ORIGINAL ARTICLE

Factors associated with early hospital arrival in acute ischemicstroke patients

Esin Kulein Koksal • Sibel Gazioglu •

Cavit Boz • Gamze Can • Zekeriya Alioglu

Received: 7 January 2014 / Accepted: 7 April 2014

� Springer-Verlag Italia 2014

Abstract Early diagnosis and treatment in acute ischemic

stroke are crucial in terms of survival and disability. Many

stroke patients remain disabled because of the treatment

delay. The purpose of this study was to investigate the

factors associated with the early hospital arrival in acute

ischemic stroke patients. 113 patients diagnosed with acute

ischemic stroke were included in this prospective study

performed at the Karadeniz Technical University Medical

Faculty Hospital. Patients’ characteristics and patients’ and

relatives’ emotional and behavioral reactions were com-

pared between early (within 3 h) and late (after 3 h) arrival

groups. 72.6 % of patients arrived at hospital within 3 h

from symptoms onset. Univariate analysis revealed that

history of atrial fibrillation (p = 0.04) and coronary heart

disease (p = 0.02), sudden onset of symptoms

(p = 0.001), loss of consciousness (p = 0.03), recognizing

symptoms as stroke (p = 0.01), seeking immediate medi-

cal attention (p \ 0.001), feelings of fear and panic

(p = 0.001), arriving at hospital by ambulance having

called the emergency medical services (p = 0.04) and

National Institute of Health Stroke Scale (NIHSS) score

(p = 0.001) were associated with hospital arrival within

3 h. A multivariate regression model demonstrated that

recognizing symptoms as stroke (OR, 3.4; 95 % CI,

1.2–9.3) and atrial fibrillation (OR, 4.3; 95 % CI, 1.1–15.7)

were independent factors associated with early arrival. The

role in early arrival at hospital of recognizing symptoms as

stroke and seeking immediate medical attention with

transportation by ambulance emphasize the importance of

public awareness concerning recognizing the symptoms of

stroke and accessing emergency medical assistance.

Keywords Ischemic stroke � Acute � Hospital � Time �Arrival � Early

Introduction

Stroke is the second most important cause of mortality and

the main cause of disability in developed countries [1]. The

most important factors determining the extent of cell

damage in acute ischemic stroke are the duration and

degree of ischemia [2, 3]. When administered within the

first 3 h from onset of acute ischemic stroke symptoms,

intravenous thrombolytic therapy with tissue plasminogen

activator (t-PA) is a treatment of proven benefit [4].

However, it must not be forgotten that the earlier the

treatment is given, the greater the benefit [5, 6]. Interven-

tion by a specialist and starting appropriate treatment as

early as possible have been shown to be associated with

reduced levels of disability [7–9].

Considering the importance of early treatment in acute

ischemic stroke, identifying the factors that may influence

early hospital arrival and increasing public awareness of

these factors may contribute to the success of treatment.

Several studies have investigated factors influencing early

hospital arrival in different countries [2, 3, 10–14]. How-

ever, little is known about factors influencing early hospital

arrival in Turkey and also about the role of emotional and

behavioral reactions to stroke on arrival times at hospital.

The purpose of this study was to investigate the factors

associated with early hospital arrival in acute ischemic

E. K. Koksal � S. Gazioglu (&) � C. Boz � Z. Alioglu

Department of Neurology, Karadeniz Technical University

Medical Faculty, 61080 Trabzon, Turkey

e-mail: sibelgazioglu@hotmail.com

G. Can

Department of Public Health, Karadeniz Technical University

Medical Faculty, 61080 Trabzon, Turkey

123

Neurol Sci

DOI 10.1007/s10072-014-1796-3

stroke patients which may contribute to the development of

new strategies for increasing the opportunities of benefiting

from treatment.

Patients and methods

Patients

This prospective study was conducted at the Karadeniz

Technical University Medical Faculty Hospital, which

provides advanced medical care to approximately 4 million

people and serves as a tertiary care center and also a ref-

erence center for the use of t-PA in acute ischemic stroke in

the northeastern part of Turkey. There are approximately

20 other hospitals including community hospitals and pri-

vate clinics in the same region which also provide health-

care to stroke patients. Patients presented directly to our

university hospital emergency department or referred by

other hospitals between 1 May 2011, and 31 January 2012,

with sudden onset of acute focal neurological deficit and

diagnosis of acute ischemic stroke confirmed following

evaluation by a neurologist supported by neuroimaging

were included in the study.

