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In New Zealand, stroke is the third leading of death and the primary cause of adult disability.[[1]] Around 8,000 New Zealanders experience a stroke each year, and many will either die or lose the ability to care for themselves one year after the event.[[1]] Although early hyperacute therapies such as thrombolysis and thrombectomy are associated with improved patient outcomes,[[2,3]] benefits are also seen with other early interventions, including early anticoagulation for patients with atrial fibrillation,[[4]] early transient ischaemic attack (TIA) assessment and management,[[5,6]] early dysphagia screening after stroke[[7]] and early intensive lowering of blood pressure and reversal of antithrombotic medication in patients with intracerebral haemorrhage.[[8]] National and regional efforts such as regular audit, service model changes, public FAST campaigns and the introduction of telestroke have improved public awareness of stroke and a number of acute treatment metrics.[[9,10]] However, despite these initiatives, there are delays in presentation to hospital following stroke in most New Zealand district health boards (DHB). For instance, thrombolysis rates for acute ischaemic stroke have plateaued at around 10–15%, largely due to delays in seeking help.[[11]] This study aims to identify the factors that lead to time delays in seeking help when stroke symptoms arise.

Design and methods

A prospective cross-sectional study of patients admitted with stroke or TIA was conducted at Palmerston North Hospital, a medium-sized hospital serving a population of 172,930 with approximately 360 stroke admissions per annum. Our institution provides a 24/7 on-site thrombolysis service with input from telestroke and thrombectomy services from Capital and Coast DHB within the conventional window due to lack of perfusion imaging. Between 24 November 2020 and 8 January 2021, convenience sampling was used to enrol consecutive patients into the study. Inclusion criteria were (1) acute stroke or transient ischaemic attack (defined as an acute, focal neurologic deficit without alternative cause with supportive imaging findings) and (2) patient requires hospitalisation, which at our institution includes all acute strokes, or TIA with high-risk features (defined as concomitant atrial fibrillation, known carotid stenosis, anticoagulant therapy or an ABCD{{2}} score ≥4 (Age ≥ 60 years (+1), blood pressure ≥140/90mmHg (+1), clinical features (+1 or 2), symptom duration (+0-2), diabetes (+1)). Exclusion criteria were (1) any diagnosis other than stroke/TIA, (2) in-hospital onset of stroke symptoms and (3) incapacity to answer the structured questionnaire and no witness available in the pre-hospital phase available to answer the structured questionnaire. We obtained informed consent prior to enrolment in the study.

One research medical student collected data on the pre-hospital phase by using health records and conducted in-person or phone interviews with all patients or eyewitnesses admitted during the study period. Two methodologies (Part A and Part B) were used.

Part A

A standardised questionnaire and health records were used to collect quantitative data on demographics, the time and location of stroke onset and the first medical assistance sought. Questions were also asked to determine the level of stroke symptom awareness. Data on response times by pre-hospital and hospital services were also recorded.

Part B

Qualitative data was collected on patient perception and understanding of their symptoms, the factors that influenced their decision to seek help and the mode and urgency of seeking help.

Statistical analysis

Descriptive and inferential statistics were used. Categorical variables were described as frequencies and percentages, and numerical variables were described as mean and standard deviation or median and interquartile range. For inferential statistics, the association between categorical variables were determined using Fisher’s exact test, and for numerical variables, mean difference was determined using independent t-test. A p-value <0.05 was used for statistical significance. The association between each variable and hospital arrival within or after 4.5 hours was also investigated. This time window was chosen as it is the standard cut-off for hyperacute therapy. A time of ≥ 4.5 hours was used to define prehospital delay for the purposes of this analysis.

Ethical approval

The study protocol was received ethical approval from the New Zealand Northern Regional Health and Disability Ethics Committee and was endorsed by the Māori Research Review Group, Pae Ora Paiaka Whaiora Hauora Māori Directorate, at MidCentral DHB.

Results

A total of 56 patients were assessed for eligibility during the recruitment period. Overall, 41 patients satisfied the inclusion/exclusion criteria and agreed to participate. Reasons for exclusions are demonstrated in Figure 1.

Figure 1: Consort diagram showing how patients were enrolled.

Part A

The mean age of patients was 70 years (range 33–94), with equal representation of both sexes. Twenty-two patients (53.7%) arrived within 4.5 hours of stroke onset. The mean National Institutes of Health Stroke Scale (NIHSS) on admission was 4, and most patients (91.4%) were functionally independent pre-stroke (Modified Rankin Scale ≤2). The majority of patients (82.9%) identified as being of New Zealand European ethnicity and 5% identified as Māori. The most prevalent vascular risk factor was hypertension (58.5%), followed by diabetes (31.7%). Almost one-quarter of patients had three or more vascular risk factors. Twenty-eight patients had a final diagnosis of ischaemic stroke (68%), three haemorrhagic stroke (7%) and 10 TIA (24%). A summary of patient characteristics is presented in Table 1.

Table 1: Baseline characteristics. View Table 1.

The mean overall delay between stroke onset and first contact with a health professional was 11 hours. Patients who presented to hospital within 4.5 hours had a mean symptom onset to first healthcare contact time of 37 minutes compared with 23 hours for patients who presented outside 4.5 hours (p=0.036). These findings are summarised graphically in Figure 2.

Overall, 23 patients called the ambulance as their first point for help, and these patients were significantly more likely to arrive in hospital within 4.5 hours (p=0.009). Thirteen patients called the ambulance within 15 minutes of symptom onset and these patients were more likely to arrive to hospital within 4.5 hours (p=0.001) and were significantly more likely to receive thrombolysis (p<0.001). Seven patients used primary care as their first contact, and in these patients the mean time from symptom onset to hospital arrival was 28 hours. Patients with higher NIHSS scores on admission were more likely to present within 4.5 hours. However, this did not meet statistical significance. Interestingly, living with others, the presence of the partner at the time of stroke or having had a prior stroke were not associated with early presentation to hospital. Finally, patients arriving within 4.5 hours had a shorter mean travel distance to hospital than those with delayed admission. (36.36 vs 54.4 km, p=0.036).

Figure 2: Delays in patient response. Time from stroke onset to first call for help and time from stroke onset to hospital arrival.

Awareness of stroke symptoms

We did not observe a significant association between knowledge of stroke symptoms or FAST awareness and arriving within 4.5 hours. Sixteen patients reported knowing their symptoms were caused by a stroke, but only 12 of these arrived within 4.5 hours (not significant). Most participants could identify aphasia, diplopia/blurred vision and hemiparesis/paresthesia as stroke symptoms (82.9%, 78% and 90.9%, respectively). Only 39% of our patients could identify sudden blindness in one eye as a stroke symptom. The majority of patients correctly excluded chest pain, shooting pain in the arm, joint pain and sudden nose bleeds as stroke-specific symptoms. However, 73.2% and 63.4% of our patients incorrectly identified dizziness and headaches as stroke specific symptoms, respectively. The ability to identify any one stroke symptom was not significantly associated with arriving within 4.5 hours. Patient stroke symptom awareness is summarised in Table 2.

Table 2: Stroke awareness.

[[a]] Chi Square test. [[b]] Independent t-test. [[c]] Fisher’s exact test.

