnaire was administered to patients with ischemic stroke and to bystanders (family or others), while clinical and paraclinical data were collected from medical records. Univariate and multivariate logistic regression analyses were used to identify the factors associated with delayed arrival at emergency department.

RESULTS

A total of 197 patients and 197 bystanders who fulfilled the criteria for the study were included. The median time from symptom onset to hospital arrival was 6hours (IQR, 4-16). Multiple regression analysis showed that illiteracy (OR 38.58; CI_95%: 3.40-437.27), waiting for symptoms to disappear (patient behavior) (OR 11.24; CI_95%: 1.57-80.45), deciding to go directly to the hospital (patient behavior) (OR 0.07; CI_95%: 0.01-0.57), bystander's knowledge that stroke is a disease requiring urgent care within a limited therapeutic window (OR 0.005; CI_95%: 0.00-0.36), and direct admission without reference (OR 0.005; CI_95%: 0.00-0.07), were independently associated with late arrival (>4.5hours) of patients with acute ischemic stroke. In addition, illiteracy (OR 24.62; CI_95%: 4.37-138.69), vertigo and disturbance of balance or coordination (OR 0.14; CI_95%: 0.03-0.73), the relative's knowledge that stroke is a disease requiring urgent care and within a limited therapeutic window (OR 0.03; CI_95%: 0.00-0.22), calling for an ambulance (relative's behavior) (OR 0.16; CI_95%: 0.03-0.80), distance between 50 and 100km (OR 10.16; CI_95%: 1.16-89.33), and direct admission without reference (OR 0.03; CI_95%: 0.00-0.14), were independently associated with late arrival (>6hours) of patients with acute ischemic stroke.

CONCLUSION

Patient behavior, bystander knowledge and direct admission to the competent hospital for stroke care are modifiable factors potentially useful for reducing onset-to-door time, and thereby increasing the implementation rates of acute stroke therapies.

A Study of the Pattern of Admissions to the Accident and Emergency (A&E) Department of a Tertiary Care Hospital in Sri Lanka

Introduction

The latest national healthcare reform policies of Sri Lanka include the development of accident and emergency (A&E) departments in all major hospitals. Provincial General Hospital Kurunegala (PGHK) is a home to the first established A&E department in Sri Lanka. PGHK provides services to a population of 2.4 million spread out in the North Western Province and part of the Sabaragamuwa Province. This study was carried out to identify the pattern of all admissions to the A&E department of PGHK.

Methods

The prospective observational study was carried out from July 1, 2016, to June 30, 2017 (one year) to identify the pattern of admissions to the A&E department.

Results

There were 49,213 admissions to PGHK's A&E department during the study period. The average number of admissions was 135 (±17.9) per day. The percentage of deaths in the A&E department was 0.21%. The mean age of admitted patients was 46.7 (±21.7) years. A further 62% of admitted patients were males. The number of medical, surgical, paediatric, and gynaecological and obstetrical admissions was 55%, 42%, 3.5%, and 0.22%, respectively. Among the common emergency medical presentations, 34% were chest pain, 11% patients presented with unilateral weakness and/or slurring of speech, 10% covered dyspnoea, and 9% complained of dizziness/giddiness. Among emergency surgical presentations, 83% were trauma due to accidents, of which 27% were road-traffic-related accidents (RTAs). Discussion. The A&E department of PGHK provides services to a significantly high number of health emergencies every day. The majority of these admissions was due to chest pain and trauma related to accidents. The lower recorded number of paediatric and gynaecological and obstetrical emergencies presented to the A&E department is a result of a government policy mandating the admission of these types of patients directly to their respective wards. Further infrastructure development, staff recruitment, and training have to be planned and implemented to address the significantly high number of admissions to the A&E Department of PGHK.

Errors in the Diagnosis of Stroke-Tales of Common Stroke Mimics and Strokes in Hiding

Introduction:

Stroke mimics are some of the common causes of misdiagnosis of stroke, with an attendant surfeit of finances and resources.

Aim:

We attempt to discuss some of the common neurological conditions mimicking stroke in the emergency.

Methods:

We reviewed the articles in English discussing stroke mimics in the last 5 years of publication.

Purpose of the Review:

We discuss the most common causes of stroke mimics encountered in neurological practice. In this short communication, we shall focus on the discussion of the diagnostic pitfalls and clinical clues that will help distinguish mimics from a true stroke.