Participants consisted of patients, or relatives of those

patients whose neurological condition was inappropriate

for individual participation and evaluation. Patients and/or

relatives unaware of the times of symptom onset, seeking

medical attention or hospital arrival, who could not recall

their experiences during the event or who had no relatives

available to provide such information (for unconsciousness

patients), who did not present to any hospital within the

first 48 h of symptom onset, who had in-hospital stroke and

patients and/or relatives who refused to participate were

not included.

The ethical committee approved the study, and informed

consent was obtained from each subject.

Data collection

A standardized questionnaire was administered to patients

and/or relatives as soon as possible after arrival at our

hospital. The questionnaire was developed based on the

relevant literature. In order to reduce the possibility of

participants being affected by information that might be

obtained during their stay in hospital, participants were first

asked to what they first attributed the symptoms. They were

immediately afterward asked about their behavioral and

emotional reactions to the stroke and the times of symptom

onset, seeking medical attention and hospital arrival in

order to prevent this information being forgotten over the

intervening period.

Time of stroke onset was defined as when patients or

relatives first noticed the symptoms, duration of seeking

medical attention as the period between awareness of

symptoms and time of seeking medical attention, and time

of hospital arrival as the period between awareness of

symptoms and presentation to any hospital. Since the aim

of the study was to determine the factors influencing early

hospital arrival which means starting early management,

time of hospital arrival was taken as arrival at the first

hospital. However, times to arrival at our university hos-

pital, the reference center for administration of t-PA in

ischemic stroke in our region, were also recorded. The

times given by patients and relatives were also checked

using hospital records and ambulance, consultation or

referral sheets. Patients were assessed in two groups, those

reaching hospital within the first 3 h being classified as

early arrivals and those arriving after 3 h as late arrivals.

Finally, demographic and clinical characteristics and

other factors that might influence the arrival time at hos-

pital were recorded. To that end, patients’ age, sex, level of

education, marital status, employment status, whether or

not the patient lived alone, risk factors for stroke, history of

stroke, mode of onset of stroke (sudden or gradual), where

stroke occurred, whether patients were alone during stroke,

where and when the stroke occurred and symptoms and

signs at stroke onset were recorded. The National Institute

of Health Stroke Scale (NIHSS) was used in assessing

neurological deficits resulting from stroke. In addition, the

ways in which patients sought assistance and were trans-

ported to hospital were recorded. The telephone number for

emergency medical services (EMS) in Turkey is 112,

which is also used to request ambulances. Calling 112 and

transportation by ambulance were therefore assessed as a

single factor. Calling 112 is free of charge in Turkey.

Statistical analysis

All statistical analyses were performed using ‘‘SPSS for

Windows 13.0’’. Main descriptive statistics were presented

as patient number, percentage, mean, standard deviation

and median. After evaluation of the assumption of normal

distribution, Student’s t test and the Mann–Whitney U test

were applied for the comparison of continuous variables

and the Chi square was applied for comparison of cate-

gorical variables. Correlations were tested using Spearman

correlation analysis. Logistic regression analysis was con-

ducted in order to estimate the contribution of the variables

associated with hospital arrival within 3 h on a model

consisting of the variables found to be statistically signif-

icant in the univariate analysis together with the factors

reported in the literature. The model included the variables

age, sex, atrial fibrillation, NIHSS score, recognizing

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123

symptoms as stroke, using EMS and ambulance and onset

time. Statistical significance was set at a p value of 0.05.

Results

During the study period, 172 patients with acute stroke

were screened for study eligibility; 113 met the criteria for

inclusion, 106 (93.8 %) with ischemic stroke and 7 (6.2 %)

with TIA. Of these, 54 (47.8 %) presented directly to our

university hospital, and 59 (52.2 %) were referred from

other hospitals. Fifty-seven (50.4 %) patients were unable

to provide information personally, therefore data concern-

ing these were given by relatives. The patient population

consisted of 45 (39.8 %) women and 68 (60.2 %) men,

with a mean age of 69 ± 13.4 (27–90).

