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(Stroke. 2000;31:2585.)
© 2000 American Heart Association, Inc.
Original Contributions |
Prehospital and Emergency Department Delays After Acute Stroke
The Genentech Stroke Presentation Survey
From the Department of Emergency Medicine, School of Medicine (D.L.M.), and the Department of Epidemiology, School of Public Health (W.R.), University of North Carolina, Chapel Hill; Marshfield, Clinic (K.M.), Marshfield, Wis; the Department of Emergency Medicine, School of Medicine (C.S.), University of Michigan, Ann Arbor; and Genentech Inc (S.H.), South San Francisco, Calif.
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Abstract |
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 Top Abstract IntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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Background and Purpose—Patient delays in seeking treatment for stroke and delays within the Emergency Department (ED) are major factors in the lack of use of thrombolytic therapy for stroke. The Genentech Stroke Presentation Survey was a multicentered prospective registry of patients with acute stroke. The study was designed to characterize prehospital delays and delays within the ED.
Methods—Patients with stroke symptoms presenting to 48 EDs participating in a clinical trial of acute stroke therapy were enrolled prospectively. A 1-page data form was completed from patient interviews and medical records.
Results—A total of 1207 subjects were entered into the study. Ninety-four percent of the 721 subjects with complete data had a diagnosis of stroke or transient ischemic attack, 13% were black, 50% were female, and 67% were aged >65 years. The median time from symptom onset to ED arrival was 2.6 (interquartile range 1.2 to 6.3) hours. The median time from ED arrival until CT scan completion was 1.1 (0.7 to 1.8) hours, and the total delay time (symptom onset until CT scan completion) had a median of 4.0 (2.3 to 8.3) hours. Patients who arrived by emergency medical services had significantly shorter prehospital delay times and times to CT scan. Age, race, sex, and educational level did not appear to affect prehospital delay times.
Conclusions—Despite its limitations, this large geographically diverse study strongly suggests that the use of emergency medical services is an important modifiable determinant of delay time for the treatment of acute stroke.
Key Words: emergency medical services • emergency service, hospital • stroke onset • stroke, acute • tomography, x-ray computed
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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Despite the approval of thrombolytic therapy for the acute treatment of stroke, only a small percentage of patients receive this therapy.1 There are number of factors that prevent the use of this treatment more frequently. However, the most important is that patients do not present early enough to be treated within 3 hours of symptom onset.2 Patient delay may be even more important with the recent understanding that the efficacy of thrombolytic therapy with recombinant tissue plasminogen activator (rtPA) appears to be directly related to the time from symptom onset to treatment, even within the 3-hour window.3 A number of studies have examined the factors that lead to delays in the treatment of stroke patients, including delays before and after arrival at the Emergency Department (ED).4 5 6 7 8 9 However, the majority of these studies have been small (<200 subjects) and confined to one geographic or medical location. The Genentech Stroke Presentation Survey (GSPS) was a large multicentered study designed to investigate patient delays in seeking care after stroke as well as delays in diagnostic studies within the ED. This large study, with its diverse patient population, will provide important information for future strategies to reduce delays in stroke treatment.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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The GSPS was designed as a prospective registry of patients presenting with acute stroke to the ED. The 48 EDs who participated in the study were all concurrently enrolling patients in a clinical trial of rtPA treatment for acute stroke during the 3- to 5-hour window.10 From March 1997 to December 1997, all patients presenting to the study EDs with symptoms of acute stroke were enrolled in the GSPS. Trained staff from each study center completed a 1-page survey on information related to symptom onset, ED arrival, and care. Information was gathered from the patient or surrogate when possible and from the ED record itself. Each center was provided with training and written standardized instructions on how to collect the data. The forms were edited on the local level and then processed centrally at Genentech, Inc.
Definitions
Symptom Onset Time
Symptom onset time was defined as the time the patient was last
known to be without symptoms or at baseline. If the patient awoke with
symptoms, symptom onset time was defined as when the patient went to
sleep or was last known awake without symptoms.
Prehospital Delay
Prehospital delay was defined as the time from symptom onset
until the earliest documented time in the ED (usually triage or
registration).
