Factors Influencing Early Hospital Arrival of Patients with Acute Ischemic Stroke, Cross Sectional Study in Mogadishu Somalia

Abstract

Background and Objective: Intravenous thrombolysis (IVT) is now considered the best a standard treatment for acute ischemic stroke in eligible patients who present within 4.5 h of symptom onset. The low rates of thrombolysis for ischemic stroke in our country and other developing countries have been attributed to delays in arrivals to the hospital.  This study aims to investigate the factors that influence the early hospital arrival of patients with acute ischemic stroke to the hospital in Mogadishu, Somalia.

Methods: This is a cross-sectional study conducted in teaching hospital in Mogadishu, Somalia. Adult patients diagnosed with acute ischemic stroke admitted to the emergency department between June 2021 and May 2022 were included in the study.  A questionnaire-based interview was administered to adult patients or patients’ relatives. Patients within the hospital while developing an ischemic stroke were excluded from the study. Patients' demographic characteristics, stroke risk factors, NIHSS Score, time to hospital arrival, factors influencing early hospital arrival including travel distance, ambulance availability, time of stroke onset, knowledge of stroke symptoms, and thrombolytic treatment were all assessed.

Results: of the 212 patients in the study, 113(53.3%) of the subjects were male, while 99(46.7%) were female. The mean age of the patients was 62±10. The majority of the patients (153 (72%) were above 60 years of age. Hypertension was the most common risk factor among patients 121(57%), followed by diabetes mellitus (65(31%)) and hyperlipidemia 73(34%). MCA infarct was the most common arterial territory of infarction 117(55%). 140(66%) of the patients lived in the city, while 72(34%) lived outside of the city.  85(40%) of the patients were brought to the ER by ambulance, and only 32(15%) reached the hospital in less than 4 hours. The thrombolytic treatment rate was 1.4% of the cases in this study.  121(57%) had no idea about stroke symptoms, and only 34(16%) of the patients/relatives knew about thrombolytic treatment for acute stroke.

In univariate and binary logistic regression analysis, delays in hospital arrivals were associated with travel distance of more than 10 km, transportation via non-ambulance means, living alone, lack of recognition of stroke symptoms, night time stroke onset, and lack of knowledge about thrombolytic treatment for acute stroke and non-hemiplegic presentation.

Conclusion: This study demonstrates factors delaying early hospital arrivals of patients with ischemic stroke. Improving the modifiable factors through public education will prevent delays in early hospital arrival of the stroke patients and will improve early thrombolytic intervention and over all outcome of these patients.

Introduction

Stroke is one of the leading causes of death and disability worldwide, especially in the elderly. 85% of strokes are ischemic strokes due to occlusion of major intracranial vessels or their branches ^[1]. Administration of intravenous thrombolytics is the best choice of treatment to selected patients with acute ischemic stroke (AIS) who are eligible to thrombolysis if they come to the hospital on therapeutic window of 4.5 hours ^[2]. The earlier patients arrive at the hospital, the more likely they are to benefit from thrombolysis. However less number of patients with acute ischemic stroke arrive at the hospital within this time zone of the therapeutic window ^[3]. The longer it takes for a patient to get to the hospital after a stroke, the less likely they are to be treated with thrombolytic and/or mechanical thrombectomy ^[4]. There are a variety of factors that have been researched in the literature that lead to patients' arriving to the hospital after the therapeutic window has passed. Among these factors are referral pattern, living alone, nocturnal onset, history of stroke or cardiovascular disease, transportation method to the hospital, knowledge of thrombolysis, and clinical status ^{[5, 8]}. In our setting, very few number of patients with acute ischemic stroke arrive at the hospital within the therapeutic window, and therefore the majority of patients miss the benefit of the thrombolytic treatment. There are no previous studies performed in our country that investigate the factors contributing to this delay. Our study aims to determine the factors affecting the arrival time to the hospital of patients with acute ischemic stroke.

Materials And Methods

This is cross sectional study conducted in tertiary teaching hospital (Mogadishu Somali Turkish training and research hospital, which is the only hospital in Mogadishu providing IV thrombolytic treatment for patients with acute ischemic stroke). MSTH Patients diagnosed with acute ischemic stroke who arrived to the emergency department between June 2021 and May 2022 were included in the study. Questionnaire based interview was administered to the patients or patients’ relatives by attending neurologists to determine the factors that delay the early arrival of patients with acute ischemic stroke to the hospital. All patients of age > 18 years (willing to participate) with symptoms of stroke and neuro-imaging (cerebral computed tomography/magnetic resonance imaging) evidence consistent with acute ischemic stroke were included. Patients who developed ischemic stroke while in the hospital and patients with intracerebral hemorrhages were excluded from the study. The time when stroke symptoms first appeared was recorded as the stroke onset time. The time when the patient was last seen as healthy was used to determine the stroke onset time in wake-up strokes. Other studies have preferred the same definition of stroke onset for patients whose symptoms were detected on awakening ^{[6, 7]}.