Ambulance response

The mean time between emergency call to arrival at the scene was 14 minutes, and the mean time from arrival of ambulance to departure for hospital was 21 minutes. The mean time delay between departure of ambulance to arrival at hospital was 38 minutes. This is shown graphically in Figure 3.

Figure 3: Ambulance response.

Hospital response

Seven patients received thrombolysis (thrombolysis rate 25%). In these patients, median door to CT time was 32 minutes, and door to needle time was 57 minutes. Of the remining 15 early presenters, reasons for not administering reperfusion therapy included: non-disabling symptoms and low NIHSS (10), absolute contraindication (1) and diagnostic uncertainty (4). Nineteen patients had delayed presentation.

Part B

Five main themes were identified as being important contributors to delays in help seeking at the time of stroke: difficulty making sense of symptoms, personal beliefs, dismissing/minimising symptoms, the influence of others and fulfilling prior commitments and responsibilities. Each of these themes will be explored in turn.

The majority of patients could not make sense of the symptoms they were experiencing. At symptom onset, patients noted that something was amiss. Some had characteristic severe stroke symptoms (eg, hemiparesis), and others experienced more subtle features, such as feeling “brain-muddled” or “out of it.” Patient 18 (83F, 2 hours), acknowledged that she “knew something was wrong, because I couldn’t move my right-hand side, and it wasn’t going away. What I used to do before (stretch out shoulder) wasn’t working, so I was thinking it was more serious.” Patient 36 (68M, 11 hours) “woke up feeling strange and weak on my right side, I took my blood pressure which was really high. So, I thought it was just due to my blood pressure. So, I just took my morning medications and hoped it would go down like it normally does.” Patient 14 (37M, 15 hours) dismissed the possibility of a stroke since, as they put it, “I wasn’t thinking of a stroke because I thought it is not for young people.”

Another theme that contributed to delays in hospital arrival were personal beliefs about seeking help. Some patients had reservations about depending on others, perceived medical services negatively or thought healthcare services should be reserved for more serious events than those experienced. Patient 41 (79F, 18 hours): “I’m not really good at depending on other people, and so I kind of just got on with and dealt with it myself. I should be at a stage where I should ask for help more.” Patient 40 (64F, 19 hours): “I have no trust in medical persons and establishment/government officials. I’m more inclined to fix things myself.” Patient 6 (67M, 11 hours): “I don’t like wasting people’s time, got to be pretty sure that I need help, normally family will look after me, I’ve been raised to think that there’s always someone worse off than you, so I didn’t want to take ambulance away from someone else, especially from my area.” Patient 16 (73F, 53 hours) said, “I wasn’t feeling I was sick enough to get an ambulance. The ambulance, in my mind was always thought of as the last and best effort. I would be embarrassed if they came, because they probably would have thought my symptoms weren’t bad enough,” and reflecting on her experience further, continued: “I think now, I would call the ambulance at a drop of a hat, because they made me feel safe and not like I was overreacting.”

A prominent theme that caused pre-hospital delay was minimising symptoms, with many patients feeling that the severity of their condition did not meet their perceived threshold which would warrant a call to emergency services. Patient 25 (87M, 43 hours): “I was reluctant to call the panic button, because I didn’t think it was critical and I had an appointment with my GP after the weekend.” However, this patient reported that he had contacted ambulance services soon after symptom onset and, unconventionally, the advice reinforced his decision to wait and see his general practitioner in the morning.

One theme that had varying effects on patients’ decisions to seek help was the influence of other people. Many patients sought advice, validation or a second opinion before contacting health services. In others, eyewitnesses identified stroke symptoms. Patient 1 (55M, 7 hours): “I didn’t have reception to talk to anyone, my symptoms were easing sometimes and I wasn’t sure it was a stroke. I knew my wife was coming home after work, and so I waited for her to see what she thought and help me get in.” Patient 41 (79F, 18 hours): “It was lucky my brother called, because he heard the slurred speech and encouraged me to get help, because he thought it was a stroke. I thought he might have been overreacting because I had been like this before.” There were a number of patients whose partners or relatives discouraged calling emergency services. Patient 34’s (72F, 35 hours) husband advised: “Just go to sleep and it will get better in the morning like it did last time with your mini stroke.” Patient 14 (37M, 15 hours) noted that his partner didn’t call earlier because “there wasn’t any bleeding or loss of consciousness, so I didn’t think it was an emergency to call.”

Finally, some patients prioritised prior commitments and responsibilities over seeking help for stroke symptoms, or delayed seeking help because they had upcoming healthcare appointments. Patient 10 (63F, 13 hours): “You look for excuses when you don’t want to come into the real world. I checked on the cat first, first called boss and told them to look after cat and that I think I’ve had a stroke. Don’t know if I was choosing to ignore it, or don’t want to bother people.” Patient 20 (86M, 4 hours): “[I] was hoping symptoms would just go away and I could focus on driving to get wife to hospital for her appointment.”

Discussion

This study investigated the health-seeking behaviour of patients experiencing stroke symptoms, with a particular focus on the factors that lead to time delays in seeking help. Only 16 patients recognised their symptoms as potentially being attributable to stroke, and only 12 of these patients presented within 4.5 hours of onset. Both our quantitative and qualitative data suggest that the decision to seek timely help is complex and multi-factorial.

The main factors causing significant delays in presentation to hospital included being a longer distance from hospital, delays in contacting health services and the five themes identified in the qualitative analysis.  

Geographical distance

We found an inverse relationship between distance from hospital and the likelihood of arriving within 4.5 hours. This highlights the challenge faced by rural communities. Reasons for delays include increased travel time, a lack of access to transportation and concerns over utilising the limited local ambulance service for fear of depriving others who may be in more need.

Delay to seeking emergency help

Patients with an early first call to emergency services for help were significantly more likely to arrive early and receive reperfusion therapy, whereas those whose first contact was primary care experienced significant delays. This finding is consistent with other studies[[12]] that associated face-to-face visits with family doctors with increased prehospital delay and decreased likelihood of receiving reperfusion therapy.

We identified five major themes that contributed to delays in presentations to hospital. We discovered that patients had good insight of stroke symptoms and the majority reported familiarity with the FAST campaign and knowing what a stroke was. However, patients’ ability to apply this knowledge to their own stroke symptoms was low. Reasons for this include, firstly, that having knowledge or awareness of stroke does not automatically translate into recognition of symptoms, and secondly, that cognitive function may be impaired in acute stroke; several of our patients describe some degree of confusion during the acute episode. Further, we found that almost half of patients did not consider stroke to be a medical emergency or think that emergency medical services should be contacted when stroke symptoms are minor. Some patients were not aware of the hyperacute treatments available.

Emergency services

We found that pre-hospital emergency services were extremely efficient at prioritising and responding to patients with stroke symptoms and transporting them to hospital. Hospital arrival to initial reperfusion therapy, more commonly referred to as “door to needle” time, is widely acknowledged to represent a stroke centre’s efficiency. Our door to needle time met the New Zealand target (less than 60 minutes in 80% of patients)[[1]] and is comparable to the performance of other international stroke centres.[[13,14]]

Limitations

Our study did have some limitations. We had relatively low numbers of study participants, which limited the ability to draw further conclusions and associations. Patients with severe strokes were under-represented, due to their inability to complete the interview, no eyewitnesses of the event or  consent to participate being withheld. This study was conducted in a single centre, limiting the generalisability of our results. Finally, we had a disproportionately low representation by Māori and Pacific peoples, ethnicities associated greater morbidity and mortality from stroke compared with other ethnic groups.[[15]]

Conclusion

This novel study identified a number of factors and themes that led to delays in patients with stoke symptoms seeking help. The findings of this study confirm that the most common reason for not receiving reperfusion therapy was prehospital delay. This study highlights gaps in the public’s awareness of stroke symptoms and the necessity of urgent treatment, and misgivings on the use of healthcare services. These factors should be addressed in future public health campaigns and by healthcare providers.