Delay to CT Scan
Delay to CT scan was defined as the time from ED arrival (see
above) until the completion of the CT scan. This was sometimes
approximated by the return of the patient to his/her bed or bay. This
time did not necessarily include interpretation of the CT scan.
Time to Neurologist Consult
Time to neurologist consult was defined as the time from ED
arrival until arrival of the neurology consultant in the
ED.
Total Delay
Total delay was defined as the time from symptom onset to
completion of the head CT scan.
Patient Selection
Patients were eligible to participate in the present study
if they were aged 
18 years and presented to the ED with signs
or symptoms of acute stroke. Patients were excluded if their symptom
onset was >24 hours. Patients were also excluded if they were
subsequently enrolled in the clinical trial of rtPA for the 3- to
5-hour window.10 (This had minimal effect, because the
majority of patients presenting in the 3- to 5-hour window were
ineligible for the clinical trial and hence eligible for the
present study.) Patients enrolled in other clinical trials or who
received rtPA outside of clinical trial were eligible for enrollment.
Investigators were limited to a total enrollment of 40 subjects at each
site to maximize geographic diversity.
Informed Consent
Each study center obtained local institutional review board
approval for the study. Some centers required written informed consent
for the survey, but most allowed undocumented verbal consent.
Analysis
Patients with missing data for symptom onset time or ED arrival
time were excluded from the main analysis. Median times were
reported primarily because the skewed distribution of the data and its
truncation made the means less descriptive. A logistic regression model
was used to help evaluate contributions of various factors associated
with delay.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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A total of 1207 subjects were entered into the present study. However, 483 of these had missing data for either the symptom onset time or ED arrival time. The demographic characteristics and diagnosis for the subjects included and excluded from the analysis are shown in Table 1
. The 2 groups
were very similar, but the excluded subjects had 10% more individuals
who were aged >65 years.
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The demographics of the subjects included in the analysis are
shown in Table 1
. Thirteen percent of the subjects were black,
50% were female, 31% did not have a high school diploma, and 37%
were enrolled at academic hospitals. Ischemic stroke was the
most common diagnosis (73%), with 13% of the patients being diagnosed
with a transient ischemic attack (TIA) and 8% with
intracerebral hemorrhage. Six percent of the
patients had diagnoses other than stroke or TIA. Twenty-two of the
patients in the study were treated with rtPA.
The median prehospital delay time in the present study was 2.6
hours, with an interquartile range of 1.2 to 6.3 hours (Table 2). The mean prehospital delay time was
5.4 hours. The distribution of these delay times is shown in Figure 1. Twenty-four percent of the patients
arrived within the first hour, 21% arrived within the second hour, and
a total of 56% arrived within 3 hours of symptom onset.
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The median time from ED arrival to CT scan was 1.1 (interquartile range
0.7 to 1.8) hours, with a mean delay time of 1.9 hours. The median
total delay time was 4.0 (interquartile range 2.3 to 8.3) hours, with a
mean total delay time of 6.8 hours. The time to neurology consult had a
median delay of 3.1 (interquartile range 1.2 to 8.2) hours. Forty-seven
percent of the patients had a total delay time of 
3 hours.
To investigate the factors associated with delay, prehospital delay, CT
scan delay and total delay times are broken down by several patient
characteristics in Table 3. Of note,
compared with black subjects, white subjects appeared to have longer
prehospital delays but shorter delays to CT scan. Patients arriving by
emergency medical services (EMS) had almost half the prehospital delay
and three fourths of the delay to CT scan than did patients arriving at
the ED by other means.
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Patients alone at symptom onset had a median prehospital delay of 3.6 hours compared with 2.1 hours for those who were not alone. As expected from the definition of symptom onset time, those who awoke with symptoms had longer prehospital delays. Those patients with an elevated diastolic blood pressure on ED arrival and those patients at an academic institution also appeared to have longer prehospital delays. No obvious geographic trends were noted (north/south), but this was not examined in detail.
Because some of the factors studied were interrelated, a logistic model
based on categorization of prehospital delay <2 hours and CT scan
delay <1 hour was used to further define factors important in delay.