Patients' demographic characteristics, stroke risk factors, NIHSS Score, time to hospital arrival, factors influencing early hospital arrival including travel distance, ambulance availability, time of stroke onset, knowledge of thrombolytic treatment, and also rate of thrombolytics application among study participants were all evaluated.

The stroke onset time was divided into day (6 am-6 pm) and night (6 pm-6 am) based on the local time. Based to the time of emergency visit after the onset of stroke onset, the patients were divided into two groups; those who arrived early (< 4 hours) and those delayed (> 4 hours). Consciousness was assessed by using the Glasgow Coma Scale (GCS), and was further categorized into less than or equal to 8/15 and greater than 8 to determine patients who were conscious and those that are unconscious. The stroke severity was measured using the National Institute of Health Stroke Scale (NIHSS). First Stroke symptom presentation was recorded as hemiplegia/hemisensory loss, aphasia/dysarthria and altered mental status.

The distance travelled by the patients to hospital was categorized as 10 km or less and more than 10 km. this distance was reasonably considered because people living within a 10-km away from the hospital, are be able to arrive within 4-hour therapeutic window period.

Statistical analysis

The variables were analyzed by using statistical package of social sciences (SPSS) version 26. Descriptive statistics, frequencies, and percentages were calculated for variables such as stroke risk factors, time of stroke onset, travel distance, transportation availability, time of arrival to hospital, rate of thrombolytic administration. To assess the univariate relationship between early presentation to the hospital and the variables of interest, Chi-square test was used for qualitative data such as educational status, living conditions, time of onset, travel distance, and transportation availability. Binary logistic regression analysis was applied for variables that were statistically significant (p < 0.05) in univariate analyzes.

Ethical approval:  This study was performed in line with the principles of the Declaration of Helsinki. The study was reviewed and accepted by the ethics committee of Mogadishu Somali Turkish Training and Research Hospital (Ethics Protocol No: MSTH/6746). All patients or caregivers were informed as to the purpose of this study. Written informed consent was obtained from the patient or relatives during the data collection and they signed the consent form. We declare that we have followed the protocols of our work center. Patients’ data confidentiality was respected.

Findings

The study contained 212 patients admitted to the emergency department due to acute ischemic stroke. 113(53.3%) of the subjects were male while 99(46.7%) were female. The mean age of the patient was 62±10. Majority of the patients 153(72%) were above 60 years of age. Hypertension was the most common risk factor among patients 121(57%), followed by diabetes mellitus and hyperlipidemia (see table 1).

A total of 111(52.4%) had NIHSS score of less than 12, while 101(47.6%) had NIHSS score of more than 12. NIHSS score was significant factor influencing early hospital arrival of patients. One hundred (47.2%) had an elevated blood pressure on admission. 67(31.6%) of the patients had elevated blood glucose level on admission.  20(9.4%) had associated metabolic derangement, 82(39%) had GCS of less 10, while 130(61%) had GCS greater than 10. MCA infarct was the most common arterial territory of infarction 117(55%), followed by ACA infarct 52(24.5%), vertebrobasilar territory infarct in 35(16.5%) had, while. 8(4%) had Internal carotid occlusion.140(66%) of the patients lived the city while 72(34%) lived in outside of the city. 72(34%) of the patients lived alone while 140(66%) lived with their families or friends. Rural residency and living alone were associated with delay of early hospital arrival (P= 0.005 and P= 0.038 respectively).

22(68.8%) of the patients with day time stroke onset reached the hospital in less than 4 hours compared to 10(31.3%) of the patients with night time  stroke onset. This was statistically significant (P= 0.016). Regarding traveling distance, 127(60%) travelled less than 10km to the hospital while 85(40%) travelled more than 10km to the hospital. 53(25%) of the patients were brought to the ER with Ambulance while 159(75%) were brought via other means of transportation. Regarding hospital arrival time, only 32(15%) of patients reached the hospital in less than 4 hours while the rest of patients were delayed (see figure 1). 49(23%) of the patients were referred from other hospital/clinics. 

