Where are the delays in the Acute Stroke Care Pathway?

Sep 18 2012

Authors: Q.T.H. Anjum1, A. Syed2, L. Dacey3, M.W. Wani4

Dept. of Stroke Medicine, Morriston Hospital, Swansea, SA6 6NL



1 Specialist Registrar, General Medicine and Geriatrics

2 Foundation Year 2, General Medicine

3 CNS in Stroke Medicine

4 Consultant Physician with interest in Stroke Medicine




Stroke is an emergency requiring a rapid response to achieve better patient outcomes. Thrombolysis for Acute Stroke is currently licensed within 3 hours [1]. Delayed response to acute stroke recognition and triaging can lead to a significant number of patients potentially missing out on thrombolysis with long term implications.


In 2002, a U.K. based multicentre observational study revealed significant delays in the assessment of acute strokes and suggested that the potential for thrombolysis in acute stroke patients can be improved by expediting ambulance services and a speedy evaluation by the admitting doctors [3].


Recently, Welsh Assembly Government in consultation with Welsh Stroke Allaince has developed Intelligent Targets (ITs) for stroke care incorporating evidence based standards of care from the RCP clinical guidelines for the management of stroke [1, 2]. These targets have been combined in the acute stroke bundle (ASB) with an aim to streamline the care of stroke patients in the first hours to three and seven days. ASB includes targets such as confirmation of stroke by an experienced clinician within 3 hours and CT head scan, prescription of Aspirin and admission to acute stroke unit within 24 hours.


The Acute stroke management pathway involves many stakeholders including patients/carers, ambulance service, emergency department, medical team on-call, radiology department, bed management and the Stroke Team.


We undertook a prospective audit to identify delays in the acute stroke pathway as we hypothesised that some eligible patients were missing out on thrombolysis for acute strokes and there were delays affecting other components of ASB. The aim of the audit was to identify delays in the stroke pathway delivery and divergence from targets.




It was a prospective audit from 8th August to 24th October 2011 (78 days). A predefined data collection form was used. Patient records were analysed at first review by the Stroke Team. Excel spread sheet was used for data analysis. Median values with interquartile range (IQR) were reported due to the skewed distribution of the data.




71 stroke patients were included in the final analysis. 23 Stroke mimics were excluded. 65% of the patients were male, median age was 75 years (IQR 60-80 yrs).


Arrival at Hospital:


Median delay between onset of stroke (excluding wake up strokes) and arrival at hospital was 87.5 minutes. 19 (26.7%) patients arrived within 3 hours of symptom onset. Only 54 (76%) patients called for help on the day of stroke (Figure 1).


26 patients (37%) woke up with stroke symptoms. For the 45 patients with known times of stroke onset; median interval between the time of stroke onset and call for help was 30.5 minutes (IQR 10.75 – 139.25 minutes). 16/45 (35.6%) patients did not have a documented time of call in the ambulance sheet.


Figure 1: Day stroke onset vs. call for help:


Median time interval between 999 call and arrival in emergency department was 57 minutes (IQR 56-64 minutes). 23 patients did not have ambulance response times documented in the ambulance sheets.


Assessment times in hospital:


53 of 71 patients had documented times of assessment in A&E. Median interval between arrival in A&E and assessment by an A&E doctor was 40 minutes (IQR 10-80 minutes). 17 of 53 (32%) patients were seen within 15 minutes of arrival by a doctor from A&E (figure 2). 38 (53%) patients had documented times of A&E assessment and medical referral both – which showed a median delay of 20 minutes between A&E assessment to specialist referral (IQR 5–52.5 minutes) (figure 3).


39 (54.9%) patients were assessed by a senior doctor from the admitting medical team (SHO grade or above) within 3 hours of arrival. Median delay between hospital arrival and evaluation by a senior medical doctor was 157 minutes (IQR 54.25-271 min). Median delay between referral from A&E to assessment by admitting medical team was 55 minutes (IQR 8.75 – 138.75 minutes).


Figure 2: Arrival to assessment times in A&E



Figure 3: Time intervals between A&E assessment & referral to specialists


CT heads within 24 hours:


For the 31 patients seen during working hours, 29 (96.6%) had CT heads before 5pm. Remaining 2 patients missed the 24 hour target as their CT’s were not requested until next morning after Consultant ward round. For the 40 patients seen out of hours, 38 (95%) had their CT’s requested early next day and they were performed within the 24 hour target. The median CT request to response time by the radiology department was 50 minutes (IQR 13-96 minutes).

Aspirin prescriptions within 24 hours:


Nearly 60% patients had aspirin prescription within 24 hours (Figure 4).


Figure 4: Aspirin prescription within 24 hours


Thrombolysis for Acute Stroke:


17(23.9%) patients were eligible for thrombolysis, however 54 (76.1%) were not (Figure 5). 8/17 (47%) eligible patients were thrombolysed. Figure 6 highlights the reasons for the 9 eligible patients not receiving thrombolysis.


Figure 5: Reasons 54 patients were not eligible for Thrombolysis


Figure 6: Reasons eligible patients missed Thrombolysis



Admission to Acute Stroke Unit (ASU) within 24 hours:


56 (78.9%) patients were admitted to the ASU within 24 hours. Figure 7 details the reasons for delayed admission of 15 patients to the ASU.


Figure 7: Reasons for delayed admission to Acute Stroke Unit (ASU)


Stroke team review:


Majority of the patients admitted on weekdays were reviewed by the stroke team within 24 hours and all weekend admissions were reviewed on Mondays (67/71 patients). Exception to this was 4 patients who were referred late in the evening by the admitting medical teams.




Just over a quarter (26.7%) of stroke patients arrived in hospital within 3 hours and 76% called for help on the day of stroke onset. 32% patients were seen within 15 minutes of arrival by a doctor from A&E, however, 28% were referred late to the admitting medical team. Evaluation by a senior doctor from the admitting medical team was undertaken in 54.9% patients within 3 hours of arrival at hospital. Median delay between hospital arrival and evaluation by a senior medical doctor was 157 minutes, which seems to be a combination of delayed assessments and referrals from A&E (figures 2 & 3) and delays in assessment by the medical team itself. 94% patients had CT scans in 24 hours, although over a quarter of ischaemic stroke patients did not receive aspirin within 24 hours. Just over a half of eligible patients missed thrombolysis due to apparent delays during the ambulance and emergency department parts of their acute stroke journey. Over 20% of patients missed the 24 hour target of admission to the ASU.


This audit highlights that efforts should be made at all levels (ambulance services, emergency department and admitting medical team) to expedite early assessment and swifter processing of all suspected acute stroke patients. Scrupulous bed management in required in order to admit stroke patients to ASU as soon as possible.


By increasing the awareness of above amongst all the stakeholders, we can save at least a few minutes at each of the steps in the acute stroke patient journey, hence saving considerable precious time for these patients in the first few hours. This can lead to more patients benefiting not only from thrombolysis for acute stroke but also other specialist interventions by the stroke team earlier on, thus leading to better patient outcomes.





1. Royal College of Physicians (2008). National Clinical Guideline on the Management of People with Stroke (3rd Edition). London. RCP Intercollegiate Stroke Working Party.


2. http://www.wales.nhs.uk/documents/Intelligent_Targets_Summary.doc


3. Harraf, F., Sharma, A.K., Brown, M.M., Lees, K.R., Vass, R.I., Kalra, L. for the Acute Stroke Intervention Study Group.  A multicentre observational study of presentation and early assessment of acute stroke. BMJ 2002; 325: 17



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