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

Abstract

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. 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. 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. 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.