Summary

Abstract

Aim

Delays in seeking help following stroke or transient ischaemic attack (TIA) are associated with worse outcomes and missed treatment opportunities, including stroke reperfusion therapy. This study aims to discover the reasons for these delays.

Method

Patients admitted with stroke or TIA were eligible for inclusion. In Part A, we collected demographic data and particulars at the time of symptom onset, with data dichotomised into early (<4.5 hours) or late (≥4.5 hours) presentation times. In Part B, we collected qualitative data on cognitive factors that led to delayed admission. A standardised questionnaire was used to collect the data.

Results

One-half of 41 patients presented early. Living closer to hospital (36.4 vs 54.4 km, p=0.036)  and early contact with healthcare services (37 vs 1382 minutes, p=0.001) were associated with early presentation; contact with emergency services within 15 minutes of symptom onset was significantly associated with treatment with thrombolytics (p<0.001). Neither patient awareness of acute stroke symptoms, having a partner present nor a history of prior stroke were associated with early presentation (all p>0.05). Themes associated with delays included: difficulty understanding symptoms, personal beliefs, minimising symptoms, the influence of others and fulfilling prior responsibilities.

Conclusion

The findings of this study provide important insights that could help healthcare organisations introduce strategies to help improve access to organised stroke services.

Author Information

Karim M Mahawish: Consultant in General Medicine and Stroke, Department of Internal Medicine, MidCentral DHB, Palmerston North Hospital. Daniel Greenblatt: Undergraduate Medical Student, University of Otago.

Acknowledgements

We would like to extend our gratitude to the MidCentral Undergraduate Fund for supporting this research and Dr Balsam Al-Zurfi for help with statistical analysis.

Correspondence

Dr Karim M Mahawish, Consultant in General Medicine and Stroke, Department of Internal Medicine, MidCentral DHB, Palmerston North Hospital

Correspondence Email

kmahawish@doctors.org.uk

Competing Interests

Nil.

1) Stroke Foundation of New Zealand and New Zealand Guidelines Group. Clinical Guidelines for Stroke Management 2010. Wellington: Stroke Foundation of New Zealand; 2010.

2) Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014;384:1929-35.

3) Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387:1723-31.

4) Seiffge DJ, Werring DJ, Paciaroni M, et al. Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation. Lancet Neurol. 2019;18(1):117-126.

5) Garg A, Limaye K, Shaban A, et al. Risk of Ischemic Stroke after an Inpatient Hospitalization for Transient Ischemic Attack in the United States. Neuroepidemiology. 2021;55(1):40-6.

6) Rothwell PM, Giles MF, Arvind Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet. 2007;370:1432-42.

7) Palli C, Fandler S, Doppelhofer K, et al. Early Dysphagia Screening by Trained Nurses Reduces Pneumonia Rate in Stroke Patients: A Clinical Intervention Study. Stroke. 2017;48(9):2583-5.

8) Campbell BCV, Khatri P. Stroke. Lancet. 2020;396(10244):129-42.

9) Liu Q, Barber PA, Abernethy G, Ranta A. (2017). Provision of stroke thrombolysis services in New Zealand: Changes between 2011 and 2016. N Z Med J. 2017;130(1453):57-62.

10) Burnell AL, Ranta A, Wu T, et al. Endovascular clot retrieval for acute ischaemic stroke in New Zealand. N Z Med J. 2018;131(1484),13-8.

11) Hedlund F, Leighs A, Barber PA, et al. Trends in stroke reperfusion treatment and outcomes in New Zealand. Intern Med J.2020; 50(11):1367-72.

12) Fladt J, Meier N, Thilemann S, et al. Reasons for Prehospital Delay in Acute Ischemic Stroke. J Am Heart Assoc. 2019; 8(20):e013101.

13) Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: Patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation; 2011:123(7),750-8.

14) Moloney E, Peters C, McGrath K, et al. Time Is Brain: Door To Needle Time: Stroke Thrombolysis Pathway in Acute Tertiary Hospital. Age Ageing. 2016; 45(suppl 2), ii13.146-ii56.

15) Feigin VL, Mcnaughton H, Dyall L. Burden of stroke in Maori and Pacific peoples of New Zealand. Int J Stroke. 2007;2(3):208-10.

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In New Zealand, stroke is the third leading of death and the primary cause of adult disability.[[1]] Around 8,000 New Zealanders experience a stroke each year, and many will either die or lose the ability to care for themselves one year after the event.[[1]] Although early hyperacute therapies such as thrombolysis and thrombectomy are associated with improved patient outcomes,[[2,3]] benefits are also seen with other early interventions, including early anticoagulation for patients with atrial fibrillation,[[4]] early transient ischaemic attack (TIA) assessment and management,[[5,6]] early dysphagia screening after stroke[[7]] and early intensive lowering of blood pressure and reversal of antithrombotic medication in patients with intracerebral haemorrhage.[[8]] National and regional efforts such as regular audit, service model changes, public FAST campaigns and the introduction of telestroke have improved public awareness of stroke and a number of acute treatment metrics.[[9,10]] However, despite these initiatives, there are delays in presentation to hospital following stroke in most New Zealand district health boards (DHB). For instance, thrombolysis rates for acute ischaemic stroke have plateaued at around 10–15%, largely due to delays in seeking help.[[11]] This study aims to identify the factors that lead to time delays in seeking help when stroke symptoms arise.

Design and methods

A prospective cross-sectional study of patients admitted with stroke or TIA was conducted at Palmerston North Hospital, a medium-sized hospital serving a population of 172,930 with approximately 360 stroke admissions per annum. Our institution provides a 24/7 on-site thrombolysis service with input from telestroke and thrombectomy services from Capital and Coast DHB within the conventional window due to lack of perfusion imaging. Between 24 November 2020 and 8 January 2021, convenience sampling was used to enrol consecutive patients into the study. Inclusion criteria were (1) acute stroke or transient ischaemic attack (defined as an acute, focal neurologic deficit without alternative cause with supportive imaging findings) and (2) patient requires hospitalisation, which at our institution includes all acute strokes, or TIA with high-risk features (defined as concomitant atrial fibrillation, known carotid stenosis, anticoagulant therapy or an ABCD{{2}} score ≥4 (Age ≥ 60 years (+1), blood pressure ≥140/90mmHg (+1), clinical features (+1 or 2), symptom duration (+0-2), diabetes (+1)). Exclusion criteria were (1) any diagnosis other than stroke/TIA, (2) in-hospital onset of stroke symptoms and (3) incapacity to answer the structured questionnaire and no witness available in the pre-hospital phase available to answer the structured questionnaire. We obtained informed consent prior to enrolment in the study.

