Parental Care–Seeking Behavior and Prehospital Timelines of Care in Childhood Arterial Ischemic Stroke
Background and Purpose—Taking appropriate action in the prehospital setting is important for rapid stroke diagnosis in adults. Data are lacking for children. We aimed to describe parental care–seeking behavior and prehospital timelines of care in childhood arterial ischemic stroke.
Methods—A structured questionnaire was developed, using value-focused event-driven conceptual modeling techniques, to interview parents of children presenting to the emergency department with arterial ischemic stroke from 2008 to 2014.
Results—Twenty-five parents (median age 41 years, interquartile range 36–45) were interviewed. Twenty-four children were awake, and 1 child was asleep at stroke onset; 23 had sudden onset symptoms. Location at stroke onset included home (72%), school (8%), or other setting (20%). Carergivers present included parent (76%), another child (8%), teacher (4%), or alone (8%). Eighty-four percent of parents thought symptoms were serious, and 83% thought immediate action was required, but only 48% considered the possibility of stroke. Initial actions included calling an ambulance (36%), wait and see (24%), calling a general practitioner (16%) or family member (8%), and driving to the emergency department or family physician (both 8%). Median time from onset to emergency department arrival was 76 minutes (interquartile range 53–187), being shorter for ambulance-transported patients.
Conclusions—Stroke recognition and care-seeking behavior are suboptimal, with less than half the parents considering stroke or calling an ambulance. Initiatives are required to educate parents about appropriate actions to facilitate time-critical interventions.
Prehospital delays exclude adults from hyperacute stroke interventions.1 Failure to recognize stroke symptoms or call an ambulance or triage stroke as an emergency are barriers to rapid diagnosis in adults.2 We aimed to describe parental care–seeking behavior, timelines of prehospital care, and pathway to the emergency department (ED) in childhood arterial ischemic stroke.
Parents of children with arterial ischemic stroke presenting to the Royal Children’s Hospital ED from 2008 to 2014 were interviewed. Those presenting between 2011 and 2014 were prospectively recruited; those between 2008 and 2010 were retrospectively identified from International Classification of Diseases (ICD-10) and Royal Children’s Hospital institutional stroke registry searches. Non–English speaking parents, other carergivers (eg, teachers), children directly admitted to an inpatient unit, or children whose stroke occurred in hospital were excluded.
Iterative operational research modeling techniques were used to map prehospital stroke care. Value-focused event-driven process modeling3 facilitated identification of key barriers to achieving timeliness of stroke diagnosis, including (1) parental recognition of symptom seriousness or (2) significance for stroke, (3) first parental action, and (4) mode of transport to ED. Questionnaire development was also informed by factors influencing care-seeking behavior and timelines of care in adults.4,5
Variables collected are outlined in Tables 1 and 2. Data were managed using REDCap (Research Electronic Data Capture) and imported to STATA version 12 (StataCorp, TX) for analysis. Categorical data are presented as numbers and percentages with 95% confidence intervals. Non-normally distributed continuous variables are presented as median and interquartile range (IQR). Potential study population bias was assessed by comparing included and excluded cases. Potential recall bias was assessed by comparing parents who were interviewed during the admission to those who were not. Fisher exact test was used to compare binary variables and the Mann–Whitney U test for continuous variables. Human Research Ethics Committee approval number was HREC 29143A.
Forty-three children met eligibility criteria. Thirteen parents did not respond to invitations, and 2 were non-English speaking. Comparative analyses between included and excluded children identified no significant differences for demographic, risk factors, symptom time course, stroke severity, circulation, and pathogenesis (Table in the online-only Data Supplement). Three parents were not involved in prehospital decision-making, leaving a study population of 25 parents; 12 were interviewed during the acute admission. Comparative analyses for potential recall bias identified a significant difference for occupational status (professional/intermediate/skilled nonmanual versus skilled manual/semiskilled and unskilled; 67% versus 100%; P=0.04).
Twenty-four parents were female; median age was 41 years (IQR 36–45 years). Child characteristics and event circumstances are presented in Table 1. Eighty-four percent of parents thought their child’s symptoms were serious, but only 48% considered the possibility of stroke. Eighty-three percent of parents felt immediate action was required, but only 36% initially called an ambulance (Table 2).
Of those who initially attended a family doctor, one called ED for advice, 2 called an ambulance, and 5 advised parents to drive to ED. Median time from onset to hospital arrival was 76 minutes (IQR 53–187), being shorter for ambulance-transported (72 minutes, IQR 62–115) than privately transported patients (120 minutes, IQR 30–352) (P=0.51). Median times from onset to arrival were similar if presenting to tertiary (72 minutes, IQR 66–115) and community hospitals (83 minutes, IQR 49–189) (P=0.95), but longer if presenting to metropolitan (115 minutes, IQR 70–190) than rural hospitals (58 minutes, IQR 30–138; P=0.12).
A previous Canadian study described prehospital factors contributing to delayed diagnosis of childhood arterial ischemic stroke, including failure to call an ambulance, milder stroke severity, and nonabrupt onset.6 This study provides more detail about parental care–seeking behavior and new information about circumstances surrounding the event, parental thoughts, and actions at the time of their child’s stroke.
Ambulance usage results in shorter time to hospital arrival in adults7 but just over one third of parents initially called an ambulance, despite almost all recognizing the need for immediate action. However, almost two thirds arrived within 2 hours, confirming previous work that most delays occur after hospital arrival.8
The vast majority of parents thought their child’s symptoms were serious, but less than half considered stroke, suggesting better education is required to ensure stroke recognition and appropriate care-seeking action. Parents were present in the vast majority of cases, whereas ≤34% of adults are alone at stroke event.9 Two teenagers were alone; emerging evidence suggests that children may benefit from education programmes to improve stroke knowledge and the need to call an ambulance.10,11
The study has limitations. Over one third of eligible parents did not participate, but there were no significance differences between included and excluded cases. The effect of prior stroke knowledge was not assessed because interviews followed diagnosis. Almost half the parents were interviewed after discharge, introducing recall bias, but there were no significant differences between interviewees during or after admission, apart from occupational status. The small sample size limited exploration of important patient, caregiver, or process factors influencing care-seeking behavior and prehospital timelines in adults4,5 or children.6
In conclusion, care-seeking behavior is suboptimal, with less than half of parents initially calling an ambulance. Parental education campaigns should link stroke awareness and symptom knowledge to calling an ambulance. Stroke advocacy organizations (eg, the American Stroke Association) and professionals treating children with conditions associated with increased stroke risk must work together to increase awareness of childhood stroke and hyperacute interventions. Parents could be given the simple message: “Stroke can occur in children, so if your child develops face drooping, arm weakness, speech difficulty or seizures, then act FAST and call 9-1-1 for help right away.”
Sources of Funding
The study was supported by National Stroke Foundation and the Murdoch Childrens Research Institute, Australia.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.116.014728/-/DC1.
- Received July 11, 2016.
- Revision received August 2, 2016.
- Accepted August 5, 2016.
- © 2016 American Heart Association, Inc.
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