A multicentre observational study of presentation and early assessment of acute stroke

doi:10.1136/bmj.325.7354.17

BMJ 2002;325:17 ( 6 July )

Papers

A multicentre observational study of presentation and early assessment of acute stroke

Farzaneh Harraf, research fellow, ^a Anil K Sharma, consultant physician, ^b Martin M Brown, professor of stroke medicine, ^c Kennedy R Lees, professor of cerebrovascular medicine, ^d Richard I Vass, healthcare development manager, ^e Lalit Kalra, professor of stroke medicine, ^a for the Acute Stroke Intervention Study Group.

^a Department of Medicine, Guy's King's, and St Thomas's Medical School, London SE5 9PJ, ^b Department of Medicine, University Hospital, Aintree, Liverpool L9 7AL, ^c Department of Vascular Neurology, Institute of Neurology, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, ^d Department of Medicine and Therapeutics, Gardiner Institute, Western Infirmary, Glasgow G11 6NT, ^e Boehringer Ingelheim, Bracknell, Berkshire RG12 8YS

Correspondence to: L Kalra lalit.kalra{at}kcl.ac.uk

Objective: To investigate delays in the presentationto hospital and evaluation of patients with suspectedstroke.
Design: Multicentre prospective observationalstudy.
Setting: 22 hospitals in the United Kingdom andDublin.
Participants: 739 patients with suspected stroke presentingtohospital.
Main outcome measures: Time from onset of stroke symptoms to arrivalat hospital, and time from arrival to evaluation by a seniordoctor.
Results: The median age of patients was 75 years, and400 were women. The median delay between onset of symptoms andarrival at hospital was 6 hours (interquartile range 1 hour 48minutes to 19 hours 12 minutes). 37% of patients arrived within3 hours, 50% within 6 hours. The median delay for patients usingthe emergency service was 2 hours 3 minutes (47 minutes to 7 hours12 minutes) compared with 7 hours 12 minutes (2 hours 5 minutesto 20 hours 37 minutes) for referrals from general practitioners(P<0.0001). Use of emergency services reduced delays to hospital(odds ratio 0.45, 95% confidence interval 0.23 to 0.61). The mediantime to evaluation by a senior doctor was 1 hour 9 minutes (interquartilerange 33 minutes to 1 hour 50 minutes) but was undertaken in only477 (65%) patients within 3 hours of arrival. This was not influencedby age, sex, time of presentation, mode of referral, hospitaltype, or the presence of a stroke unit. Computed tomography wasrequested within 3 hours of arrival in 166 (22%) patients butundertaken in only 60 (8%).
Conclusion: Delays in patients arriving at hospital withsuspected stroke can be reduced by the increased use of emergencyservices. Over a third of patients arrive at hospital within threehours of stroke; their management can be improved by expeditingmedical evaluation and performing computed tomographyearly.

What is already known on this topic
Delay in presentation and assessment of patients with suspected stroke prevents the possible benefits from thrombolysis being achieved

Little is known about the presentation and early management of patients with acute stroke in the United Kingdom

What this study adds
Most patients with suspected stroke in the United Kingdom arrive at hospital within six hours of the onset of symptoms

Not all patients are evaluated by a senior doctor within three hours of arrival at hospital and most do not undergo computed tomography

The potential for thrombolysis in patients with acute stroke can be improved significantly by greater use of emergency services and expediting evaluation and investigations by doctors

© BMJ 2002

CiteULike

Complore

Connotea

Del.icio.us Add to Digg

Digg

StumbleUpon Add to Technorati

Technorati What's this?

