Stroke education focusing on recognition and response to decrease pre-hospital delay in India: Need of the hour to save hours

Background: Pre-hospital delays contribute to late arrival for acute ischemic stroke (AIS) treatment in the emergency department and are an important barrier preventing people from receiving thrombolytic therapy. This study looked into the factors causing pre-hospital delay in a tertiary care centre in South India with the aim of identifying measures to decrease pre-hospital delay. Methods: Consecutive cases of AIS from October 2018 to June 2019 were included. A structured questionnaire was used to collect data regarding demographic details, presenting symptoms, time of stroke onset and arrival, mode of transport and knowledge about stroke and thrombolysis. Pre-hospital delay was defined as > 4 h (Considering our door-to-needle time of 30 min) between stroke onset or the time point of wake-up and the time of arrival. Results: Overall, 505 patients were enrolled. Prehospital delay was observed in 352patients (69.7%). The median pre-hospital delay was 9.5 h. In the multivariable analysis, the odds of early arrival were increased in patients who perceived the initial symptoms as serious (OR: 45.57; 95%CI, 11.43-181.63), those with prior knowledge of stroke symptoms (OR: 4.64; 95% CI, 1.86-11.55), those using ambulance services (OR: 3.11; 95% CI, 1.39-6.95), and those developing hemiparesis (OR: 2.50; 95% CI, 1.25-4.97). The odds of early arrival were lower in those visiting their family doctor after the stroke (OR: 0.17; 95%CI, 0.05-0.51). Conclusions: Modifiable factors related to stroke recognition and response behavior continue to cause significant pre-hospital delay in India. There is an immediate need for a strong education campaign focusing on stroke specific knowledge to decrease pre-hospital delay.