One research medical student collected data on the pre-hospital phase by using health records and conducted in-person or phone interviews with all patients or eyewitnesses admitted during the study period. Two methodologies (Part A and Part B) were used.

Part A

A standardised questionnaire and health records were used to collect quantitative data on demographics, the time and location of stroke onset and the first medical assistance sought. Questions were also asked to determine the level of stroke symptom awareness. Data on response times by pre-hospital and hospital services were also recorded.

Part B

Qualitative data was collected on patient perception and understanding of their symptoms, the factors that influenced their decision to seek help and the mode and urgency of seeking help.

Statistical analysis

Descriptive and inferential statistics were used. Categorical variables were described as frequencies and percentages, and numerical variables were described as mean and standard deviation or median and interquartile range. For inferential statistics, the association between categorical variables were determined using Fisher’s exact test, and for numerical variables, mean difference was determined using independent t-test. A p-value <0.05 was used for statistical significance. The association between each variable and hospital arrival within or after 4.5 hours was also investigated. This time window was chosen as it is the standard cut-off for hyperacute therapy. A time of ≥ 4.5 hours was used to define prehospital delay for the purposes of this analysis.

Ethical approval

The study protocol was received ethical approval from the New Zealand Northern Regional Health and Disability Ethics Committee and was endorsed by the Māori Research Review Group, Pae Ora Paiaka Whaiora Hauora Māori Directorate, at MidCentral DHB.

Results

A total of 56 patients were assessed for eligibility during the recruitment period. Overall, 41 patients satisfied the inclusion/exclusion criteria and agreed to participate. Reasons for exclusions are demonstrated in Figure 1.

Figure 1: Consort diagram showing how patients were enrolled.

Part A

The mean age of patients was 70 years (range 33–94), with equal representation of both sexes. Twenty-two patients (53.7%) arrived within 4.5 hours of stroke onset. The mean National Institutes of Health Stroke Scale (NIHSS) on admission was 4, and most patients (91.4%) were functionally independent pre-stroke (Modified Rankin Scale ≤2). The majority of patients (82.9%) identified as being of New Zealand European ethnicity and 5% identified as Māori. The most prevalent vascular risk factor was hypertension (58.5%), followed by diabetes (31.7%). Almost one-quarter of patients had three or more vascular risk factors. Twenty-eight patients had a final diagnosis of ischaemic stroke (68%), three haemorrhagic stroke (7%) and 10 TIA (24%). A summary of patient characteristics is presented in Table 1.

Table 1: Baseline characteristics. View Table 1.

The mean overall delay between stroke onset and first contact with a health professional was 11 hours. Patients who presented to hospital within 4.5 hours had a mean symptom onset to first healthcare contact time of 37 minutes compared with 23 hours for patients who presented outside 4.5 hours (p=0.036). These findings are summarised graphically in Figure 2.

Overall, 23 patients called the ambulance as their first point for help, and these patients were significantly more likely to arrive in hospital within 4.5 hours (p=0.009). Thirteen patients called the ambulance within 15 minutes of symptom onset and these patients were more likely to arrive to hospital within 4.5 hours (p=0.001) and were significantly more likely to receive thrombolysis (p<0.001). Seven patients used primary care as their first contact, and in these patients the mean time from symptom onset to hospital arrival was 28 hours. Patients with higher NIHSS scores on admission were more likely to present within 4.5 hours. However, this did not meet statistical significance. Interestingly, living with others, the presence of the partner at the time of stroke or having had a prior stroke were not associated with early presentation to hospital. Finally, patients arriving within 4.5 hours had a shorter mean travel distance to hospital than those with delayed admission. (36.36 vs 54.4 km, p=0.036).

Figure 2: Delays in patient response. Time from stroke onset to first call for help and time from stroke onset to hospital arrival.

Awareness of stroke symptoms

We did not observe a significant association between knowledge of stroke symptoms or FAST awareness and arriving within 4.5 hours. Sixteen patients reported knowing their symptoms were caused by a stroke, but only 12 of these arrived within 4.5 hours (not significant). Most participants could identify aphasia, diplopia/blurred vision and hemiparesis/paresthesia as stroke symptoms (82.9%, 78% and 90.9%, respectively). Only 39% of our patients could identify sudden blindness in one eye as a stroke symptom. The majority of patients correctly excluded chest pain, shooting pain in the arm, joint pain and sudden nose bleeds as stroke-specific symptoms. However, 73.2% and 63.4% of our patients incorrectly identified dizziness and headaches as stroke specific symptoms, respectively. The ability to identify any one stroke symptom was not significantly associated with arriving within 4.5 hours. Patient stroke symptom awareness is summarised in Table 2.

Table 2: Stroke awareness.

[[a]] Chi Square test. [[b]] Independent t-test. [[c]] Fisher’s exact test.

Ambulance response

The mean time between emergency call to arrival at the scene was 14 minutes, and the mean time from arrival of ambulance to departure for hospital was 21 minutes. The mean time delay between departure of ambulance to arrival at hospital was 38 minutes. This is shown graphically in Figure 3.

Figure 3: Ambulance response.

Hospital response

Seven patients received thrombolysis (thrombolysis rate 25%). In these patients, median door to CT time was 32 minutes, and door to needle time was 57 minutes. Of the remining 15 early presenters, reasons for not administering reperfusion therapy included: non-disabling symptoms and low NIHSS (10), absolute contraindication (1) and diagnostic uncertainty (4). Nineteen patients had delayed presentation.

Part B

Five main themes were identified as being important contributors to delays in help seeking at the time of stroke: difficulty making sense of symptoms, personal beliefs, dismissing/minimising symptoms, the influence of others and fulfilling prior commitments and responsibilities. Each of these themes will be explored in turn.

The majority of patients could not make sense of the symptoms they were experiencing. At symptom onset, patients noted that something was amiss. Some had characteristic severe stroke symptoms (eg, hemiparesis), and others experienced more subtle features, such as feeling “brain-muddled” or “out of it.” Patient 18 (83F, 2 hours), acknowledged that she “knew something was wrong, because I couldn’t move my right-hand side, and it wasn’t going away. What I used to do before (stretch out shoulder) wasn’t working, so I was thinking it was more serious.” Patient 36 (68M, 11 hours) “woke up feeling strange and weak on my right side, I took my blood pressure which was really high. So, I thought it was just due to my blood pressure. So, I just took my morning medications and hoped it would go down like it normally does.” Patient 14 (37M, 15 hours) dismissed the possibility of a stroke since, as they put it, “I wasn’t thinking of a stroke because I thought it is not for young people.”

Another theme that contributed to delays in hospital arrival were personal beliefs about seeking help. Some patients had reservations about depending on others, perceived medical services negatively or thought healthcare services should be reserved for more serious events than those experienced. Patient 41 (79F, 18 hours): “I’m not really good at depending on other people, and so I kind of just got on with and dealt with it myself. I should be at a stage where I should ask for help more.” Patient 40 (64F, 19 hours): “I have no trust in medical persons and establishment/government officials. I’m more inclined to fix things myself.” Patient 6 (67M, 11 hours): “I don’t like wasting people’s time, got to be pretty sure that I need help, normally family will look after me, I’ve been raised to think that there’s always someone worse off than you, so I didn’t want to take ambulance away from someone else, especially from my area.” Patient 16 (73F, 53 hours) said, “I wasn’t feeling I was sick enough to get an ambulance. The ambulance, in my mind was always thought of as the last and best effort. I would be embarrassed if they came, because they probably would have thought my symptoms weren’t bad enough,” and reflecting on her experience further, continued: “I think now, I would call the ambulance at a drop of a hat, because they made me feel safe and not like I was overreacting.”