Only 4 factors (race, sex, arrival by EMS, and awakening with symptoms)
contributed substantially to the model. These are shown in Table 4. Compared with those arriving by other
means, those arriving by EMS were almost twice as likely to arrive at
the ED in <2 hours. They were also 1.6 times as likely to get their CT
scans in <1 hour. Those patients awakening with symptoms were a third
as likely to arrive at the ED in <2 hours as opposed to those who did
not awake with symptoms. None of the other factors had statistically
significant relationships with delay time in this
multivariate model.
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The relationship between EMS use and delay is further described in
Figure 2, in which the percentages of
patients arriving at the ED in <2 hours and having their CT scans in
<1 hour are displayed by whether they arrived by EMS. Fifty-one
percent of the patients arriving by EMS had prehospital delays <2
hours; 33% of those not arriving by EMS had prehospital delays <2
hours. Those arriving by EMS also had significantly shorter times to CT
scan.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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In the present study, the median prehospital delay was 2.6 hours, with approximately half the patients arriving at the ED in <3 hours. This figure is somewhat lower than that reported in several other studies. For example, a study performed in Houston, Tex, consisted of 241 patients with a median prehospital delay time of 4.5 hours,9 and one in Cincinnati Ohio included 119 patients with a delay time of 5.7 hours.5 Part of the reason for the shorter prehospital delay times in the present study is that the study was truncated at 24 hours, thus cutting off the small but significant number of patients who may have come in >24 hours after symptom onset. In a small study of delay in which enrollment was truncated at 36 hours,7 the median delay was 2.8 for stroke patients, which is closer to that observed in the present study.
Although several factors have been associated with shorter prehospital delay times,5 8 11 only arrival by EMS and awakening with symptoms were significantly related to prehospital delay in the present study. The median prehospital delay time for those patients arriving by ambulance was 1.9 hours shorter than those who arrived by other means. Clearly, this time differential represents much more than time saved in the actual transport. Rather, use of EMS likely prevents delays such as waiting for another family member, waiting for a ride, or waiting for a physician to call back.
Delay from ED arrival to CT scan was chosen as a relatively easily measurable point in the treatment pathway for rtPA. Although additional steps after completion of the CT scan (interpretation, physician consultation, and consent) may clearly need to be undertaken, getting the scan itself has been reported as a major obstacle.12 In the present study, the median time to CT scan completion was 1.1 hours. This is clearly above the 25 minutes to initiation of the CT scan and 45 minutes to interpretation of the CT scan, which have been set as a standard by a National Institute of Neurological Disorders and Stroke advisory committee.13
Median time to CT scan was also shorter for those patients arriving by EMS (1.0 versus 1.3 hours). This phenomenon has been cited in other studies.12 14 15 16 It may be that these patients have more severe strokes than those not arriving by EMS. What is likely more important is that these patients avoid triage, registration, and waiting for a room or bed. The physician may also perceive that these patients need to be seen sooner simply because they arrived by ambulance. In some centers, EMS may also alert the ED before arrival and allow the ED staff to prepare for the arrival and treatment of the patients.
Study Limitations
The large number of subjects excluded because of missing data are
clearly a potential problem in interpreting the results of the
present study. It is reassuring, as shown in Table 1, that
the characteristics of those patients who were excluded are very
similar to the characteristics of those patients who were included in
the study. Another concern is that all of the EDs were involved in at
least one clinical trial of acute stroke treatment. This may have
altered their approach to stroke patients, and there may have been
efforts within the communities to attract stroke patients and reduce
delay time. Whereas this might affect the median times noted, it would
likely not alter factors affecting delay.
Stroke severity was not measured in the present study; clearly,
this may influence both prehospital delay times and time to CT scan. It
is likely that greater proportions of the severe patients were
transported by ambulance and would likely be seen sooner within the ED.
However, the absolute number of severe patients is likely to be small.
