Reasons for diagnostic delay in patients with out-of-hospital acute ischemic stroke

BACKGROUND: Time window is a common problem in various therapies of acute ischemic stroke, and diagnostic duration plays an important role in prognosis. OBJECTIVE: To analyze the main reasons for out-of-hospital diagnostic delay of patients with acute ischemic stroke. DESIGN: Survey and analysis. SETTING: Department of Neurology, the First Affiliated Hospital of Jinan University. PARTICIPANTS: A total of 116 patients with acute ischemic stroke were selected from the Department of Neurology, the First Affiliated Hospital of Jinan University from December 2002 to December 2005, including 79 males and 37 females aged from 35 to 90 years with the mean age of (65±10) years. All patients met the diagnostic criteria of "mainly diagnostic points of various cerebrovascular diseases" established by the 4th National Cerebrovascular Diseases Meeting in 1995. Patients having acute ischemic stroke in hospital were excluded. Moreover, 32 nurses received questionnaires of partial items. All patients and nurses provided informed consent. METHODS: ① Information, such as social position, educational level and incomes, was added up based on questionnaires. ② Out-of-hospital diagnostic delay was surveyed based on the recorded time of patients treated in emergency department and out-patient clinic or during hospitalization. ③ Ability of patients and nurses to identify symptoms of stroke during an early period was evaluated; meanwhile, understanding concept of stroke and using emergent system of social medicine by patients were surveyed. Especially, whether patients understood the emergent number "120" or not and how they used it practically were investigated further. ④ Attitude and behavior of patients to stroke were surveyed. ⑤ Whether patients were able to identify the symptoms of stroke or not was investigated; furthermore, identification of stroke by patients and nurses was dealt with semi-quantitative analysis. The scores ranged from -10 to 10. The higher the scores were, the better the identification was. ⑥ All factors which was possibly related to stroke were dealt with one-way Logistic regression analysis. MAIN OUTCOME MEASURES: ① Out-of-hospital diagnostic delay; ② evaluating results of general knowledge of stroke; ③ attitude and behavior to stroke; ④ identification of symptoms of stroke; ⑤ results of relative factors with regression analysis. RESULTS: All 116 patients with stroke were involved in the survey of out-of-hospital diagnostic delay. Among them, 81 patients and 32 nurses finished the questionnaires of general knowledge of stroke. ① Out-of-hospital diagnostic delay: A total of 26 patients directly received the treatment in local hospitals, and the median was 4.00 hours. Another 73 patients directly received the treatment in emergency department of our hospital. The diagnostic rate was 26% within 3 hours and 7% from 3 hours to 6 hours. ② Evaluating results of general knowledge of stroke: About 57% (46/81) patients and 81% (26/32) nurses knew how to use emergent number. In addition, after the onset of stroke, 26% (21/81) people knew how to call the first aid; however, only 19% (15/18) cases gave a telephone call of first aid. Among them, about 53% (43/81) patients and 81% (26/32) nurses clearly understood what stroke was. Only 22% (18/81) patients realized that the best time for treating stroke was within 6 hours after its onset. ③ Attitude and behavior to stroke: Once stroke was occurred, about 47% (38/81) patients directly received the treatment in some famous hospital; meanwhile, 25% (20/81) patients waited for observing whether the symptoms disappeared or not; however, 27% (22/81) patients did not know what to do at the phase of onset of stroke; furthermore, 26% (21/81) patients received regular review in local clinics. ④ Identification of symptoms of stroke: Patients and nurses in this survey were poorly able to identify symptoms of stroke. The minimal scores of patients were 6, the maximal was 9 and the median was 2; moreover, among 31 nurses, scores ranged from 0 to 8 and the median was 3. ⑤ Results of relative factors with regression analysis: Educational level was the basic factor for symptom identification and diagnostic delay for patient at the phase of onset of stroke (OR value = 0.466, 0.225, 9.831, P < 0.05). CONCLUSION: Patients and nurses are poorly able to identify the symptoms of stroke. Out-of-hospital diagnostic delay is related to educational level, delay treatment in local hospital or medical community, and poorly common information of stroke.