A prominent theme that caused pre-hospital delay was minimising symptoms, with many patients feeling that the severity of their condition did not meet their perceived threshold which would warrant a call to emergency services. Patient 25 (87M, 43 hours): “I was reluctant to call the panic button, because I didn’t think it was critical and I had an appointment with my GP after the weekend.” However, this patient reported that he had contacted ambulance services soon after symptom onset and, unconventionally, the advice reinforced his decision to wait and see his general practitioner in the morning.

One theme that had varying effects on patients’ decisions to seek help was the influence of other people. Many patients sought advice, validation or a second opinion before contacting health services. In others, eyewitnesses identified stroke symptoms. Patient 1 (55M, 7 hours): “I didn’t have reception to talk to anyone, my symptoms were easing sometimes and I wasn’t sure it was a stroke. I knew my wife was coming home after work, and so I waited for her to see what she thought and help me get in.” Patient 41 (79F, 18 hours): “It was lucky my brother called, because he heard the slurred speech and encouraged me to get help, because he thought it was a stroke. I thought he might have been overreacting because I had been like this before.” There were a number of patients whose partners or relatives discouraged calling emergency services. Patient 34’s (72F, 35 hours) husband advised: “Just go to sleep and it will get better in the morning like it did last time with your mini stroke.” Patient 14 (37M, 15 hours) noted that his partner didn’t call earlier because “there wasn’t any bleeding or loss of consciousness, so I didn’t think it was an emergency to call.”

Finally, some patients prioritised prior commitments and responsibilities over seeking help for stroke symptoms, or delayed seeking help because they had upcoming healthcare appointments. Patient 10 (63F, 13 hours): “You look for excuses when you don’t want to come into the real world. I checked on the cat first, first called boss and told them to look after cat and that I think I’ve had a stroke. Don’t know if I was choosing to ignore it, or don’t want to bother people.” Patient 20 (86M, 4 hours): “[I] was hoping symptoms would just go away and I could focus on driving to get wife to hospital for her appointment.”

Discussion

This study investigated the health-seeking behaviour of patients experiencing stroke symptoms, with a particular focus on the factors that lead to time delays in seeking help. Only 16 patients recognised their symptoms as potentially being attributable to stroke, and only 12 of these patients presented within 4.5 hours of onset. Both our quantitative and qualitative data suggest that the decision to seek timely help is complex and multi-factorial.

The main factors causing significant delays in presentation to hospital included being a longer distance from hospital, delays in contacting health services and the five themes identified in the qualitative analysis.  

Geographical distance

We found an inverse relationship between distance from hospital and the likelihood of arriving within 4.5 hours. This highlights the challenge faced by rural communities. Reasons for delays include increased travel time, a lack of access to transportation and concerns over utilising the limited local ambulance service for fear of depriving others who may be in more need.

Delay to seeking emergency help

Patients with an early first call to emergency services for help were significantly more likely to arrive early and receive reperfusion therapy, whereas those whose first contact was primary care experienced significant delays. This finding is consistent with other studies[[12]] that associated face-to-face visits with family doctors with increased prehospital delay and decreased likelihood of receiving reperfusion therapy.

We identified five major themes that contributed to delays in presentations to hospital. We discovered that patients had good insight of stroke symptoms and the majority reported familiarity with the FAST campaign and knowing what a stroke was. However, patients’ ability to apply this knowledge to their own stroke symptoms was low. Reasons for this include, firstly, that having knowledge or awareness of stroke does not automatically translate into recognition of symptoms, and secondly, that cognitive function may be impaired in acute stroke; several of our patients describe some degree of confusion during the acute episode. Further, we found that almost half of patients did not consider stroke to be a medical emergency or think that emergency medical services should be contacted when stroke symptoms are minor. Some patients were not aware of the hyperacute treatments available.

Emergency services

We found that pre-hospital emergency services were extremely efficient at prioritising and responding to patients with stroke symptoms and transporting them to hospital. Hospital arrival to initial reperfusion therapy, more commonly referred to as “door to needle” time, is widely acknowledged to represent a stroke centre’s efficiency. Our door to needle time met the New Zealand target (less than 60 minutes in 80% of patients)[[1]] and is comparable to the performance of other international stroke centres.[[13,14]]

Limitations

Our study did have some limitations. We had relatively low numbers of study participants, which limited the ability to draw further conclusions and associations. Patients with severe strokes were under-represented, due to their inability to complete the interview, no eyewitnesses of the event or  consent to participate being withheld. This study was conducted in a single centre, limiting the generalisability of our results. Finally, we had a disproportionately low representation by Māori and Pacific peoples, ethnicities associated greater morbidity and mortality from stroke compared with other ethnic groups.[[15]]

Conclusion

This novel study identified a number of factors and themes that led to delays in patients with stoke symptoms seeking help. The findings of this study confirm that the most common reason for not receiving reperfusion therapy was prehospital delay. This study highlights gaps in the public’s awareness of stroke symptoms and the necessity of urgent treatment, and misgivings on the use of healthcare services. These factors should be addressed in future public health campaigns and by healthcare providers.

Summary

Abstract

Aim

Delays in seeking help following stroke or transient ischaemic attack (TIA) are associated with worse outcomes and missed treatment opportunities, including stroke reperfusion therapy. This study aims to discover the reasons for these delays.

Method

Patients admitted with stroke or TIA were eligible for inclusion. In Part A, we collected demographic data and particulars at the time of symptom onset, with data dichotomised into early (<4.5 hours) or late (≥4.5 hours) presentation times. In Part B, we collected qualitative data on cognitive factors that led to delayed admission. A standardised questionnaire was used to collect the data.

Results

One-half of 41 patients presented early. Living closer to hospital (36.4 vs 54.4 km, p=0.036)  and early contact with healthcare services (37 vs 1382 minutes, p=0.001) were associated with early presentation; contact with emergency services within 15 minutes of symptom onset was significantly associated with treatment with thrombolytics (p<0.001). Neither patient awareness of acute stroke symptoms, having a partner present nor a history of prior stroke were associated with early presentation (all p>0.05). Themes associated with delays included: difficulty understanding symptoms, personal beliefs, minimising symptoms, the influence of others and fulfilling prior responsibilities.

Conclusion

The findings of this study provide important insights that could help healthcare organisations introduce strategies to help improve access to organised stroke services.

Author Information

Karim M Mahawish: Consultant in General Medicine and Stroke, Department of Internal Medicine, MidCentral DHB, Palmerston North Hospital. Daniel Greenblatt: Undergraduate Medical Student, University of Otago.

Acknowledgements

We would like to extend our gratitude to the MidCentral Undergraduate Fund for supporting this research and Dr Balsam Al-Zurfi for help with statistical analysis.

Correspondence

Dr Karim M Mahawish, Consultant in General Medicine and Stroke, Department of Internal Medicine, MidCentral DHB, Palmerston North Hospital

Correspondence Email

kmahawish@doctors.org.uk

Competing Interests

Nil.

