Delayed hospital arrival for acute stroke: The Minnesota stroke survey

Background: Although recent advances have been made in the treatment of acute stroke, patients often arrive at the hospital too late to receive the maximum benefit from these new therapies. Objective: To investigate characteristics that influence the time from symptom onset to hospital arrival (delay time) for patients with acute stroke. Design: Retrospective medical record review. Setting: Minneapolis-St. Paul metropolitan hospitals. Patients: A 50% random sample of all patients 30 to 79 years of age who were hospitalized with acute stroke from 1991 to 1993. Measurements: Patients were identified through discharge diagnosis lists by using the International Classification of Diseases, 9th Revision. Trained nurses abstracted the medical records. Stroke events were validated by using neuroimaging reports and additional clinical criteria (1895 patients). An accelerated failure time model was used to identify patient characteristics that independently predicted delay time. For 70% of patients (n = 1334), delay time was calculated from the medical record by subtracting the recorded time of symptom onset from the admission time. For the remaining 30% of patients (n = 561), the time of symptom onset was not recorded, and an approximate delay time was estimated from all available information. Results: Among patients with a calculated delay time, half arrived within 3 hours of symptom onset and 90% arrived within 24 hours. Patients with approximated delay times tended to have longer delays, and less than 40% of these patients arrived within 24 hours of symptom onset. Some characteristics associated (P < 0.05) with longer delay included Asian/Pacific Islander ethnicity, dependence in any activities of daily living before stroke, and several symptoms at stroke onset. Characteristics associated (P < 0.05) with shorter delay included admission through the emergency department, presence of syncope or seizures at stroke onset, previous myocardial infarction, abnormal mental status, and greater disability at presentation (measured by the Rankin scale). Conclusions: Most patients arrive at the hospital too late to receive the maximum benefit from emerging stroke therapies. Efforts to reduce delays in hospital arrival after acute stroke can maximize the effectiveness of these thera pies by specifically targeting persons at risk for longer delay.