In another study of stroke delay, almost 95% of the patients
presenting had Glasgow coma scales of 14.7
Conclusions
The present study offered an opportunity to examine
prehospital and ED delays in a large and geographically diverse group
of patients. As in other studies, a majority of patients would not
arrive at the ED early enough to diagnose and treat acute stroke with
rtPA or other therapies requiring a short time window. It also
confirms, in a geographically diverse population with many different
EMS systems, that arrival by ambulance is associated with markedly
shorter prehospital and ED delay times. Because EMS use by stroke
patients is a potentially modifiable behavior,17 efforts
in this direction may be the most direct way to increase the number of
patients eligible for acute stroke therapies. Intervention programs,
which emphasize stroke recognition and appropriate response (calling
911), should be developed and critically evaluated.
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Acknowledgments |
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This project was funded by Genentech, Inc. The authors would like to acknowledge Stewart Hallett for managing the study.
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Footnotes |
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Reprint requests to Dexter L. Morris, PhD, MD, Department of Emergency Medicine, CB 7594, University of North Carolina, Chapel Hill, NC 27599-7594.
Drs Morris and Rosamond have been consultants to Genentech, Inc, in the past but have no current conflict of interest. Dr Hamilton is employed by Genentech, Inc.
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Appendix 1 |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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Principal Investigators
The following institutions, principal investigators, and study coordinators participated in the GSPS study: Erfan A. Albakri, MD, and Liliana Vinci, RN, Columbia Brandon Regional Medical Center, Brandon, Fla; Gregory W. Albers, MD, and Nanette Hock, RN, MS, Stanford University Medical Center, Stanford, Calif; Richard P. Atkinson, MD, Deidre Wentworth, MSN, RN, and Christi Delemos, RN, Mercy General Hospital, Sacramento, Calif; Rodney D. Bell, MD, Jamie Strause, RN, BSN, Patricia Lynch, RN, and Toby R. Mazer, MPH, Thomas Jefferson University Hospital, Philadelphia, Pa; Andrew M. Blumenfeld, MD, and Carol Elliott, RNP, Southern California Kaiser Permanente Medical Center, San Diego; William H. Brooks, MD, and Patricia K. Howard, RN, MSN, CCRN, CEN, Central Baptist Hospital, Lexington, Ky; Thomas G. Brott, MD, and Judith Spilker, RN, The University of Cincinnati Hospital, Cincinnati, Ohio; David Brown, MD, and Anne Courtney-Eighmy, Washington Regional Medical Center, Fayetteville, Ark; Askiel Bruno, MD, Linda Chadwick, BSN, RN, and Carol Kempf, RN, Indiana University Medical Center, Indianapolis; John C. Brust, MD, and Norman Pflaster, MD, Harlem Hospital Center, New York, NY; James Bumgartner, MD, and Patty Brown, RN, CNRN, Roper Hospital, Charleston, SC; Paul Casale, MD, Lawrence Rodichok, MD, Lisa Hollywood, RN, Lou Anne Frey, RN, Kay Knepper, RN, and Joann Tuze, RN, Lancaster General Hospital, Lancaster, Pa; Craig Coccia, MD, Robert Glanzman, MD, Dagmar Prout, RN, MSN, CCRN, and Terry Durley, RN, BSN, CCRN, Marquette General