Relevant Articles

Influence of general practice opening hours on delay in seeking medical attention after transient ischaemic attack (TIA) and minor stroke: prospective population based study: Daniel S Lasserson, Arvind Chandratheva, Matthew F Giles, David Mant, and Peter M Rothwell
BMJ 2008 337: a1569. [Abstract] [Full Text] [PDF]

Secondary prevention for stroke and transient ischaemic attacks: Author's reply: Keith W Muir
BMJ 2004 328: 897. [Extract] [Full Text]

Barriers to effective stroke care out of hours need to be broached: Mark F Nicol
BMJ 2002 325: 596. [Extract] [Full Text]

Using emergency service saves time
BMJ 2002 325: 0. [Full Text]

This article has been cited by other articles:

Jones, S. P., Jenkinson, A. J., Leathley, M. J., Watkins, C. L. (2009). Stroke knowledge and awareness: an integrative review of the evidence. Age Ageing 0: afp196v1-afp196 [Abstract] [Full text]
Rafay, M. F., Pontigon, A.-M., Chiang, J., Adams, M., Jarvis, D. A., Silver, F., MacGregor, D., deVeber, G. A. (2009). Delay to Diagnosis in Acute Pediatric Arterial Ischemic Stroke. Stroke 40: 58-64 [Abstract] [Full text]
Lees, K.R., Ford, G.A., Muir, K.W., Ahmed, N., Dyker, A.G., Atula, S., Kalra, L., Warburton, E.A., Baron, J.-C., Jenkinson, D.F., Wahlgren, N.G., Walters, M.R., for the SITS-UK Group, (2008). Thrombolytic therapy for acute stroke in the United Kingdom: experience from the safe implementation of thrombolysis in stroke (SITS) register. QJM 101: 863-869 [Abstract] [Full text]
Lasserson, D. S, Chandratheva, A., Giles, M. F, Mant, D., Rothwell, P. M (2008). Influence of general practice opening hours on delay in seeking medical attention after transient ischaemic attack (TIA) and minor stroke: prospective population based study. BMJ 337: a1569-a1569 [Abstract] [Full text]
Maestroni, A, Mandelli, C, Manganaro, D, Zecca, B, Rossi, P, Monzani, V, Torgano, G (2008). Factors influencing delay in presentation for acute stroke in an emergency department in Milan, Italy. Emerg. Med. J. 25: 340-345 [Abstract] [Full text]
McCarron, M O, Armstrong, M, McCarron, P (2008). Potential for quality improvement of acute stroke management in a district general hospital. Emerg. Med. J. 25: 270-273 [Abstract] [Full text]
de la Ossa, N. P., Sanchez-Ojanguren, J., Palomeras, E., Millan, M., Arenillas, J. F., Dorado, L., Guerrero, C., Abilleira, S., Davalos, A. (2008). Influence of the stroke code activation source on the outcome of acute ischemic stroke patients. Neurology 70: 1238-1243 [Abstract] [Full text]
McCormick, M. T., Reeves, I., Baird, T., Bone, I., Muir, K. W. (2008). Implementation of a stroke thrombolysis service within a tertiary neurosciences centre in the United Kingdom. QJM 101: 291-298 [Abstract] [Full text]
Jarrell, B., Tadros, A., Whiteman, C., Crocco, T., Davis, S. M. (2007). National Healthline Responses to a Stroke Scenario: Implications for Early Intervention. Stroke 38: 2376-2378 [Abstract] [Full text]
Hodgson, C., Lindsay, P., Rubini, F. (2007). Can Mass Media Influence Emergency Department Visits for Stroke?. Stroke 38: 2115-2122 [Abstract] [Full text]
Roebers, S., Wagner, M., Ritter, M. A., Dornbach, F., Wahle, K., Heuschmann, P. U. (2007). Attitudes and Current Practice of Primary Care Physicians in Acute Stroke Management. Stroke 38: 1298-1303 [Abstract] [Full text]
