|Year : 2016 | Volume
| Issue : 4 | Page : 263-267
Barriers for acute ischemic stroke treatment using recombinant tissue plasminogen activator in Mansoura Emergency Hospital: prehospital and inhospital delay factors
Mohammad Abu-Hegazy MD, PhD, FAAN , Ibrahim Elmenshawi, Mohamed Saad
Department of Neurology, Mansoura University, Mansoura, Egypt
|Date of Submission||24-Dec-2016|
|Date of Acceptance||30-Dec-2016|
|Date of Web Publication||17-Mar-2017|
195 B, El-Gomhoria Street, Mansoura, 35511
Source of Support: None, Conflict of Interest: None
Effective treatment must start as early as possible as brain cells die rapidly after stroke. To increase the number of patients who are eligible to receive tissue plasminogen activator, measures are needed to reduce the prehospital and inhospital delay time. The study aimed to evaluate the possibility of thrombolytic therapy in acute ischemic stroke patients in Mansoura Emergency Hospital (MEH) by studying the effect of prehospital and inhospital delay factors.
Patients and methods
A standardized, structured questionnaire was completed for every stroke suspect; in it we documented the exact time of stroke onset, the way of referral and transport to hospital, and their demographic data. The exact time of patient arrival, time to neurology consultation, and detailed time delay inside MEH was marked on the forms of the hospital as well.
In total, 435 patients had arrived MEH in less than 24 h, their mean age being 61.7 years. The median prehospital time was 2.7 h. Patients with younger age, locals, those who reached by private vehicle, or reached directly without any medical reference were significantly associated with early hospital admission. Sex, time of arrival, or severity of stroke had no influence on reaching hospital early. The median times to computed tomography request and acquisition were 20 and 35 min versus 25 and 45 min, respectively, National Institute of Neurological Disorders and Stroke recommendations.
Hyperacute treatment of ischemic stroke is possible in MEH. Methods to improve the emergency medical services and reduction of the patient circulation system in MEH will give more chance for these therapies by reducing prehospital and inhospital delay times.
Keywords: eligibility, inhospital delay, prehospital, thrombolytic therapy
|How to cite this article:|
Abu-Hegazy M, Elmenshawi I, Saad M. Barriers for acute ischemic stroke treatment using recombinant tissue plasminogen activator in Mansoura Emergency Hospital: prehospital and inhospital delay factors. Egypt J Neurol Psychiatry Neurosurg 2016;53:263-7
|How to cite this URL:|
Abu-Hegazy M, Elmenshawi I, Saad M. Barriers for acute ischemic stroke treatment using recombinant tissue plasminogen activator in Mansoura Emergency Hospital: prehospital and inhospital delay factors. Egypt J Neurol Psychiatry Neurosurg [serial online] 2016 [cited 2017 Aug 22];53:263-7. Available from: http://www.ejnpn.eg.net/text.asp?2016/53/4/263/202377
| Introduction and purpose|| |
Effective treatment of acute ischemic stroke must start as early as possible as brain cells die rapidly .
Thrombolytic therapy using tissue plasminogen activator (tPA) can reduce the burden of stroke, but the short-time window for safe and effective treatment is a limiting factor . If administered within 4.5 h of presentation, thrombolysis is effective in improving functional outcome .
Timely arrival to the hospital, followed by urgent assessment, including brain imaging, are the prerequisites to access to thrombolysis . Minority of eligible ischemic stroke patients receive recanalizing therapies .
Patients’ delay in seeking treatment for stroke and delays within the emergency department are major factors in the lack of use of thrombolytic therapy and the emerging introduction of ultra-early hemostatic therapy in ischemic and hemorrhagic strokes, respectively ,,.
Identifying characteristics associated with prehospital delay, however, correlates of delays in diagnosis and treatment have not been as extensively examined. Computed tomography (CT) scan of the head is a crucial component in diagnosing stroke and essential before tPA therapy as well . In the late 1990s, he guidelines of the National Institute of Neurological Disorders and Stroke (NINDS)  suggested that stroke patients receive an initial CT scan within 25 min of hospital arrival and CT interpretation not more than 45 min; yet, compliance with this guideline has not been well addressed.