Hospital, Marquette, Mich; John Comber, MD, and Trish Bankes, RN, BSN, Abington Memorial Hospital, Abington, Pa; Antonio Culebras, MD, and Mary Therese Dean, US Veterans Medical Center, Syracuse, NY; T.J. Curfman, MD, and Charlotte Howells, RN, Home Hospital, Lafayette, Ind; James DeMatties, MD, and Ruth Fries, BSM, ASCP, Hamot Medical Center, Erie, Pa; Dennis W. Dietrich, MD, Janet Horton, RN, and Debbie Wilson, RN, Benefits Health Care, Great Falls, Mont; Jonathan Dissin, MD, and Connie Borschell, Albert Einstein Medical Center, Philadelphia, Pa; Jay M. Ellis, DO, and Patricia Rosier, RN, MS, CS, Berkshire Medical Center, Pittsfield, Mass; William M. Feinberg, MD, and Diane Rose Taylor, University Medical Center, Tucson, Ariz; C. Stephen Ford, MD, and Jill Wright, RN, High Point Regional Hospital, High Point, NC; Michael Frankel, MD, Grady Health System, Atlanta, Ga; Thomas Giancarlo, DO, and Alice Schuster, RN, St. John Hospital and Medical Center, Detroit, Mich; Camilo R. Gomez, MD, Nancy Lemons, RN, and Keith W. Brooks, RN, University of Alabama Hospitals, Birmingham; Brad Grayum, MD, and Kathie Dermott, Crozer Chester Medical Center, Chester, Pa; Alan B. Grindal, MD, and Michael R. Halbert, PharmD, Sarasota Memorial Hospital, Sarasota, Fla; Rizwan Hassan, MD, and Edwina Hand, RN, Columbia Wesley Medical Center, Wichita, Kan; David C. Hess, MD, and Angela D. Touhey, BS, US Veterans Medical Center, Augusta, Ga; Andrea Hidalgo, MD, and R. Doreen Monks, RN, CS, MSN, CNRN, University of Medicine and Dentistry, New Jersey Medical School, Newark; Daniel Homer, MD, and Barbara Small, MBA, RN, Evanston Hospital, Evanston, Ill; Deborah Ronnie Horowitz, MD, Sandra Augustine, RN, and Jameelah Ali, RN, Mt. Sinai Medical Center, New York, NY; Steven Horowitz, MD, Joan Estrem, RN, and Anne L. Bonnett, RN, University of Missouri Hospital and Clinic, Columbia; Kinan K. Hreib, MD, PhD, Lauri Dion, RN, and Elizabeth Kennedy, Lahey Hitchcock Medical Center, Burlington, Mass; Chung Y. Hsu, MD, PhD, and Ellen Balestreri, RN, Barnes-Jewish Hospital, St. Louis, Mo; Richard L. Hughes, MD, and Clark A. Anderson, MD, University Hospital, Denver, Colo; Te-Long Hwang, MD, and Robert L. Frank, RN, EdD, Richland Memorial Hospital, Columbia, SC; Michael R.K. Jacoby, MD, and Lori Parsons, Mercy Hospital Medical Center, Des Moines, Iowa; Dara G. Jamieson, MD, and Michelle Hellstern, RN, BSN, CCRN, Pennsylvania Hospital, Philadelphia; Ronald Karlsberg, MD, David Reisbord, MD, Susan Jackman, and Tracey S. Gerez, BS, MA, Brotman Medical Center, Culver City, Calif; Scott E. Kasner, MD, Jeanne A. Dora, MSN, RN, CNRN, and Susan Unipan, BSN, RN, University of Pennsylvania Medical Center, Philadelphia; Roger E. Kelley, MD, and Colette Hilliard, Louisiana State University Medical Center, Shreveport; Teri Kintzer, MD, and Donna Post, RN, Columbia St. Petersburg Medical Center, St. Petersberg, Fla; Howard S. Kirshner, MD, and Sharon O’Connell, RN, Vanderbilt University Medical Center, Nashville, Tenn; Richard L. Koller, MD, and Pam Andrews, Abbott Northwestern, Center City, Minneapolis Minn; Dexter Koons, MD, James A. Farrier, MD, and Debbie Gobin, Parkview Episcopal Medical Center, Pueblo, Colo; Derk W. Krieger, MD, Patti Bratina, RN, and Mary Ann Young, RN, Hermann Hospital, Houston, Tex; E. Francis LaFranchise, MD, and Trixy Schrimpf, RN, Candler General