Factors Associated with Hospital Arrival Time for Stroke Patients

Lenora M. Maze; Tamilyn Bakas

Disclosures

J Neurosci Nurs. 2004;36(3) 

In This Article

Abstract and Introduction

Patients who experience a sudden ischemic stroke can benefit from administration of intravenous tissue plasminogen activator (tPA) to reduce the resulting disability, yet few arrive in time to be eligible for tPA administration. The purpose of this study was to determine (a) the stroke warning signs that most commonly result in the decision to seek hospital care, (b) who makes the decision to seek hospital care, (c) the most common mode of transportation to the hospital, (d) hospital arrival time in relation to the onset of the first warning sign, and (e) factors most associated with hospital arrival time for stroke survivors. Using a descriptive, cross-sectional design, data from a convenience sample of 50 stroke survivors and/or their companions (family, friends, or others seeking hospital care for the patient) were obtained by face-to-face interview during the patient's hospital stay using a structured interview guide developed by the investigator. The most common stroke warning sign resulting in the decision to seek medical care was sudden confusion and trouble speaking or understanding speech, followed by sudden numbness or weakness on one side of the body. Patients themselves were the most common initiators of care, followed by spouses, other relatives, and others. A majority of patients arrived by ambulance, followed by private car or taxi. Only 28.9% of patients arrived at the hospital within 3 hours of the first warning sign, with the mean arrival time for the group being 330.4 minutes (5.5 hours). Mode of transportation and perceived adequacy of income were the only significant factors associated with hospital arrival time, with no significant interaction effects. Patients arriving by private car or taxi and those perceiving their incomes as comfortable had the longest arrival times, suggesting public education efforts also should target people from higher socioeconomic groups. The nonsignificant associations between hospital arrival time, warning signs, and other demographic characteristics of initiators suggest there may be other unmeasured behavioral factors that play a more important role in reducing hospital arrival time for stroke patients. Further study of additional factors associated with early hospital arrival time is recommended to support educational efforts for early stroke treatment and prevention.

Stroke is currently the third-leading cause of death in the United States (American Heart Association, 2002), with stroke mortality projected to double during the next 30 years (Elkins & Johnston, 2003). Even more frightening is the morbidity resulting from stroke. It is a leading cause of severe, long-term disability, with up to 30% of stroke patients becoming permanently disabled, and 20% requiring institutional care 3 months after stroke (American Heart Association). Both direct and indirect costs for stroke, including loss of productivity for morbidity and mortality, were expected to total $51.2 billion in 2003 (American Heart Association).

Although the number of people affected by stroke is large, the public's awareness of stroke symptoms and the need for immediate treatment evaluation is poor (Hickenbottom & Morgenstern, 2002; Williams, Bruno, Rouch, & Marriott, 1997). The five most common warning signs of stroke are (a) sudden numbness or weakness of the face, arm, or leg (especially on one side of the body); (b) sudden confusion, trouble speaking, or understanding speech; (c) sudden difficulty seeing in one or both eyes; (d) sudden difficulty walking, dizziness, or loss of balance or coordination; and (e) sudden severe headache with no known cause (National Institute of Neurologic Disorders and Stroke, 2003). Pancioli et al. (1998) found that 57% of the general public was able to identify only one of the warning signs of stroke, 28% were able to identify two signs, and only 8% were able to identify three signs. Although Schneider and colleagues (2003) reported a significant improvement in the identification of warning signs by the general public between 1995 and 2000, those who are most at risk for stroke, such as people older than 75 years, African-Americans, and males, are the least knowledgeable about the warning signs and risk factors for stroke (Schneider et al.).

Lack of public awareness about the emergent nature of stroke warning signs can delay stroke patients seeking medical attention (Hickenbottom & Morgenstern, 2002; Williams et al. 1997). The availability of thrombolytic therapy has brought with it a need to shorten the length of time it takes a person to reach the hospital after experiencing one or more warning signs of a stroke. The time window for intravenous administration of tissue plasminogen activator (tPA) is 3 hours from the time of onset of the first warning signs until drug infusion (Lewandowski & Lotfipour, 2002; Menon, Pandey, & Morgenstern, 1998). This period includes time for recognition of warning signs, getting to the hospital, preliminary diagnosis of stroke by the emergency department physician, completion of a head computed tomography (CT) scan, reading of the CT scan by a neurologist or radiologist, and administration of tPA if appropriate.

Accomplishing all of these things within 3 hours requires early hospital arrival time and prompt action by healthcare providers once the patient has arrived. Although recent treatment options include the administration of intraarterial tPA, which can extend the time window to 6 hours, this intervention is limited to specialized institutions. Consequently, early hospital arrival time is still essential (Jovin, Gebel, & Wechsler, 2002). Studies have documented that fewer than half of stroke patients are admitted within 3 hours. Kothari et al. (1999) found only 30% of their stroke patients arrived in 3 hours, and Williams et al. (1997) found that less than 25% arrived within 3 hours. More recently, Lacy and colleagues (2001) found that 46% of stroke patients arrived to the emergency room within 3 hours. These findings suggest a need for further information about factors associated with early hospital arrival. More information about these factors may guide public educational efforts in this context.

The purpose of this study was to determine (a) the warning signs that most commonly result in the decision to seek hospital care, (b) who makes the decision to seek hospital care, (c) the most common mode of transportation to the hospital, (d) hospital arrival time in relation to the onset of the first warning sign, and (e) the factors most associated with hospital arrival time for stroke patients. Exploring these areas will provide health professionals with the information they need to develop educational initiatives to improve hospital arrival time for stroke patients.

Five research questions were addressed by this study:

  1. What are the most commonly recognized warning signs that result in decisions to seek hospital care for stroke patients?

  2. What are the demographic characteristics (relationship, gender, education, employment, perceived adequacy of income, race, and age) of initiators who seek hospital care for stroke patients?

  3. What modes of transportation do stroke patients use to arrive at the hospital (ambulance, private vehicle, taxi, other)?

  4. What is the average hospital arrival time in relation to the onset of the first warning sign for stroke patients?

  5. Which warning signs, demographic characteristics, and modes of transportation are most associated with hospital arrival time for stroke patients?

The conceptual model in Fig 1 depicts the relationships among the variables proposed in this study. The warning signs include those identified by the National Institute of Neurological Disorders and Stroke (NINDS; www.ninds.nih.gov). The initiator is the person who made the decision to seek hospital care for the stroke patient. This person may be the patient, a family member, a coworker, or any other individual. Demographic characteristics of the initiator included gender, education, employment status, income, age, and race. The mode of transportation to the hospital could have been through activation of the emergency medical system (EMS) by calling 911 for an ambulance, or by private vehicle, taxi, or another mode of transportation. Hospital arrival time is defined as the amount of time from the onset of the first warning sign until arrival at the hospital in minutes.

Conceptual model

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