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Emergency Treatment For Strokes Still Needs Improvement In British Hospitals

Immediate treatment of stroke in British hospitals needs to be brought into line with the rest of Western Europe and North America.

Improved treatment includes the use of thrombolysis, allied with greater use of emergency services, quicker examination by senior doctors of suspected acute stroke, and more computed tomography examinations among patients.

This is the assessment by clinicians at Guy's, King's and St Thomas's Medical School, London, of outcomes in a multicentre study of 400 women and 339 men, median age 75, with suspected stroke, admitted to 22 hospitals in Britain and Ireland.

Recent research shows thrombolysis is effective in selected patients but needs to be undertaken within three hours, and no later than six hours, from the onset of symptoms. Most stroke patients are not assessed as rapidly as they should be. American research has found that underutilisation of emergency medical services and delays in hospital assessment are important impediments to thrombolysis.

British clinicians are more cautious in using thrombolysis than in the rest of Western Europe or North America because a meta-analysis indicates benefit is marginal and mortality may be increased. This is allied with their general perception that most patients present too late to be eligible for treatment.

The clinicians, in their assessment, found that the median delay between onset of symptoms and arrival at hospital was six hours: 37 percent of patients arrived within three hours, 50 percent within six hours. The median delay for patients using the emergency service was two hours, three minutes, compared with seven hours, 12 minutes, for referrals to hospital by a family doctor.

Use of emergency services reduced the time a patient was taken to hospital. Only 477 patients (65 percent) were evaluated by a senior doctor within three hours of arriving at hospital. Computed tomography was requested within three hours of arrival for 166 (22 percent) patients but was carried out in only 60 of them (8 percent).

The clinicians said their findings highlight the need to improve the management of acute stroke, including better utilisation of emergency services. as the most direct means of reducing delays in getting to hospital, and increasing the number of patients eligible for therapies.

Most importantly of all, they conclude, the perception in Britain that delays in presentation prevent early specialist management of stroke is not justified, "and there is a good case for bringing stroke practice in line with other developed countries."
BMJ 2002;325:17. "A multicentre observational study of presentation and early assessment of acute stroke"

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