Hospital, Savannah, Ga; Steven R. Levine, MD, Christopher A. Lewandowski, MD, and Patricia Marchese, RN, Henry Ford Hospital and Health Sciences Center, Detroit, Mich; David A. Lombardi, MD, and Yvonne Schooley, RN, MS, Western Medical Center Santa Ana, Santa Ana, Calif; Patrick Lyden, MD, Karen Rapp, RN, and Terri McLean, RN, UCSD Medical Center/Hillcrest, San Diego, Calif; Kenneth Madden, MD, and Lynda Stephani, Marshfield Clinic, Marshfield, Wis; Jonathan Maisel, MD, K.N. Sena, MD, and Donna Yasick, RN, Bridgeport Hospital, Bridgeport, Conn; Robert Margolis, MD, and Therese Gaertner, Christian Hospital North East, St. Louis, Mo; Lee C. Marmion, MD, and James Cwengros, PharmD, Butterworth Hospital, Grand Rapids, Mich; Thomas G. Mattio, MD, PhD, and Kathy Gendron, RN, MSN, FNPC, Theda Clark Regional Medical Center, Neenah, Wis; Jerold Mikszewski, MD, and Maureen Burke, RN, Fairfax Hospital, Falls Church, Va; Dexter L. Morris, MD, PhD, and Susan N. Pusek, RN, University of North Carolina Hospitals, Chapel Hill; Richard Mortara, MD, and Les Gardina, St. Joseph’s Hospital, Lexington, Ky; Frederick Munschauer, MD, and Sandra S. Starr, RN, Buffalo General Hospital, Buffalo, NY; Susan Nadis, MD, and Terri Flegel, RN, BSN, MacNeal Hospital, Berwin, Ill; George C. Newman, MD, University Hospital at Stony Brook, Stony Brook, NY; Aurora K. Pajeau, MD, and Annette R. Kinsella, RN, Mt. Sinai Hospital Medical Center, Chicago, Ill; Stefan M. Pulst, MD, and Brenda Williams, RN, Cedars-Sinai Medical Center, Los Angeles, Calif; Louis Rosa III, MD, Jane Gaeta, RN, and Jacky Saeger, RN, Morton Plant Hospital, Clearwater, Fla; Daniel M. Rosenbaum, MD, and J.P. Noonan, RN, Montefiore Medical Center, Bronx, NY; Vernon D. Rowe, MD, and Tricia Gentzler, RN, North Kansas City Hospital, North Kansas City, Mo; Michael O. Sauter, MD, Robert Hickey, and Phyllis Parker, RN, St. Charles Hospital and Rehabilitation Center, Port Jefferson, NY; Michael K. Sauter, MD, MSc, and Carol P. Clayton, RN, Westmoreland Hospital, Greensburg, Pa; Michael J. Schneck, MD, and Cynthia Motton, RN, BSN, Cook County Hospital, Chicago, Ill; Carol Schultz, MD, and Shirley Frederiksen, MSN, RN, University of Michigan Medical Center, Ann Arbor; Christopher Shields, MD, and Marlot Wigginton, Norton Hospital, Louisville, Ky; Richard H. Smith, MD, Vivian Noonan, RN, and Margaret Kelly, RN, Provenant St. Anthony Hospital Central, Denver, Colo; Rodney Smith, St. Joseph Mercy Hospital, Ann Arbor, Mich; Wade Smith, MD, PhD, Carol Applebury, and Nel O’Neil, RN, MSN, FNP, San Francisco General Hospital, San Francisco, Calif; Raymond M. Stephens, MD, and Kacey Hansen, RN, John Muir Medical Center, Walnut Creek, Calif; Gary A. Stobbe, MD, and Kathy E. Dalton, CMA, Stevens Memorial Hospital, Edmonds, Wash; Lynne P. Taylor, MD, and Cheryl C. Weaver, CCRC, Virginia Mason Medical Center, Seattle, Wash; Gretchen Tietjen, MD, and Andrea Korsnack, RN, Medical College of Ohio, Toledo; Anthony Turel, MD, and Edie Szoke, Geisinger Medical Center, Danville, Pa; Janet L. Wilterdink, MD, and Jo-Ann Sarafin, RN, BSN, Rhode Island Hospital, Providence; Stanley D. Wissman, MD, and Mary Ann Wissman, RN, MSN, Lutheran Hospital of Indiana, Fort Wayne, Ind; Mark L. Young, MD, and Gail Wallace, RN, St. Mary’s Medical Center, Duluth, Minn.
Received June 8, 2000; revision received June 8, 2000; accepted July 14, 2000.