Giles, M. F., Flossman, E., Rothwell, P. M. (2006). Patient Behavior Immediately After Transient Ischemic Attack According to Clinical Characteristics, Perception of the Event, and Predicted Risk of Stroke. Stroke 37: 1254-1260 [Abstract] [Full text]
Hand, P. J., Kwan, J., Lindley, R. I., Dennis, M. S., Wardlaw, J. M. (2006). Distinguishing Between Stroke and Mimic at the Bedside: The Brain Attack Study. Stroke 37: 769-775 [Abstract] [Full text]
Qureshi, A. I., Kirmani, J. F., Sayed, M. A., Safdar, A., Ahmed, S., Ferguson, R., Hershey, L. A., Qazi, K. J., for the Buffalo Metropolitan Area and Erie County, (2005). Time to hospital arrival, use of thrombolytics, and in-hospital outcomes in ischemic stroke. Neurology 64: 2115-2120 [Abstract] [Full text]
Task Force Members, , Schwamm, L. H., Pancioli, A., Acker, J. E. III, Goldstein, L. B., Zorowitz, R. D., Shephard, T. J., Moyer, P., Gorman, M., Johnston, S. C., Duncan, P. W., Gorelick, P., Frank, J., Stranne, S. K., Smith, R., Federspiel, W., Horton, K. B., Magnis, E., Adams, R. J. (2005). Recommendations for the Establishment of Stroke Systems of Care: Recommendations From the American Stroke Association's Task Force on the Development of Stroke Systems. Stroke 36: 690-703 [Full text]
Schwamm, L. H., Pancioli, A., Acker, J. E. III, Goldstein, L. B., Zorowitz, R. D., Shephard, T. J., Moyer, P., Gorman, M., Johnston, S. C., Duncan, P. W., Gorelick, P., Frank, J., Stranne, S. K., Smith, R., Federspiel, W., Horton, K. B., Magnis, E., Adams, R. J. (2005). Recommendations for the Establishment of Stroke Systems of Care: Recommendations From the American Stroke Association's Task Force on the Development of Stroke Systems. Circulation 111: 1078-1091 [Full text]
Kwan, J., Hand, P., Sandercock, P. (2004). Improving the efficiency of delivery of thrombolysis for acute stroke: a systematic review. QJM 97: 273-279 [Abstract] [Full text]
Muir, K. W (2004). Secondary prevention for stroke and transient ischaemic attacks: Author's reply. BMJ 328: 897-897 [Full text]
Carroll, C, Hobart, J, Fox, C, Teare, L, Gibson, J (2004). Stroke in Devon: knowledge was good, but action was poor. J. Neurol. Neurosurg. Psychiatry 75: 567-571 [Abstract] [Full text]
Chang, K.-C., Tseng, M.-C., Tan, T.-Y. (2004). Prehospital Delay After Acute Stroke in Kaohsiung, Taiwan. Stroke 35: 700-704 [Abstract] [Full text]
Lorberboym, M., Lampl, Y., Sadeh, M. (2003). Correlation of 99mTc-DTPA SPECT of the Blood-Brain Barrier with Neurologic Outcome After Acute Stroke. JNM 44: 1898-1904 [Abstract] [Full text]
Nedeltchev, K., Arnold, M., Brekenfeld, C., Isenegger, J., Remonda, L., Schroth, G., Mattle, H. P. (2003). Pre- and In-Hospital Delays From Stroke Onset to Intra-arterial Thrombolysis. Stroke 34: 1230-1234 [Abstract] [Full text]
Gray, C.S., O'Connell, J.E. (2003). Stroke: beyond thrombolysis and back to basics. QJM 96: 179-181 [Full text]
Nicol, M. F (2002). Barriers to effective stroke care out of hours need to be broached. BMJ 325: 596-596 [Full text]

Rapid Responses:

Read all Rapid Responses

Barriers to Evidence Based Stroke care in Emergency Departments: Mark F Nicol
bmj.com, 5 Jul 2002 [Full text]
ACUTE STROKE CARE IN UK: ABHAYA GUPTA, et al.
bmj.com, 22 Aug 2002 [Full text]
The role of Accident and Emergency in early diagnosis and management: Christopher J L Hetherington, et al.
bmj.com, 4 Sep 2002 [Full text]