1) Stroke Foundation of New Zealand and New Zealand Guidelines Group. Clinical Guidelines for Stroke Management 2010. Wellington: Stroke Foundation of New Zealand; 2010.

2) Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014;384:1929-35.

3) Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387:1723-31.

4) Seiffge DJ, Werring DJ, Paciaroni M, et al. Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation. Lancet Neurol. 2019;18(1):117-126.

5) Garg A, Limaye K, Shaban A, et al. Risk of Ischemic Stroke after an Inpatient Hospitalization for Transient Ischemic Attack in the United States. Neuroepidemiology. 2021;55(1):40-6.

6) Rothwell PM, Giles MF, Arvind Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet. 2007;370:1432-42.

7) Palli C, Fandler S, Doppelhofer K, et al. Early Dysphagia Screening by Trained Nurses Reduces Pneumonia Rate in Stroke Patients: A Clinical Intervention Study. Stroke. 2017;48(9):2583-5.

8) Campbell BCV, Khatri P. Stroke. Lancet. 2020;396(10244):129-42.

9) Liu Q, Barber PA, Abernethy G, Ranta A. (2017). Provision of stroke thrombolysis services in New Zealand: Changes between 2011 and 2016. N Z Med J. 2017;130(1453):57-62.

10) Burnell AL, Ranta A, Wu T, et al. Endovascular clot retrieval for acute ischaemic stroke in New Zealand. N Z Med J. 2018;131(1484),13-8.

11) Hedlund F, Leighs A, Barber PA, et al. Trends in stroke reperfusion treatment and outcomes in New Zealand. Intern Med J.2020; 50(11):1367-72.

12) Fladt J, Meier N, Thilemann S, et al. Reasons for Prehospital Delay in Acute Ischemic Stroke. J Am Heart Assoc. 2019; 8(20):e013101.

13) Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: Patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation; 2011:123(7),750-8.

14) Moloney E, Peters C, McGrath K, et al. Time Is Brain: Door To Needle Time: Stroke Thrombolysis Pathway in Acute Tertiary Hospital. Age Ageing. 2016; 45(suppl 2), ii13.146-ii56.

15) Feigin VL, Mcnaughton H, Dyall L. Burden of stroke in Maori and Pacific peoples of New Zealand. Int J Stroke. 2007;2(3):208-10.

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In New Zealand, stroke is the third leading of death and the primary cause of adult disability.[[1]] Around 8,000 New Zealanders experience a stroke each year, and many will either die or lose the ability to care for themselves one year after the event.[[1]] Although early hyperacute therapies such as thrombolysis and thrombectomy are associated with improved patient outcomes,[[2,3]] benefits are also seen with other early interventions, including early anticoagulation for patients with atrial fibrillation,[[4]] early transient ischaemic attack (TIA) assessment and management,[[5,6]] early dysphagia screening after stroke[[7]] and early intensive lowering of blood pressure and reversal of antithrombotic medication in patients with intracerebral haemorrhage.[[8]] National and regional efforts such as regular audit, service model changes, public FAST campaigns and the introduction of telestroke have improved public awareness of stroke and a number of acute treatment metrics.[[9,10]] However, despite these initiatives, there are delays in presentation to hospital following stroke in most New Zealand district health boards (DHB). For instance, thrombolysis rates for acute ischaemic stroke have plateaued at around 10–15%, largely due to delays in seeking help.[[11]] This study aims to identify the factors that lead to time delays in seeking help when stroke symptoms arise.

Design and methods

A prospective cross-sectional study of patients admitted with stroke or TIA was conducted at Palmerston North Hospital, a medium-sized hospital serving a population of 172,930 with approximately 360 stroke admissions per annum. Our institution provides a 24/7 on-site thrombolysis service with input from telestroke and thrombectomy services from Capital and Coast DHB within the conventional window due to lack of perfusion imaging. Between 24 November 2020 and 8 January 2021, convenience sampling was used to enrol consecutive patients into the study. Inclusion criteria were (1) acute stroke or transient ischaemic attack (defined as an acute, focal neurologic deficit without alternative cause with supportive imaging findings) and (2) patient requires hospitalisation, which at our institution includes all acute strokes, or TIA with high-risk features (defined as concomitant atrial fibrillation, known carotid stenosis, anticoagulant therapy or an ABCD{{2}} score ≥4 (Age ≥ 60 years (+1), blood pressure ≥140/90mmHg (+1), clinical features (+1 or 2), symptom duration (+0-2), diabetes (+1)). Exclusion criteria were (1) any diagnosis other than stroke/TIA, (2) in-hospital onset of stroke symptoms and (3) incapacity to answer the structured questionnaire and no witness available in the pre-hospital phase available to answer the structured questionnaire. We obtained informed consent prior to enrolment in the study.

One research medical student collected data on the pre-hospital phase by using health records and conducted in-person or phone interviews with all patients or eyewitnesses admitted during the study period. Two methodologies (Part A and Part B) were used.

Part A

A standardised questionnaire and health records were used to collect quantitative data on demographics, the time and location of stroke onset and the first medical assistance sought. Questions were also asked to determine the level of stroke symptom awareness. Data on response times by pre-hospital and hospital services were also recorded.

Part B

Qualitative data was collected on patient perception and understanding of their symptoms, the factors that influenced their decision to seek help and the mode and urgency of seeking help.

Statistical analysis

Descriptive and inferential statistics were used. Categorical variables were described as frequencies and percentages, and numerical variables were described as mean and standard deviation or median and interquartile range. For inferential statistics, the association between categorical variables were determined using Fisher’s exact test, and for numerical variables, mean difference was determined using independent t-test. A p-value <0.05 was used for statistical significance. The association between each variable and hospital arrival within or after 4.5 hours was also investigated. This time window was chosen as it is the standard cut-off for hyperacute therapy. A time of ≥ 4.5 hours was used to define prehospital delay for the purposes of this analysis.

Ethical approval

The study protocol was received ethical approval from the New Zealand Northern Regional Health and Disability Ethics Committee and was endorsed by the Māori Research Review Group, Pae Ora Paiaka Whaiora Hauora Māori Directorate, at MidCentral DHB.

Results

A total of 56 patients were assessed for eligibility during the recruitment period. Overall, 41 patients satisfied the inclusion/exclusion criteria and agreed to participate. Reasons for exclusions are demonstrated in Figure 1.

Figure 1: Consort diagram showing how patients were enrolled.

Part A

The mean age of patients was 70 years (range 33–94), with equal representation of both sexes. Twenty-two patients (53.7%) arrived within 4.5 hours of stroke onset. The mean National Institutes of Health Stroke Scale (NIHSS) on admission was 4, and most patients (91.4%) were functionally independent pre-stroke (Modified Rankin Scale ≤2). The majority of patients (82.9%) identified as being of New Zealand European ethnicity and 5% identified as Māori. The most prevalent vascular risk factor was hypertension (58.5%), followed by diabetes (31.7%). Almost one-quarter of patients had three or more vascular risk factors. Twenty-eight patients had a final diagnosis of ischaemic stroke (68%), three haemorrhagic stroke (7%) and 10 TIA (24%). A summary of patient characteristics is presented in Table 1.