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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K. M. Rose, W. D. Rosamond, S. L. Huston, C. V. Murphy, and C. H. Tegeler Predictors of Time From Hospital Arrival to Initial Brain-Imaging Among Suspected Stroke Patients: The North Carolina Collaborative Stroke Registry Stroke, December 1, 2008; 39(12): 3262 - 3267. [Abstract] [Full Text] [PDF]
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 A Maestroni, C Mandelli, D Manganaro, B Zecca, P Rossi, V Monzani, and G Torgano Factors influencing delay in presentation for acute stroke in an emergency department in Milan, Italy Emerg. Med. J., June 1, 2008; 25(6): 340 - 345. [Abstract] [Full Text] [PDF]
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I. Mosley, M. Nicol, G. Donnan, I. Patrick, F. Kerr, and H. Dewey The Impact of Ambulance Practice on Acute Stroke Care Stroke, October 1, 2007; 38(10): 2765 - 2770. [Abstract] [Full Text] [PDF]
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B. Jarrell, A. Tadros, C. Whiteman, T. Crocco, and S. M. Davis National Healthline Responses to a Stroke Scenario: Implications for Early Intervention Stroke, August 1, 2007; 38(8): 2376 - 2378. [Abstract] [Full Text] [PDF]
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C. Hodgson, P. Lindsay, and F. Rubini Can Mass Media Influence Emergency Department Visits for Stroke? Stroke, July 1, 2007; 38(7): 2115 - 2122. [Abstract] [Full Text] [PDF]
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 H. P. Adams Jr, G. del Zoppo, M. J. Alberts, D. L. Bhatt, L. Brass, A. Furlan, R. L. Grubb, R. T. Higashida, E. C. Jauch, C. Kidwell, et al. Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation, May 22, 2007; 115(20): e478 - e534. [Abstract] [Full Text] [PDF]
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H. P. Adams Jr, G. del Zoppo, M. J. Alberts, D. L. Bhatt, L. Brass, A. Furlan, R. L. Grubb, R. T. Higashida, E. C. Jauch, C. Kidwell, et al. Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists Stroke, May 1, 2007; 38(5): 1655 - 1711. [Abstract] [Full Text] [PDF]
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I. Mosley, M. Nicol, G. Donnan, I. Patrick, and H. Dewey Stroke Symptoms and the Decision to Call for an Ambulance Stroke, February 1, 2007; 38(2): 361 - 366. [Abstract] [Full Text] [PDF]
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P. J. Lindsberg, O. Happola, M. Kallela, L. Valanne, M. Kuisma, and M. Kaste Door to thrombolysis: ER reorganization and reduced delays to acute stroke treatment. Neurology, July 25, 2006; 67(2): 334 - 336. [Abstract] [Full Text] [PDF]
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D. K. Moser, L. P. Kimble, M. J. Alberts, A. Alonzo, J. B. Croft, K. Dracup, K. R. Evenson, A. S. Go, M. M. Hand, R. U. Kothari, et al. Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke: A Scientific Statement From the American Heart Association Council on Cardiovascular Nursing and Stroke Council Circulation, July 11, 2006; 114(2): 168 - 182. [Abstract] [Full Text] [PDF]
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O. Agyeman, K. Nedeltchev, M. Arnold, U. Fischer, L. Remonda, J. Isenegger, G. Schroth, and H. P. Mattle Time to Admission in Acute Ischemic Stroke and Transient Ischemic Attack Stroke, April 1, 2006; 37(4): 963 - 966. [Abstract] [Full Text] [PDF]
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B. S. Jacobs, G. Birbeck, A. J. Mullard, S. Hickenbottom, R. Kothari, S. Roberts, and M. J. Reeves Quality of hospital care in African American and white patients with ischemic stroke and TIA Neurology, March 28, 2006; 66(6): 809 - 814. [Abstract] [Full Text] [PDF]
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P. Schestatsky, P. D. Picon, D. O. Kleindorfer, P. Khatri, I. Katzan, and D. Cocho Reasons for exclusion from thrombolytic therapy following acute ischemic stroke Neurology, December 13, 2005; 65(11): 1844 - 1844. [Full Text] [PDF]