Median time to seeking medical attention was 15 min

(3–2,580), and median time to arrival at any hospital was

75 min (15–2,640). There was a positive correlation

between time to seeking medical attention and median

hospital arrival time (p \ 0.001). Median time for all our

patients to arrive at our university hospital was 193 min

(15–7,200). Eighty-two (72.6 %) patients arrived at any

hospital within the first 3 h, while 55 (48.7 %) patients

arrived to our university hospital within the first 3 h.

Seventeen (30.9 %) of the 55 patients presenting to our

university hospital in the first 3 h had been referred from

other hospitals. Median time to arrival of those patients

presenting directly to our university hospital was signifi-

cantly shorter than those of referred patients (p \ 0.001).

Seventy-two (63.7 %) patients arrived at the first hospital

by private vehicle, and 41 (36.3 %) by ambulance. Median

time to arrival of those using private vehicles was signifi-

cantly longer than those using ambulances (p = 0.03).

The onset of symptoms was sudden in 100 (88.5 %) of

patients. Mean NIHSS score for all patients was

6.63 ± 5.6. Sixty-four (56.6 %) of the 113 participants

recognized stroke as the cause of their symptoms, 21

(18.6 %) recognized them as something important but

could not determine what, 13 (11.5 %) thought their

symptoms were caused by existing diseases and 15

(13.3 %) reported that they did not think they were any-

thing important. In terms of behavioral responses during

stroke, 72 (63.7 %) individuals immediately sought medi-

cal assistance, while 29 (25.7 %) did not seek assistance

since they thought the symptoms would pass, 6 (5.3 %)

because they were alone, 3 (2.7 %) because it was late and

3 because they thought they had more important things to

do. In terms of emotional responses by patients or their

relatives during stroke, 72 (63.7 %) reported feeling fear or

panic while 41 (36.3 %) remained calm.

Comparison of the demographic characteristics of

patients who arrived at hospital within the first 3 h and those

arriving after 3 h revealed no significant difference between

the groups in terms of age, sex, marital status, employment

status or living alone. There was no significant difference

between the individuals deciding to seek medical attention

in the two groups in terms of age, sex or level of education.

Of the stroke risk factors, history of coronary heart

disease (p = 0.02) and atrial fibrillation (p = 0.04) were

statistically more frequent in the early hospital arrival

group. No significant difference was determined between

Table 1 Comparisons of characteristics between early arrivals

(within 3 h) and late arrivals (after 3 h). Univariate analyses

Characteristics Early arrivals

(B3 h)

(n = 82)

Late arrivals

([3 h)

(n = 31)

p value

Age (mean ± SD) 70.2 ± 13.25 65.77 ± 13.54 0.11

Age [70 (%) 50 (61) 14 (45.2) 0.19

Sex, male (%) 45 (54.9) 23 (74.2) 0.09

Marital status, married

(%)

81 (98.8) 28 (90.3) 0.06

Unemployed (%) 74 (90.2) 26 (83.9) 0.34

Living alone (%) 6 (7.3) 3 (9.7) 0.7

Risk factors (%)

Hypertension 66 (80.5) 24 (77.4) 0.92

Coronary heart disease 25 (30.5) 3 (9.7) 0.02

Atrial fibrillation 28 (34.1) 4 (12.9) 0.04

Hyperlipidemia 28 (34.1) 11 (35.5) 1

Diabetes 19 (23.2) 8 (25.8) 0.96

Congestive heart failure 13 (15.9) 2 (6.5) 0.23

Previous stroke 21 (25.6) 7 (22.6) 0.92

Family history of stroke 29 (35.4) 8 (25.8) 0.45

Smoking 26 (31.7) 13 (41.9) 0.42

Clinical characteristics

NIHSS score

(mean ± SD)

7.6 ± 5.6 4 ± 4.5 0.001

Loss of consciousness

(%)

20 (24.4) 2 (6.5) 0.03

Motor weakness (%) 51 (62.2) 13 (41.9) 0.08

Sudden onset (%) 78 (95.1) 22 (71) 0.001

Recognizing symptoms as

stroke (%)