Table 1: Baseline characteristics. View Table 1.

The mean overall delay between stroke onset and first contact with a health professional was 11 hours. Patients who presented to hospital within 4.5 hours had a mean symptom onset to first healthcare contact time of 37 minutes compared with 23 hours for patients who presented outside 4.5 hours (p=0.036). These findings are summarised graphically in Figure 2.

Overall, 23 patients called the ambulance as their first point for help, and these patients were significantly more likely to arrive in hospital within 4.5 hours (p=0.009). Thirteen patients called the ambulance within 15 minutes of symptom onset and these patients were more likely to arrive to hospital within 4.5 hours (p=0.001) and were significantly more likely to receive thrombolysis (p<0.001). Seven patients used primary care as their first contact, and in these patients the mean time from symptom onset to hospital arrival was 28 hours. Patients with higher NIHSS scores on admission were more likely to present within 4.5 hours. However, this did not meet statistical significance. Interestingly, living with others, the presence of the partner at the time of stroke or having had a prior stroke were not associated with early presentation to hospital. Finally, patients arriving within 4.5 hours had a shorter mean travel distance to hospital than those with delayed admission. (36.36 vs 54.4 km, p=0.036).

Figure 2: Delays in patient response. Time from stroke onset to first call for help and time from stroke onset to hospital arrival.

Awareness of stroke symptoms

We did not observe a significant association between knowledge of stroke symptoms or FAST awareness and arriving within 4.5 hours. Sixteen patients reported knowing their symptoms were caused by a stroke, but only 12 of these arrived within 4.5 hours (not significant). Most participants could identify aphasia, diplopia/blurred vision and hemiparesis/paresthesia as stroke symptoms (82.9%, 78% and 90.9%, respectively). Only 39% of our patients could identify sudden blindness in one eye as a stroke symptom. The majority of patients correctly excluded chest pain, shooting pain in the arm, joint pain and sudden nose bleeds as stroke-specific symptoms. However, 73.2% and 63.4% of our patients incorrectly identified dizziness and headaches as stroke specific symptoms, respectively. The ability to identify any one stroke symptom was not significantly associated with arriving within 4.5 hours. Patient stroke symptom awareness is summarised in Table 2.

Table 2: Stroke awareness.

[[a]] Chi Square test. [[b]] Independent t-test. [[c]] Fisher’s exact test.

Ambulance response

The mean time between emergency call to arrival at the scene was 14 minutes, and the mean time from arrival of ambulance to departure for hospital was 21 minutes. The mean time delay between departure of ambulance to arrival at hospital was 38 minutes. This is shown graphically in Figure 3.

Figure 3: Ambulance response.

Hospital response

Seven patients received thrombolysis (thrombolysis rate 25%). In these patients, median door to CT time was 32 minutes, and door to needle time was 57 minutes. Of the remining 15 early presenters, reasons for not administering reperfusion therapy included: non-disabling symptoms and low NIHSS (10), absolute contraindication (1) and diagnostic uncertainty (4). Nineteen patients had delayed presentation.

Part B

Five main themes were identified as being important contributors to delays in help seeking at the time of stroke: difficulty making sense of symptoms, personal beliefs, dismissing/minimising symptoms, the influence of others and fulfilling prior commitments and responsibilities. Each of these themes will be explored in turn.

The majority of patients could not make sense of the symptoms they were experiencing. At symptom onset, patients noted that something was amiss. Some had characteristic severe stroke symptoms (eg, hemiparesis), and others experienced more subtle features, such as feeling “brain-muddled” or “out of it.” Patient 18 (83F, 2 hours), acknowledged that she “knew something was wrong, because I couldn’t move my right-hand side, and it wasn’t going away. What I used to do before (stretch out shoulder) wasn’t working, so I was thinking it was more serious.” Patient 36 (68M, 11 hours) “woke up feeling strange and weak on my right side, I took my blood pressure which was really high. So, I thought it was just due to my blood pressure. So, I just took my morning medications and hoped it would go down like it normally does.” Patient 14 (37M, 15 hours) dismissed the possibility of a stroke since, as they put it, “I wasn’t thinking of a stroke because I thought it is not for young people.”

Another theme that contributed to delays in hospital arrival were personal beliefs about seeking help. Some patients had reservations about depending on others, perceived medical services negatively or thought healthcare services should be reserved for more serious events than those experienced. Patient 41 (79F, 18 hours): “I’m not really good at depending on other people, and so I kind of just got on with and dealt with it myself. I should be at a stage where I should ask for help more.” Patient 40 (64F, 19 hours): “I have no trust in medical persons and establishment/government officials. I’m more inclined to fix things myself.” Patient 6 (67M, 11 hours): “I don’t like wasting people’s time, got to be pretty sure that I need help, normally family will look after me, I’ve been raised to think that there’s always someone worse off than you, so I didn’t want to take ambulance away from someone else, especially from my area.” Patient 16 (73F, 53 hours) said, “I wasn’t feeling I was sick enough to get an ambulance. The ambulance, in my mind was always thought of as the last and best effort. I would be embarrassed if they came, because they probably would have thought my symptoms weren’t bad enough,” and reflecting on her experience further, continued: “I think now, I would call the ambulance at a drop of a hat, because they made me feel safe and not like I was overreacting.”

A prominent theme that caused pre-hospital delay was minimising symptoms, with many patients feeling that the severity of their condition did not meet their perceived threshold which would warrant a call to emergency services. Patient 25 (87M, 43 hours): “I was reluctant to call the panic button, because I didn’t think it was critical and I had an appointment with my GP after the weekend.” However, this patient reported that he had contacted ambulance services soon after symptom onset and, unconventionally, the advice reinforced his decision to wait and see his general practitioner in the morning.

One theme that had varying effects on patients’ decisions to seek help was the influence of other people. Many patients sought advice, validation or a second opinion before contacting health services. In others, eyewitnesses identified stroke symptoms. Patient 1 (55M, 7 hours): “I didn’t have reception to talk to anyone, my symptoms were easing sometimes and I wasn’t sure it was a stroke. I knew my wife was coming home after work, and so I waited for her to see what she thought and help me get in.” Patient 41 (79F, 18 hours): “It was lucky my brother called, because he heard the slurred speech and encouraged me to get help, because he thought it was a stroke. I thought he might have been overreacting because I had been like this before.” There were a number of patients whose partners or relatives discouraged calling emergency services. Patient 34’s (72F, 35 hours) husband advised: “Just go to sleep and it will get better in the morning like it did last time with your mini stroke.” Patient 14 (37M, 15 hours) noted that his partner didn’t call earlier because “there wasn’t any bleeding or loss of consciousness, so I didn’t think it was an emergency to call.”

Finally, some patients prioritised prior commitments and responsibilities over seeking help for stroke symptoms, or delayed seeking help because they had upcoming healthcare appointments. Patient 10 (63F, 13 hours): “You look for excuses when you don’t want to come into the real world. I checked on the cat first, first called boss and told them to look after cat and that I think I’ve had a stroke. Don’t know if I was choosing to ignore it, or don’t want to bother people.” Patient 20 (86M, 4 hours): “[I] was hoping symptoms would just go away and I could focus on driving to get wife to hospital for her appointment.”