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B. S. Jacobs, P. L. Baker, C. Roychoudhury, R. H. Mehta, and S. R. Levine Improved Quality of Stroke Care for Hospitalized Medicare Beneficiaries in Michigan Stroke, June 1, 2005; 36(6): 1227 - 1231. [Abstract] [Full Text] [PDF]
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J. P. Stansbury, H. Jia, L. S. Williams, W. B. Vogel, and P. W. Duncan Ethnic Disparities in Stroke: Epidemiology, Acute Care, and Postacute Outcomes Stroke, February 1, 2005; 36(2): 374 - 386. [Abstract] [Full Text] [PDF]
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D. Hanley and W. Hacke Critical Care and Emergency Medicine Neurology in Stroke Stroke, February 1, 2005; 36(2): 205 - 207. [Full Text] [PDF]
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 J. Kwan, P. Hand, and P. Sandercock Improving the efficiency of delivery of thrombolysis for acute stroke: a systematic review QJM, May 1, 2004; 97(5): 273 - 279. [Abstract] [Full Text] [PDF]
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K.-C. Chang, M.-C. Tseng, and T.-Y. Tan Prehospital Delay After Acute Stroke in Kaohsiung, Taiwan Stroke, March 1, 2004; 35(3): 700 - 704. [Abstract] [Full Text] [PDF]
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 J. E. Stahl, K. L. Furie, S. Gleason, and G. S. Gazelle Stroke: Effect of Implementing an Evaluation and Treatment Protocol Compliant with NINDS Recommendations Radiology, September 1, 2003; 228(3): 659 - 668. [Abstract] [Full Text] [PDF]
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G. J. Thomalla, T. Kucinski, V. Schoder, J. Fiehler, R. Knab, H. Zeumer, C. Weiller, and J. Rother Prediction of Malignant Middle Cerebral Artery Infarction by Early Perfusion- and Diffusion-Weighted Magnetic Resonance Imaging Stroke, August 1, 2003; 34(8): 1892 - 1899. [Abstract] [Full Text] [PDF]
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M. Fisher Recommendations for Advancing Development of Acute Stroke Therapies: Stroke Therapy Academic Industry Roundtable 3 Stroke, June 1, 2003; 34(6): 1539 - 1546. [Abstract] [Full Text] [PDF]
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K. Nedeltchev, M. Arnold, C. Brekenfeld, J. Isenegger, L. Remonda, G. Schroth, and H. P. Mattle Pre- and In-Hospital Delays From Stroke Onset to Intra-arterial Thrombolysis Stroke, May 1, 2003; 34(5): 1230 - 1234. [Abstract] [Full Text] [PDF]
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I. L. Katzan, T. W. Graber, A. J. Furlan, S. Sundararajan, C. A. Sila, G. Houser, and D. M. Landis Cuyahoga County Operation Stroke Speed of Emergency Department Evaluation and Compliance With National Institutes of Neurological Disorders and Stroke Time Targets Stroke, April 1, 2003; 34(4): 994 - 998. [Abstract] [Full Text] [PDF]
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Y. Yoneda, T. Uehara, H. Yamasaki, Y. Kita, M. Tabuchi, and E. Mori Hospital-Based Study of the Care and Cost of Acute Ischemic Stroke in Japan Stroke, March 1, 2003; 34(3): 718 - 724. [Abstract] [Full Text] [PDF]
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A. T. Schneider, A. M. Pancioli, J. C. Khoury, E. Rademacher, A. Tuchfarber, R. Miller, D. Woo, B. Kissela, and J. P. Broderick Trends in Community Knowledge of the Warning Signs and Risk Factors for Stroke JAMA, January 15, 2003; 289(3): 343 - 346. [Abstract] [Full Text] [PDF]
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L. B. Morgenstern, L. Staub, W. Chan, T. H. Wein, L. K. Bartholomew, M. King, R. A. Felberg, W. S. Burgin, J. Groff, S. L. Hickenbottom, et al. Improving Delivery of Acute Stroke Therapy: The TLL Temple Foundation Stroke Project Stroke, January 1, 2002; 33(1): 160 - 166. [Abstract] [Full Text] [PDF]
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I. Philp, S. Ebrahim, P. Connelly, D. Jenkinson, G. Ford, R. J McManus, L. Lumley, M. Gough, L. Jhass, K. Deacon, et al. New beginning for care for elderly people? BMJ, August 11, 2001; 323(7308): 337 - 337. [Full Text]
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