Hemiplegia was the major stroke presentation in majority of the patients 111(52.5%), aphasia/dysarthria in 52(24.5%), while 49(23%) presented as altered mental status for their stroke (see table 2). Decision to visit the emergency was made by family member in 167(79%), while 56(21%) of the decision was made by the patient. Thrombolytic treatment was applied in 1.4% of the patients.  91(43%) of the patients/relatives had known about stroke symptoms while 121(57%) had no idea about stroke symptoms. 34(16%) of the patients/relatives had known about thrombolytic treatment for acute stroke.

In univariate and binary logistic regression analysis, delay in hospital arrivals were associated with female gender (OR 0.39, 95% CI 0.17-0.89, P<0.022), having lower education background (OR 4.22, 95% CI 1.59-12.49, P<0.001), living in outside of the city (OR 4.25, 95% CI 1.42-13.64, P<0.005), GCS score of more than 8 (OR 0.42, 95% CI 1.08-4.99, P<0.027), travel distance of more than 10km (OR 2.73, 95% CI 1.12-6.64, P<0.022), living alone (OR 2.21, 95% CI 1.03-4.74, P< 0.038), lack of recognition of stroke symptoms (OR 4.20, 95% CI 1.84-9.62, P<0.001), night time stroke onset(OR 2628, 95% CI 1.17-5.86. P<0.016), lack of knowledge about thrombolytic treatment for acute stroke (OR 3.57, 95% CI 1.52-8.37, P<0.002), and non-hemiplegic presentation (OR 3.89, 95% CI 1.79-8.46. P<0.001). The following factors were not associated with hospital arrival delay: referral from local hospital/clinic, transportation means, income level, emergency visit decision maker, past history of stroke/TIA and NIHSS score of the patient (see Table 3). 

Discussion

Ischemic Stroke is neurologic emergency and remains a major global health problem and leading cause of mortality and morbidity. Ischemic stroke represents 85% of acute stroke.  Due to ongoing demographic shifts, such as population aging and health transformations seen in developing countries, its importance is expected to increase in the future. ^{[9, 10]}. Currently, intravenous thrombolytic treatment (IVT) is considered the most effective intervention treatment for patients presenting with acute ischemic stroke (AIS). Majority of the patients come late to the hospital and miss this golden opportunity ^{[11, 12]}. In this study, we investigated the various factors influencing the early arrival of AIS patients to the emergency department in Mogadishu.  Compared to other Western and developed countries, where prehospital delays typically range from 3 to 6 hours ^{[13, 14]}, the median prehospital delay in this study is 14 hours, which is much longer. Of the patients, only 32 (15%) arrived at the hospital within the therapeutic window of 4.5 hours. This has negative impact on management and outcomes of patients with acute ischemic stroke. This should public health concern and therefore should become top priority for healthcare professionals. In univariate and multivariate analysis of this study, factors associated with early hospital arrival were male gender), having higher education living in city low GCS score, travel distance of less than 10km, living with family or friends, knowledge of stroke symptoms day time stroke onset, knowledge of thrombolytic treatment for acute stroke, and hemiplegic Presentation. There was not any previous study evaluating the factors contributing to the prehospital delay of acute ischemic stroke patients. 

The cut-off point for classifying patients delayed and early arrival groups varied from study to study. Some studies kept 2 hours as cut-off point, considering the hospital delay ^{[17, 18]}. Two studies from India used 3 hours as the cutoff for categorizing early and late arrivals ^{[19, 20]}. In our study, the cut-off point for early arrival for ischemic stroke thrombolysis is 4 hours. The proportion of patients’ arrival in the therapeutic window varies from one study to the other. Study by Guveli et al ^[15] 30.7% of patients arrived the hospital within 3 hours after the onset of stroke symptoms. In another study by Kocak et al ^[16], 29.5% of patients came to the hospital in < 4 hours. As per study by Caroline Mithi et el, only 23.9% of patients with acute ischemic strokes arrived early to the hospital with in the therapeutic window ^[21]. In this study only 15% of the patient came within the therapeutic window and therefore majority of the patients missed the golden opportunity.

Male patients had shorter prehospital delays than female patients. Male patients were more likely to arrive early than female patients. Age was significant factor in terms of prehospital delay. According to a study by Jin et al, people over the age of 65 and female patients were just more likely to arrive early than younger patients and men ^[22]. According to univariate analysis, higher educational level and residence in the city were associated with fewer prehospital delays. However, in our analysis,  age and income status had no impact on prehospital delay. Some studies showed that educational status and income level of patients had no effect on hospital arrival delays ^{[23, 24]}. 

