Identifying characteristics of early arrivers after stroke may be useful to improve delivery of acute stroke treatment. We sought to identify the clinical characteristics and outcomes of patients with ischemic stroke who present early after symptom onset using data collected from a representative sample of hospitals in the state of Georgia.
Data were obtained retrospectively from a statewide observational stroke registry from December 1, 2001, to February 28, 2002, and from February 1 to March 31, 2003. Clinical characteristics of patients with stroke arriving to the hospital within 2 hours were compared with those arriving later.
Of the 409 patients with ischemic stroke identified with a specified time of onset, 172 (42%) presented within 2 hours. Univariate analysis showed hospital arrival within 2 hours was associated with history of coronary artery disease (P = .0400), dyslipidemia (P = .0100), ambulance transport (P = .0285), stroke team consultation (P = .0070), higher National Institutes of Health Stroke Scale score (P < .0001), and lower Glasgow Coma Scale score (P = .0018). Race, sex, age, smoking history, previous stroke, myocardial infarction, congestive heart failure, prosthetic heart valve, hypertension, diabetes, and family history of stroke were not associated with arrival within 2 hours. Multivariate analysis revealed National Institutes of Health Stroke Scale score (odds ratio = 1.20, confidence interval 1.08-1.34, P = .0013) and Glasgow Coma Scale score (odds ratio = 0.84, confidence interval 0.75-0.94, P = .0027) were associated with arrival within 2 hours. Patients with stroke arriving within 2 hours had higher in-hospital mortality (13% v 4%) (P = .0284), but a higher rate of independent ambulation at discharge (55% v 37%) (P = .0419).
Early arrival after ischemic stroke symptom onset is associated with increased stroke severity, higher mortality, and better functional outcome.
"In NHAMCS, ambulance patients were older and more likely to be admitted to an intensive care unit . In Georgia USA, the 172/409 patients who arrived within 2 hours of symptom onset were more likely to have attended by ambulance with a greater severity of neurological deficit and inpatient mortality . A prospective study across 14 tertiary hospitals in Korea showed significant associations between arrival by emergency ambulance (36% of total admissions), stroke severity, previous stroke and poorer outcome . "
[Show abstract][Hide abstract] ABSTRACT: Effective provision of urgent stroke care relies upon admission to hospital by emergency ambulance and may involve pre-hospital redirection. The proportion and characteristics of patients who do not arrive by emergency ambulance and their impact on service efficiency is unclear. To assist in the planning of regional stroke services we examined the volume, characteristics and prognosis of patients according to the mode of presentation to local services.
A prospective regional database of consecutive acute stroke admissions was conducted in North East, England between 01/09/10-30/09/11. Case ascertainment and transport mode were checked against hospital coding and ambulance dispatch databases.
Twelve acute stroke units contributed data for a mean of 10.7 months. 2792/3131 (89%) patients received a diagnosis of stroke within 24 hours of admission: 2002 arrivals by emergency ambulance; 538 by private transport or non-emergency ambulance; 252 unknown mode. Emergency ambulance patients were older (76 vs 69 years), more likely to be from institutional care (10% vs 1%) and experiencing total anterior circulation symptoms (27% vs 6%). Thrombolysis treatment was commoner following emergency admission (11% vs 4%). However patients attending without emergency ambulance had lower inpatient mortality (2% vs 18%), a lower rate of institutionalisation (1% vs 6%) and less need for daily carers (7% vs 16%). 149/155 (96%) of highly dependent patients were admitted by emergency ambulance, but none received thrombolysis.
Presentations of new stroke without emergency ambulance involvement were not unusual but were associated with a better outcome due to younger age, milder neurological impairment and lower levels of pre-stroke dependency. Most patients with a high level of pre-stroke dependency arrived by emergency ambulance but did not receive thrombolysis. It is important to be aware of easily identifiable demographic groups that differ in their potential to gain from different service configurations.
PLoS ONE 10/2013; 8(10):e76997. DOI:10.1371/journal.pone.0076997 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Our purpose was to determine whether the onset-to-arrival time affects the outcome of stroke patients.
We carried out a prospective multicenter study involving 1,817 patients with ischemic stroke and 1,226 with intracerebral hemorrhage who presented to hospitals within 24 h of symptom onset. The primary outcome was independent activity of daily living corresponding to a modified Rankin Scale (mRS) score <or=2 at discharge approximately 3 weeks after stroke.
In ischemic stroke patients, the initial NIH Stroke Scale (NIHSS) score decreased as the onset-to-arrival time increased: 9 (median) in the earliest tertile group (<3 h), 5 in the second tertile group (3-8 h) and 4 in the latest tertile group (>or=8 h, p < 0.001). The median mRS scores at discharge in these groups were 3, 2 and 2, respectively (p < 0.001). After adjustment for underlying features and the initial NIHSS score, the independent activity of daily living at discharge was 1.73 times more common in patients in the earliest group than in the latest group (95% CI = 1.24-2.42, p = 0.001). A similar tendency was shown in the subanalysis for large-artery atherosclerosis and cardioembolic stroke. In intracerebral hemorrhage patients, both the initial NIHSS score and the mRS score at discharge decreased as the onset-to-arrival time increased. After multivariate adjustment, the independent activity of daily living was 2.33 times (p < 0.001) and 1.69 times (p = 0.006) less common in patients in the earliest (<1.2 h) and second tertile groups (1.2-3.5 h), respectively, than in the latest tertile group (>or=3.5 h).
Early hospital arrival improved the clinical outcome in ischemic stroke patients but not in patients with intracerebral hemorrhage.
[Show abstract][Hide abstract] ABSTRACT: The aim was to determine if an intensive restructuring of the approach to acute stroke improved time to thrombolysis over a 3-year study period and to determine whether delay modifications correlated with increased thrombolytic intervention or functional outcome.
The study examined the pretreatment process to define specific time intervals (delays) of interest in the acute management of 289 consecutive ischemic stroke patients who were transported by the emergency medical services (EMS) and received intravenous (IV) thrombolytic therapy in the emergency department (ED) of Helsinki University Central Hospital. Time interval changes of the 3-year period and use of thrombolytics was measured. Functional outcome, measured with the modified Rankin Scale (mRS) at 3 months, was assessed with multivariable statistical analysis.
During implementation of the restructuring program from 2003 to 2005, the median total time delay from symptom onset to drug administration dropped from 149 to 112 minutes (p < 0.0001). Prehospital delays did not change significantly during the study period. The median delay in calling an ambulance remained at 13 minutes, and the total median prehospital delay stayed at 71 minutes. In-hospital delays decreased from 67 to 34 minutes (p < 0.0001). The median call delay was 25 minutes in patients with mild symptoms (National Institute of Health Stroke Scale [NIHSS] score < 7) and 8 minutes with severe symptoms (NIHSS > 15). In the multivariate model, stroke severity (odds ratio [OR] = 0.83, 95% confidence interval [CI] = 0.78 to 0.88, p < 0.0001), age (OR = 0.57, 95% CI = 0.42 to 0.77, p < 0.0001), and in-hospital delay (OR = 0.47, 95% CI = 0.22 to 0.97, p = 0.04) were suggesting a good outcome.
Restructuring of the teamwork between the EMS personnel and the reorganized ED significantly reduced in-hospital, but not prehospital, delays. The present data suggest that a decreased in-hospital delay improves the accessibility of the benefits of thrombolysis.
Academic Emergency Medicine 09/2010; 17(9):965-9. DOI:10.1111/j.1553-2712.2010.00828.x · 2.01 Impact Factor
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