Time to hospital presentation in acute ischaemic stroke
Background: In Ireland, stroke is the third most common cause of death and remains the leading cause of acquired disability, affecting approximately 10,000 people annually. Revascularisation treatment with thrombolysis is associated with reductions in morbidity and mortality, however it must be initiated within 4.5 hours following stroke symptom onset. Despite its proven benefits, thrombolysis therapy is under-utilised in clinical practice with patient delay in presenting to hospital with symptoms identified as the leading barrier to thrombolysis administration. Population-focussed behaviour change interventions such as mass media interventions have demonstrated impacts on population stroke knowledge and intentions to seek medical help when symptoms occur. However their impact on behaviour during stroke onset is not established.
Aim: The programme of work in this dissertation seeks to: determine the success of interventions to reduce patient delay with stroke symptoms; investigate the behavioural impact of an Irish mass media intervention for stroke awareness; examine the complex factors involved in decision-making during stroke onset; and examine the long-term impact of hospital arrival time on patient outcome.
Methods: This dissertation presents a systematic review and three inter-related studies, as follows:
1) The systematic review synthesises findings from twelve studies which examine the impact of public and professional interventions to reduce patient delay in presenting to hospital with stroke symptoms;
2) Study 1 examines whether an Irish mass media intervention, the FAST campaign (Face, Arm, Speech, Time, the Irish Heart Foundation national stroke awareness campaign), had a health service impact by assessing changes in Emergency Department (ED) activity for presentations with stroke symptoms over a one-year period (N=870);
3) Study 2 examines factors related to patient delay during stroke onset in a cohort of stroke survivors (N=149);
4) Study 3 examines the physical, cognitive and psychological outcomes at six months post-stroke of the study cohort identified in Study 2, and assesses whether time to hospital arrival has an impact on these post-stroke outcomes.
Main findings: The review found that behaviour change interventions for stroke were heterogeneous in type, duration and content of interventions. The findings suggest that, as a result of weak study designs, observed effects largely could not be attributed to the specified interventions. The parallel delivery of public and professional interventions also complicated the identification of successful components of the interventions.
Segmented poisson regression in Study 1 revealed that the first wave of the FAST campaign had a significant impact on increasing ED usage, with ED presentations increasing during Wave One and in the period following Wave One of the campaign (level trend: jS = 0.84, 95% Cl, 0.43 to 1.24, slope trend: /3 0-.079, 95% Cl, -0.14 to - 0.01). There were no significant increases during or following Waves Two and Three of the campaign and additionally there was no statistically significant effect of the FAST campaign on presentations within 3.5 hours.
Examination of factors associated with hospital arrival time in Study 2 revealed that the presence of others was critical in fast response to stroke symptoms, with EMS activation initiated by another (HR=1.78) associated with shorter arrival times. The FAST message may have played a role in initiating faster response to symptoms, with faster arrival times reported for patients who were affected by the FAST message at the time of symptom onset (HR=1.82).
Exploratory multinomial logistic regression modelling in Study 3 suggested that in the absence of thrombolysis treatment, longer patient delay time was associated with a range of poorer outcomes at six months post-stroke, specifically for presence of depressive symptoms (p
The results highlight the complexity of changing help-seeking behaviour during stroke onset. The FAST campaign is associated with demonstrated changes in help-seeking behaviour for stroke, however there is scope for further improvement. A number of implications for stroke education strategies and future research are documented. The potential clinical benefits of media interventions such as FAST are far-reaching and the challenge remains in translating knowledge improvements and correct behavioural intentions to appropriate behaviour, where people act on the message. Minimising pre-hospital delay in this way serves to reduce the potentially devastating impact of stroke.