The present study aimed to evaluate the possibility of thrombolytic therapy in acute ischemic stroke patients in Mansoura Emergency Hospital (MEH) by studying the effect of prehospital and inhospital delay factors (sex, age, residence, mode of transportation, the referring person, Glasgow Coma Scale, and arrival time) and inhospital delay factors (MEH organization and its impact on patient circulation system inside the hospital).
| Patients and methods|| |
This cross-sectional study was carried out in 2 successive years, starting in January 2012 at MEH, Mansoura, Egypt, after obtaining approved from the Research Committee of Neurology Department, Mansoura University. A total of 525 patients with acute stroke were enrolled. Patients with inhospital stroke onset, age less than 18 years, or without a clear history of the questionnaire were excluded. For every stroke patient, a standardized structured questionnaire was completed, by interviewing the patient or one of his or her family members, in which we documented the exact time of stroke onset, the way of referral and transport to hospital, and their demographic data. The exact time of patient arrival to MEH is routinely marked on the forms of the hospital as well as the time to neurology consultation.
Mansoura Emergency Hospital
It is a six-storied building with 118 beds and was built beside the Mansoura University Hospital, with easy access on its eastern side to a main street and on its west side to the main hospital. The 3600 m2 first floor is specialized for receiving casualty cases from its northern side and has ancillary rooms on its eastern and western side for toxicology, critical care, small therapeutics, orthopedics, and radiology rooms (CT, radiography, and ultrasound) leaving its southern side for first floor emergency operating theaters.
Emergency in Mansoura is distributed on three hospitals with MEH working only 3 days weekly, on Sundays, Tuesdays, and Thursdays. This system is well known to the public, other hospitals, and emergency medical services (EMS).
The hospital is staffed with (inhouse) at least a resident and assistant lecturer (finished residency training and holds master’s degree) of each specialty and on call (out of house) higher staff working round the clock. Technicians, including those of CT scan, are available in their corresponding rooms round the clock too. It admits on an average 3500 emergency neurology patients a year.
Patient’s circulation in Mansoura Emergency Hospital
Patients arriving to MEH are first split vertically into two directions, depending on whether the condition is medical or surgical, and then into male and female rooms. A critical care specialist then examines the patient; stroke suspects are recommended to neurology consultation through an infloor sound system. Suspect stroke patients are evaluated by the neurologists and confirmed stroke patients are sent for CT diagnosis. In the first year of the study, patients were transported to the main hospital, radiology department, for CT acquisition (during replacement of the old CT machine), whereas in the second year, a new CT machine was installed in the main floor of MEH and all the patients had their CT done inside the hospital. All rooms are supplied by the necessary request forms for CT, laboratory, and other specialty consultations. For medicolegal issues, the exact time of patient arrival to MEH is routinely marked on the forms of the hospital as well as the time for every consultation including of course, neurology, and CT consultation.
The following definitions illustrate the different time intervals from symptom onset till complete CT diagnosis.
Symptom onset time
The time the patient was last known to be without symptoms or at baseline was defined as symptom onset time. If the patient awoke with symptoms, it was defined as the time at which the patient went to sleep or was last known awake without symptoms.
The time from symptom onset till the hospital arrival time, documented in patient registration sheet, was defined as prehospital delay.
Time to neurology consultation
Time to neurology consultation was defined as the time from emergency department (ED) arrival until the time of call of the neurology consultant in the ED.
Delay to computed tomography request
It is the time delay between neurology consultations and completion of CT request.
Time to computed tomography diagnosis
It is the time delay from CT request until the completion of the CT scan.
Total hospital time
It was defined as the time from hospital arrival to complete stroke diagnosis by the head CT scan.
