Barriers to Prompt Presentation to Emergency Departments in Colorado after Onset of Stroke Symptoms

INTRODUCTION: Despite significant morbidity and mortality from stroke, patient delays to emergency department (ED) presentation following the onset of stroke symptoms are one of the main contraindications to treatment for acute ischemic stroke (AIS). Our objective was to identify patient and environmental factors associated with delayed presentations to the ED after onset of stroke symptoms. METHODS: This was a pre-planned secondary analysis of data from a multicenter, retrospective observational study at three hospitals in Colorado. We included consecutive adult patients if they were admitted to the hospital from the ED, and the ED diagnosed or initiated treatment for AIS. Patients were excluded if they were transferred from another hospital. Primary outcome was delayed presentation to the ED (> 3.5 hours) following onset stroke symptoms. RESULTS: Among 351 patients, 63% presented to the ED more than 3.5 hours after onset of stroke symptoms. Adjusted results show that patients who presented in the evening hours (odds ratio OR 0.45, 95% confidence interval CI 0.3-0.8), as compared to daytime, were significantly less likely to have a delayed presentation. Speaking a language other than English (Spanish OR 3.3, 95% CI 1.2-8.9 and "other" OR 9.1, 95% CI 1.2-71.0), having known cerebrovascular risk factors (>2 risk factors OR 2.4, 95% CI 1.05-5.4 and 1-2 risk factors OR 2.3, 95% CI 1.03-5.1, compared to zero risk factors), and presenting to a rural hospital (OR 2.2, 95% CI 1.2-4.2), compared to urban, were significantly associated with delayed presentation. CONCLUSION: Important patient and environmental factors are significantly associated with delayed ED presentations following the onset of stroke symptoms. Identifying how best to educate patients on stroke risk and recognition remains critically important.