53 (64.6) 11 (35.5) 0.01

Seeking immediate

medical attention (%)

71 (86.6) 1 (3.2) <0.001

Using EMS- ambulance

transport (%)

34 (41.5) 6 (19.4) 0.04

Alone at onset (%) 19 (23.2) 7 (22.6) 1

Feelings of fear and panic

(%)

60 (73.2) 12 (38.7) 0.001

Onset location, home (%) 69 (84.1) 24 (77.4) 0.57

Onset time, daytime (%) 46 (56.1) 22 (71) 0.22

Onset time, weekend (%) 31 (37.8) 12 (38.7) 1

Bold values indicate significance (p \ 0.05)

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123

the early and late arrival groups in terms of hypertension,

diabetes, hyperlipidemia, congestive heart failure, previous

history of stroke, cigarette consumption and whether stroke

occurred at night or in the daytime, or at the weekend or

midweek, the place where stroke occurred, and whether or

not the subject was alone at the time of symptom onset.

Sudden onset of symptoms (p = 0.001) and loss of

consciousness (p = 0.03) were more frequent in the early

hospital arrival group. Mean NIHSS score was also higher

in the early arrival group (p = 0.001). No difference was

observed between the two groups in terms of other symp-

toms of stroke, such as speech disturbance, motor paresis,

facial paralysis, vertigo and ataxia, nausea and vomiting,

headache and dysphagia.

Recognizing symptoms as stroke (p = 0.01), seeking

immediate medical attention (p \ 0.001), feelings of fear

and panic (p = 0.001) and using EMS and ambulance

(p = 0.04) rates were higher in the early arrival group

compared to the late arrival group. Table 1 shows the

comparisons of the characteristics of the early and late

arrival groups.

Results from logistic regression analysis indicated that

recognizing symptoms as stroke and atrial fibrillation were

independent factors associated with early arrival at hospi-

tal. Compared with the cases that did not recognize

symptoms as stroke, those cases that recognized symptoms

as stroke were 3.4 times (95 % CI, 1.2–9.3) more likely to

arrive early at hospital. Compared with the patients who

had no atrial fibrillation, those patients with a history of

atrial fibrillation were 4.3 times (95 % CI, 1.2–9.3) more

likely to arrive early at hospital (Table 2).

Discussion

Median arrival time at any hospital in acute ischemic

stroke patients in our study was 75 min, and 72.6 % of

patients arrived at a hospital within the first 3 h. Median

time to arrival at our university hospital, where thrombo-

lytic therapy can be administered, was 193 min, and

48.7 % of patients arrived within the first 3 h. Median time

to arrival at hospital in several studies in the literature

ranges from 1.5 to 16 h, with 12–68 % of patients arriving

hospital within the first 3 h [15]. The high level of early

arrival at a hospital in our study is probably due to the

region not having a wide geographical distribution. This

high level of early arrival determined in our study is

promising in terms of the use of thrombolytic therapy.

However, the median time to arrival at university hospital,

a tertiary health center at which thrombolytic therapy is

administered, of patients referred from other hospitals was

significantly longer compared to that of patients arriving

directly and the rate of arrival at our university hospital

within the first 3 h was lower compared to that of arrival at

any hospital. This may probably be attributed to lack of

sufficient awareness among the public and the health per-

sonnel involved in patient transportation about the impor-

tance of thrombolytic therapy in acute ischemic stroke and

of the institutions where it is available. Raising awareness

on this subject may increase the number of patients arriving

earlier at institutions where thrombolytic therapy is avail-

able and thus having the opportunity to use it.

Time to arrival at hospital in our study increased as time

to seeking medical attention was prolonged, and the rate of

seeking immediate medical attention in the early arrival

group was significantly higher than that of the late arrival

group. Previous studies also reported the importance of

time to seeking medical attention. Chang et al. [16]

reported that time to seeking medical attention represented

45 % of total time to arrival at hospital. Rosamond et al.

[17] reported that time to seeking medical attention was the

most important factor affecting time to arrival at hospital.

Although there are conflicting reports on the influence of

demographic factors on early admission, age, sex, educa-

tion, marital and employment status, living alone, onset

location and time or being alone at onset were not asso-

ciated with early arrival in the present study.

