Determinants of use of emergency medical services in a population with stroke symptoms: the Second Delay in Accessing Stroke Healthcare (DASH II) Study.

BACKGROUND AND PURPOSE: With the advent of time-dependent thrombolytic therapy for ischemic stroke, it has become increasingly important for stroke patients to arrive at the hospital quickly. This study investigates the association between the use of emergency medical services (EMS) and delay time among individuals with stroke symptoms and examines the predictors of EMS use. METHODS: The Second Delay in Accessing Stroke Healthcare Study (DASH II) was a prospective study of 617 individuals arriving at emergency departments in Denver, Colo, Chapel Hill, NC, and Greenville, SC, with stroke symptoms. RESULTS: EMS use was associated with decreased prehospital and in-hospital delay. Those who used EMS had a median prehospital delay time of 2.85 hours compared with 4.03 hours for those who did not use EMS (P:=0.002). Older individuals were more likely to use EMS (odds ratio [OR] 1.21 for each 5-year increase, 95% CI 1.14 to 1.29), as were individuals who expressed a high sense of urgency about their symptoms (OR 1.69, 95% CI 1.09 to 2.62). Knowledge of stroke symptoms was not associated with increased EMS use (OR 0.63, 95% CI 0.40 to 0.98). Patients were more likely to use EMS if someone other than the patient first identified that there was a problem (OR 2.35, 95% CI 1.61 to 3.44). CONCLUSIONS: Interventions aimed at increasing EMS use among stroke patients need to stress the urgency of stroke symptoms and the importance of calling 911 and need to be broad-based, encompassing not only those at high risk for stroke but also their friends and family.

Time delays in accessing stroke care in the emergency department.

OBJECTIVE: To delineate components of delay within the hospital ED for patients presenting with symptoms of stroke. METHODS: A prospective registry of patients presenting to the ED with signs or symptoms of stroke was established at a university hospital from July 1995 to March 1996. The ED arrival time, time to being seen by an emergency physician (EP), time to CT scan, and time to neurology consultation were obtained by medical record review. RESULTS: The median delay (interquartile range) from ED arrival to being seen by an EP for the 170 eligible subjects was 0.42 (0.20-0.75) hours. The median delay to CT scan was 1.88 hours (1.25-2.67) and the median delay to neurology consultation was 2.42 hours (1.50-3.48). Age, race, sex, and hospital discharge diagnosis had little influence on delay. Subjects arriving by emergency medical services (EMS) had a significantly shorter time to being seen by an EP (0.33 vs 0.50 hours) when compared with those who arrived by other means. Time to CT scan was shorter by 0.5 hours for patients arriving by EMS as well. These differences persisted when stratified by out-of-hospital delay times. CONCLUSIONS: These data suggest that arriving by EMS is associated with shorter times to being seen by an EP and receiving a CT scan. The influence of EMS on delays associated with rapid medical care of stroke patients reaches beyond the out-of-hospital transport phase.

Rapid response to stroke symptoms: the Delay in Accessing Stroke Healthcare (DASH) study.

OBJECTIVE: To assess the determinants of prehospital delay for patients with presumed acute cerebral ischemia (ACI) in order to provide the background necessary to develop interventions to shorten such delays. METHODS: A prospective registry of patients presenting to the ED with signs and symptoms of stroke was established at a university hospital from July 1995 to March 1996. Trained nurses performed a structured ED interview, which assessed prehospital delay and potential confounders. RESULTS: The median delay (interquartile range) from symptom onset to ED arrival for all patients seeking care for stroke-like symptoms (n = 152) was 3.0 hours (1.5-7.8 hr). The median delay from symptom onset to ED arrival was less in cases where a witness first recognized that there was a serious problem than it was when the patient first identified the problem. A heightened sense of urgency by the patient about his or her symptoms, and use of 911/emergency medical services (EMS) transport were also associated with rapid arrival in the ED within 3 hours of symptom onset. After adjusting for all predictor variables in a multivariable logistic regression model, only recognition of symptoms by a witness and calling 911/EMS transport remained statistically significant. CONCLUSIONS: These data suggest that future efforts to intervene on prolonged prehospital delay for patients with ACI should include strategies for the community as a whole as well as persons at risk for stroke and should reinforce the use of 911 and EMS transport.