All data were analyzed using statistical package for the social sciences 14 (SPSS; SPSS Inc., Chicago, Illinois, USA). Data were expressed as mean±SD or median unless otherwise stated. For parametric variables, Student’s t-test was used to ascertain the significance of differences between mean. The χ2 and Krusal–Wallis tests were used to test significance between two and more than two nonparametric groups, respectively. The level of P less than 0.05 was considered the cut-off value of significance.
| Results|| |
Out of 523 acute stroke patients recruited over the study years, only 435 patients reached the emergency hospital (EH) within 24 h and subjected for statistical analysis. In total, 215 patients were enrolled in the first year and 220 patients in the second year. Their demographic data are shown in [Table 1]. Their conscious level was further assessed by using the Glasgow Coma Scale, with a mean of 13.6. The median prehospital time was 2.75 h. Only 13.6% of the patients arrived within the first hour, whereas 22.1 and 20.9% arrived within the second and third hours, respectively. We investigated the factors associated with early (within 3 h) versus late (after 3 h) admission to EH. Those of younger age, locals, and those reaching EH by private vehicle or directly without any way of medical referral were significantly associated with early hospital admission ([Table 1]). Sex, time of arrival, or severity of stroke had no an influence on reaching hospital early ([Table 1]). The median time to CT request was 20 min and to CT completion were 75 and 35 min in the first and second years, respectively. The mean total hospital time in the second year was significantly shorter than that of the first year ([Figure 1]). This reflected a significantly shorter time to neurology consultation and time to CT interpretation, as shown in the same figure.
|Figure 1 Different median hospital times delay during the study period. T-CTDx, time to computed tomography diagnosis; T-NC, time to neurology consultation; total HT, total hospital time; NC-CTR, neurology consultation to computed tomography request|
Click here to view
Patients’ age, sex, consciousness, prehospital delay, or time of the day arrival had no significant effect on the total hospital time, as shown in [Figure 2] and [Figure 3].
|Figure 2 The median total hospital time in the second year in relation to age, sex, prehospital delay, and Glasgow Coma Scale. GCS, Glasgow Coma Scale; PHD, prehospital delay|
Click here to view
|Figure 3 Time to computed tomography request and total hospital time throughout the day hours. T-CTR, time to computerized tomography request; THT, total hospital time|
Click here to view
| Discussion|| |
The total time from stroke onset till the final stroke diagnosis is critical in determining its therapeutic options. In this study the median prehospital time was 2.75 h. This is nearly similar to a study conducted by Morris et al. , in which a median time of 2.6 h was reported, whereas a longer prehospital time was reported in other studies in the USA (4.5 h  and 5.7 h ). We excluded patients arriving EH 24 h from symptom onset time. Moreover, the well-known emergency days of the MEH might also have shortened our prehospital time. Unsurprisingly, younger patients, those from Mansoura city, and going directly to the hospital without referral had reached early. We were surprised that patients arriving EH by private vehicles were significantly earlier than those who arrived by ambulance. This may be explained by absence of stroke call system in the EMS in our locality. Stroke unit admission in France is the fastest in patients brought to the hospital by EMS . A recent study conducted in Taiwan concluded that patients arriving at ED by EMS shortened the mean onset-to-needle time for 26 min . Other American studies have also shown that stroke patients transported by the EMS were more likely to arrive within the first 3 h than those transported by other means ,. EMS may essentially help out of town patients to reach the hospital earlier than that reported in our study. Our study shows that patients who go directly to MEH without consulting their neurologist or general practioners arrived earlier than those who did. Other studies performed in Europe and the USA have shown that the initial call of the general practioner is a factor of delayed admission in acute stroke ,,. A study by Nedeltchev et al.  indicated that direct referral without prior CT imaging at community hospitals shortens the time until intra-arterial thrombolysis. Patients in our study coming with their CT had shown at MEH significantly later than those who arrived without it.
Our inhospital time delay was comparable to that of the NINDS  recommendation, as in the present study, the median time to CT request in the first (CT machine outside MEH) and second year (CT machine within the MEH) was 20 min, whereas time to CT interpretation in the first and second year was 75 and 35 min, respectively, versus 25 and 45 min in the NINDS. This emphasizes the importance of inhospital CT machine. Time window for tPA was extended to 4.5 h. Patients with a total time less than 4.5 h were best met from 1 a.m. to 6 a.m. This was not only explained by shorter prehospital time because of ease of transportation but also by shorter inhospital time as fewer patients are usually served at this time of the day.
| Conclusion|| |
- This study practically confirmed the possibility of using hyperacute treatment as tPA for acute stroke patients arriving at MEH.