History of coronary heart disease and atrial fibrillation

were more frequent in the early arrival group and atrial

fibrillation was identified as an independent risk factor

affecting early arrival at hospital in the multivariate ana-

lysis in our study. Similar to our results, significant cor-

relations between atrial fibrillation or heart disease and

early arrival at hospital have been reported in the literature

[12, 13]. Patients with cardiac disease generally arriving

early may probably be attributed to higher public aware-

ness of heart disease.

Wester et al. [18] reported that subjects unable to rec-

ognize symptoms as stroke or those who did not seek

assistance within the first hour even if they did identify

them as stroke took longer to reach hospital. Kim et al. [19]

identified perception of symptoms as stroke and knowledge

of thrombolytic therapy as a powerful factor in early arrival

Table 2 Predictors of arrival at hospital within 3 h. Multivariate

analyses

Variable OR (95 % CI) p value

Age [70 1.8 (0.7–4.8) 0.21

Sex, male 0.6 (0.2–2) 0.46

Atrial fibrillation 4.3 (1.1–15.7) 0.02

NIHSS score 1.1 (0.9–1.2) 0.06

Recognizing symptoms as stroke 3.4 (1.2–9.3) 0.01

Using EMS-ambulance transport 1.7 (0.5–5.3) 0.36

Onset time, daytime 0.4 (0.1–1.3) 0.15

Bold values indicate significance (p \ 0.05)

Neurol Sci

123

at hospital. Feldman et al. [20] also reported that recog-

nizing symptoms as stroke was correlated with early arri-

val. We also identified recognition of symptoms as stroke

as an independent factor in early arrival at hospital, a

finding which again emphasizes the importance of educa-

tion concerning stroke related symptoms.

Rates of seeking emergency medical services (EMS) as

the first medical contact in the literature have been reported

at between 16 and 49 %, and rates of transportation by

ambulance or EMS at 16–94 % [15]. In our study 36.3 %

of participants arrived at hospital by ambulance after

calling the EMS. Although these patients had a shorter

arrival time to hospital than those using private vehicles

and higher rates of arrival at hospital within the first 3 h,

using EMS and ambulance was not significant on multi-

variate analysis. Most studies in the literature have reported

a significant correlation between being transported to

hospital by ambulance and early arrival at hospital [10–13,

16–19, 21, 22]. Our study did not investigate the reasons

for not choosing ambulances for transfer, but the low level

determined emphasizes the need for society to be educated

on the importance of EMS and ambulance use in early

arrival at hospital.

Differing results obtained in studies investigating the

factors associate with early arrival at hospital in various

regions are probably due to sociocultural and healthcare

service delivery variations. To the best of our knowledge,

this is the first study to investigate factors associated with

early hospital arrival in acute ischemic stroke patients in

Turkey, including the role of clinical characteristics and

patients’ and relatives’ behavior during acute ischemic

stroke. Previous studies investigating the factors affecting

late arrival at hospital of acute ischemic stroke patients

have examined ischemic and hemorrhagic strokes together,

and the effect of patients’ clinical characteristics and

patients’ and relatives’ behaviors has not been assessed

[23, 24]. There are limitations to this study, however. One

is the small sample size and hospital-based design

involved, which limit the possibility of generalizing the

findings to the entire population. As many patients with

acute stroke admitted to other hospitals and not all patients

with acute stroke referred to our hospital, our study does

not cover all patients with acute stroke in the region.

Another limitation is that the question of to what patients

first attributed their symptoms may have been affected by

their knowledge that they were taking part in a study

concerning stroke or referred patients knowing that stroke

was the reason for their referral. In order to reduce this

possibility to a minimum, we sought to obtain this infor-

mation from participants as soon as possible.

In conclusion, seeking immediate medical attention by

recognizing symptoms as stroke and using EMS and

ambulance for transfer to hospital were identified as the

most significant factors affecting early arrival. Educa-

tional campaigns in order to increase public awareness of

the importance of early treatment in acute ischemic

stroke and associated factors, especially stroke related

symptoms and signs, the role of seeking immediate

medical assistance and using EMS and ambulance for

transfer, may increase the number of patients arriving at

hospital earlier and having the opportunity to receive

early management.

Acknowledgments None.

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