According to certain prior studies (mainly from western countries), Living alone is a significant factor in the delay in getting medical treatment among stroke patients ^[25,26]. In our study, majority of patients were living with their families (80%). Those living with family/friend had fewer hospital delays than those living alone according to the univariate analysis.  In this study, past history of stroke, TIA, other comorbidities such as hypertension, diabetes, and hyperlipidemia were not significant factors influencing early hospital arrival. 

In univariate analysis, recognition of symptoms of stroke by patients/relatives was significantly associated with early hospital arrival. Patients/relatives without knowledge of stroke symptoms were more likely to arrive late. Fifty seven percent of the subjects did not know stroke symptoms. Likewise, only 16% of patients/relatives knew the availability of thrombolytic treatment for acute ischemic stroke. These findings emphasize the urgent need to educate the public about stroke and specially the patients in the risk group.  In contrary, some studies revealed that identification of stroke symptoms had no appreciable impact on timely presentation at the emergency room. ^{[27, 29]}. However some previous studies showed that knowledge and awareness of stroke symptoms has substantial impact on early hospital arrival ^{[2, 28]}. In the literature, there are number of studies showing that use of ambulances can reduce prehospital delays in acute stroke patients ^{[30, 28]}. The patients who arrived the hospital via ambulance were 25% in this study. This rate is very low compared to that of the developed countries, which is 60% ^[6]. In Somalia, since there aren't many emergency ambulance services, patients must rely on other transportation options to get to the hospital. However 25% arrival of via ambulance is still good number, but was not significant enough to reduce prehospital delay of patients. This indicates that readily availability, quick access and organization of emergency ambulance services are not developed in the country.

In our study, the average of hospital arrival for the patients was 14 hours. This delay is almost similar in other African countries, for example, in the neighboring Kenya where patients present to the ER between 1 and 3 days from the onset ^[31]. Patients were significantly more likely to arrive at the hospital early if they lived in Mogadishu or its vicinity, similar to what has been found by Ashraf VV et al., where early emergency arrival was substantially related with living within 15 km of the hospital ^[2]. In this study, patients with day time stroke onset were more likely to arrive early to the hospital than those who had night time stroke onset. This is in contrast to a research by Haki Cemile et al., which revealed no association between the time of arrival at the hospital and the onset of symptoms as day or night ^[1].

Strengths and Limitations

This research is the first to be published that addresses the major challenges and barriers towards receiving acute care for acute ischemic stroke patients in Somalia. The study specifically focused the factors influencing early hospital arrival of patients with acute ischemic stroke.  Our findings have implications for reducing stroke patients' prehospital delays and therefore addressing these factors will improve stroke care in the country. 

The study is a single-centered study using a modest sample size. However this study provides a useful, representative picture of the current issues surrounding prehospital delay in presentation of acute stroke in this part of the world. Further studies with larger sample size nvolving various stroke centers are required to verify these conclusions. Another limitations in our study is utilization of information from the parapatients incases when the patient cannot communicate properly, which may become less representative.

Conclusion

The study showed greater hospital delays after stroke onset. The study found that lack of recognition of stroke symptoms, living rural area, travelling more than 10 km to hospital, low education level, and night time stroke onset were the independent factors contributing hospital delay patients with acute ischemic stroke.  Public education and health promotion measures to improve public awareness of early recognition of stroke symptoms, early transfer of patients to hospitals with thrombolysis treatments and improving ambulance services are practical and reasonable methods to speed up early presentation to hospital by stroke patients.  

Declarations

Ethical approval:  This study was performed in line with the principles of the Declaration of Helsinki. The study was reviewed and accepted by the ethics committee of Mogadishu Somali Turkish Training and Research Hospital (Ethics Protocol No: MSTH/7418). 

Funding: None

Conflict of interest:  The authors declare no conflict of interest

Author contribution 

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

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Tables

Table 1: Demographic characteristics of patients

N (%)                                         N/%

HTN: hypertension, DM: diabetes mellitus, TIA: transient ischemic stroke

Table 2: Patients’ stroke related features

                                                                                            N/%

NIHSS: National Institutes of Health Stroke Scale, GCS: Glasgow Coma Scale 

MCA: Middle cerebral artery, ACA: Anterior Cerebral Artery

Table 3