Calls to doctor's office may delay stroke treatment

Calling a primary care doctor instead of 9-1-1 at the first sign of a stroke can delay patients from reaching an emergency room during the most critical period - the first three hours after onset of stroke symptoms, researchers reported at the American Stroke Association's International Stroke Conference 2008.

In two separate studies, one in the United States and the other in Australia, investigators found possible significant delays when doctors' offices were called first. Calling an emergency number or an ambulance is the quickest way to reach a hospital within the three-hour window of opportunity for acute stroke treatment that can potentially avert serious post-stroke disability.

In the West Virginia study (P523), researchers randomly called primary care physicians' offices seeking advice for hypothetical stroke or heart attack symptoms. About 40 receptionists were asked to choose one of four responses to the scenario: wait to see if symptoms go away, schedule an office appointment later that day, schedule an appointment within two days, or call 9-1-1.

The receptionists were aware of heart attack symptoms and correctly advised an emergency 9-1-1 call for heart attack scenarios. However, for stroke scenarios, nearly one-third of the receptionists recommended scheduling an appointment later in the day if symptoms continued.

“Calling 9-1-1 is the only correct answer,” said co-author Stephen Davis, M.P.A., M.S.W., author of the study and an adjunct assistant professor of emergency medicine at West Virginia University–Morgantown. “We seem to have done an excellent job educating people about heart attacks, but we need more work with stroke education. Almost 30 percent of the receptionists recommended a wait-and-see strategy. We can do much better than that.”

The study was presented by lead author Brett Jarrell, M.D., an assistant professor of emergency medicine at the University of Kentucky.

The second study (P537) was not a hypothetical survey. It included interviews with 198 patients who had arrived at three Australian emergency rooms via ambulance over six months. Researchers found that calling doctors' offices lengthened the time before an ambulance was called and delayed the patient reaching hospital.

Overall, 22 percent of emergency room stroke patients had first called a family doctor. Only 32 percent called an ambulance immediately.

Among those who called a family doctor, 45 percent were screened over the phone and advised to call an ambulance. Thirty-six percent were advised to be seen by the doctor. Of these two groups, those advised to call an ambulance experienced a median time of 92 minutes to ambulance call while those who waited to be examined experienced median times of 412 minutes – nearly 7 hours prior to an ambulance being called.

The delay in calling an ambulance was nearly 10 times greater for those who waited to be seen by their physician (median 412 minutes) than for those who called an ambulance immediately (median 44 minutes).

Time to hospital arrival was more than five times greater for patients who saw their physician first (median 475 minutes) compared to those who first called an ambulance (median 92 minutes), said study author Ian T. Mosley M.B.A., R.N.

“Family doctors and their staff have an important role to play in reducing potential delays by screening calls and providing advice for stroke patients who call their family doctor following the onset of stroke symptoms,” said Mosley, who is a research fellow at the National Stroke Research Institute at the University of Melbourne. “The best response for people who experience or observe stroke symptoms in others is to call an ambulance.”

The study was presented by senior author Helen M. Dewey, M.B.B.S., Ph.D., Associate Director of the National Stroke Research Institute and Associate Professor in the Department of Medicine at the University of Melbourne.

The American Stroke Association recommends calling 9-1-1 immediately if any of these stroke warning signs occur:

• Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
• Sudden confusion, trouble speaking or understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden, severe headache with no known cause.