Discussion

This study investigated the health-seeking behaviour of patients experiencing stroke symptoms, with a particular focus on the factors that lead to time delays in seeking help. Only 16 patients recognised their symptoms as potentially being attributable to stroke, and only 12 of these patients presented within 4.5 hours of onset. Both our quantitative and qualitative data suggest that the decision to seek timely help is complex and multi-factorial.

The main factors causing significant delays in presentation to hospital included being a longer distance from hospital, delays in contacting health services and the five themes identified in the qualitative analysis.  

Geographical distance

We found an inverse relationship between distance from hospital and the likelihood of arriving within 4.5 hours. This highlights the challenge faced by rural communities. Reasons for delays include increased travel time, a lack of access to transportation and concerns over utilising the limited local ambulance service for fear of depriving others who may be in more need.

Delay to seeking emergency help

Patients with an early first call to emergency services for help were significantly more likely to arrive early and receive reperfusion therapy, whereas those whose first contact was primary care experienced significant delays. This finding is consistent with other studies[[12]] that associated face-to-face visits with family doctors with increased prehospital delay and decreased likelihood of receiving reperfusion therapy.

We identified five major themes that contributed to delays in presentations to hospital. We discovered that patients had good insight of stroke symptoms and the majority reported familiarity with the FAST campaign and knowing what a stroke was. However, patients’ ability to apply this knowledge to their own stroke symptoms was low. Reasons for this include, firstly, that having knowledge or awareness of stroke does not automatically translate into recognition of symptoms, and secondly, that cognitive function may be impaired in acute stroke; several of our patients describe some degree of confusion during the acute episode. Further, we found that almost half of patients did not consider stroke to be a medical emergency or think that emergency medical services should be contacted when stroke symptoms are minor. Some patients were not aware of the hyperacute treatments available.

Emergency services

We found that pre-hospital emergency services were extremely efficient at prioritising and responding to patients with stroke symptoms and transporting them to hospital. Hospital arrival to initial reperfusion therapy, more commonly referred to as “door to needle” time, is widely acknowledged to represent a stroke centre’s efficiency. Our door to needle time met the New Zealand target (less than 60 minutes in 80% of patients)[[1]] and is comparable to the performance of other international stroke centres.[[13,14]]

Limitations

Our study did have some limitations. We had relatively low numbers of study participants, which limited the ability to draw further conclusions and associations. Patients with severe strokes were under-represented, due to their inability to complete the interview, no eyewitnesses of the event or  consent to participate being withheld. This study was conducted in a single centre, limiting the generalisability of our results. Finally, we had a disproportionately low representation by Māori and Pacific peoples, ethnicities associated greater morbidity and mortality from stroke compared with other ethnic groups.[[15]]

Conclusion

This novel study identified a number of factors and themes that led to delays in patients with stoke symptoms seeking help. The findings of this study confirm that the most common reason for not receiving reperfusion therapy was prehospital delay. This study highlights gaps in the public’s awareness of stroke symptoms and the necessity of urgent treatment, and misgivings on the use of healthcare services. These factors should be addressed in future public health campaigns and by healthcare providers.

Summary

Abstract

Aim

Delays in seeking help following stroke or transient ischaemic attack (TIA) are associated with worse outcomes and missed treatment opportunities, including stroke reperfusion therapy. This study aims to discover the reasons for these delays.

Method

Patients admitted with stroke or TIA were eligible for inclusion. In Part A, we collected demographic data and particulars at the time of symptom onset, with data dichotomised into early (<4.5 hours) or late (≥4.5 hours) presentation times. In Part B, we collected qualitative data on cognitive factors that led to delayed admission. A standardised questionnaire was used to collect the data.

Results

One-half of 41 patients presented early. Living closer to hospital (36.4 vs 54.4 km, p=0.036)  and early contact with healthcare services (37 vs 1382 minutes, p=0.001) were associated with early presentation; contact with emergency services within 15 minutes of symptom onset was significantly associated with treatment with thrombolytics (p<0.001). Neither patient awareness of acute stroke symptoms, having a partner present nor a history of prior stroke were associated with early presentation (all p>0.05). Themes associated with delays included: difficulty understanding symptoms, personal beliefs, minimising symptoms, the influence of others and fulfilling prior responsibilities.

Conclusion

The findings of this study provide important insights that could help healthcare organisations introduce strategies to help improve access to organised stroke services.

Author Information

Karim M Mahawish: Consultant in General Medicine and Stroke, Department of Internal Medicine, MidCentral DHB, Palmerston North Hospital. Daniel Greenblatt: Undergraduate Medical Student, University of Otago.

Acknowledgements

We would like to extend our gratitude to the MidCentral Undergraduate Fund for supporting this research and Dr Balsam Al-Zurfi for help with statistical analysis.

Correspondence

Dr Karim M Mahawish, Consultant in General Medicine and Stroke, Department of Internal Medicine, MidCentral DHB, Palmerston North Hospital

Correspondence Email

kmahawish@doctors.org.uk

Competing Interests

Nil.

1) Stroke Foundation of New Zealand and New Zealand Guidelines Group. Clinical Guidelines for Stroke Management 2010. Wellington: Stroke Foundation of New Zealand; 2010.

2) Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014;384:1929-35.

3) Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387:1723-31.

4) Seiffge DJ, Werring DJ, Paciaroni M, et al. Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation. Lancet Neurol. 2019;18(1):117-126.

5) Garg A, Limaye K, Shaban A, et al. Risk of Ischemic Stroke after an Inpatient Hospitalization for Transient Ischemic Attack in the United States. Neuroepidemiology. 2021;55(1):40-6.

6) Rothwell PM, Giles MF, Arvind Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet. 2007;370:1432-42.

7) Palli C, Fandler S, Doppelhofer K, et al. Early Dysphagia Screening by Trained Nurses Reduces Pneumonia Rate in Stroke Patients: A Clinical Intervention Study. Stroke. 2017;48(9):2583-5.

8) Campbell BCV, Khatri P. Stroke. Lancet. 2020;396(10244):129-42.

9) Liu Q, Barber PA, Abernethy G, Ranta A. (2017). Provision of stroke thrombolysis services in New Zealand: Changes between 2011 and 2016. N Z Med J. 2017;130(1453):57-62.

10) Burnell AL, Ranta A, Wu T, et al. Endovascular clot retrieval for acute ischaemic stroke in New Zealand. N Z Med J. 2018;131(1484),13-8.

11) Hedlund F, Leighs A, Barber PA, et al. Trends in stroke reperfusion treatment and outcomes in New Zealand. Intern Med J.2020; 50(11):1367-72.

12) Fladt J, Meier N, Thilemann S, et al. Reasons for Prehospital Delay in Acute Ischemic Stroke. J Am Heart Assoc. 2019; 8(20):e013101.

13) Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: Patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation; 2011:123(7),750-8.

14) Moloney E, Peters C, McGrath K, et al. Time Is Brain: Door To Needle Time: Stroke Thrombolysis Pathway in Acute Tertiary Hospital. Age Ageing. 2016; 45(suppl 2), ii13.146-ii56.

15) Feigin VL, Mcnaughton H, Dyall L. Burden of stroke in Maori and Pacific peoples of New Zealand. Int J Stroke. 2007;2(3):208-10.

Contact diana@nzma.org.nz
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