- Methods to improve the EMS to be a rapid alternative way of transportation of stroke patients might give more chance for more patients to get advantage of these therapies as it happens in Europe and the USA.
- Inhouse stroke team, CT machine, and radiology team, working around the clock, significantly shortened the total inhospital time allowing rapid stroke detection and treatment in ED as recommended by NINDS guidelines.
The manuscript has been read and approved by all the authors, requirements for authorship have been met, each author believe that the manuscript represent honest work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Audebert HJ, Saver JL, Starkman S, Lees KR, Endres M. Prehospital stroke care: new prospects for treatment and clinical research. Neurology 2013; 81:501–508.
Wardlaw JM, Murray V, Berge E, del Zoppo G, Sandercock P, Lindley RL, Cohen G. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updatedsystematic review and meta-analysis. Lancet 2012; 379:2364–2372.
Hacke WH, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D et al.
Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359:1317–1329.
Sheppard JP, Mellor RM, Greenfield S, Mant J, Quinn T, Sandler D et al.
The association between prehospital care and in-hospital treatment decisions in acute stroke: a cohort study. Emerg Med J 2015; 32:93–99.
Leys D, Ringelstein EB, Kaste M, Hacke W. Facilities available in European hospitals treating stroke patients. Stroke 2007; 38:2985–2991.
Morris DL, Rosamond W, Madden K, Schultz C, Hamilton S. Prehospital and emergency department delays after acute stroke: the Genentech Stroke Presentation Survey. Stroke 2000; 31:2585–2590.
Mandelzweig L, Goldbourt U, Boyko V, Tanne D. Perceptual, social, and behavioral factors associated with delays in seeking medical care in patients with symptoms of acute stroke. Stroke 2006; 37:1248–1253.
Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN et al.
Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 2005; 352:777–785.
Nedeltchev K, Arnold M, Brekenfeld C, Isenegger J, Remonda L, Schroth G, Mattle HP. Pre- and in-hospital delays from stroke onset to intra-arterial thrombolysis. Stroke 2003; 34:1230–1234.
Rose KM, Rosamond WD, Huston SL, Murphy CV, Tegeler CH. Predictors of time from hospital arrival to initial brain-imaging among. Stroke 2008; 39:3262–3267.
Menon SC, Pandey DK, Morganstern LB. Critical factors in determining access to acute stroke care. Neurology 1998; 51:427–432.
Kothari R, Jauch E, Broderick J, Brott T, Sauerbeck L, Khoury J, Liu T. Acute stroke: delays to presentation and emergency department evaluation. Ann Emerg Med 1999; 33:3–8.
Derex L, Adeleine P, Nighghossian N, Honnorate J, Trouillas P. Factors influencing early admission in a French stroke unit. Stroke 2002; 33:153–159.
Hsieh MJ, Tang SC, Chiang WC, Huang KY, Chang AM, Ko PC et al.
Utilization of emergency medical service increases chance of thrombolytic therapy in patients with acute ischemic stroke. J Formos Med Assoc 2014; 113:813–819.
Williams LS, Bruno A, Rouch D, Marriott DJ. Stroke patients’ knowledge of stroke: influence on time to presentation. Stroke 1997; 28:912–915
Kothari R, Sauerbeck L, Jauch E, Broderick J, Liu T. Patients’ awareness of stroke signs, symptoms, and risk factors. Stroke 1997; 28:1871–1875
Ferro JM, Melo TP, Oliveira V, Crespo M, Canhao P, Pinto AN. An analysis of the admission delay of acute strokes. Cerebrovasc Dis 1994; 4:72–75.
Menon SC, Pandey DK, Morgenstern LB. Critical factors determining access to acute stroke care. Neurology 1998; 51:427–432.
Marler J, Winters Jones P, Emr M. editors. Proceedings of a national symposium on rapid identification and treatment of acute stroke [Publication No. (NIH) 97-4239]. Washington, DC: National Institute of Neurological Disorders and Treatment of Acute Stroke; 1997.
[Figure 1], [Figure 2], [Figure 3]