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Trends in acute stroke presentations to an emergency department: implications for specific communities in accessing acute stroke care services
  1. Sonu Bhaskar1,2,3,4,
  2. Peter Thomas1,2,
  3. Qi Cheng1,2,
  4. Nik Clement5,
  5. Alan McDougall1,2,4,
  6. Suzanne Hodgkinson1,2,4,
  7. Dennis Cordato1,2,3,4
  1. 1 Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia
  2. 2 Stroke and Neurology Research Group, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
  3. 3 South West Sydney Clinical School, School of Medicine, Western Sydney University, Liverpool, NSW, Australia
  4. 4 The University of New South Wales, Sydney, NSW, Australia
  5. 5 Business Intelligence Unit, Liverpool Hospital and South West Sydney Local Health District (SWSLHD), Liverpool, New South Wales, Australia
  1. Correspondence to Dr Sonu Bhaskar, Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, NSW 2170, Australia; Sonu.Bhaskar{at}


Background and purpose South Western Sydney comprises of a culturally and linguistically diverse (CALD) and lower socioeconomic status population group within the state of New South Wales. Geographic location and sociodemographic factors play important roles in access to healthcare and may be crucial in the success of time-critical acute stroke intervention. The aim of this study was to examine the trends in the delayed presentation to emergency department (ED) and identify factors associated with prehospital delay for an acute stroke/transient ischaemic attack (TIA) at a comprehensive stroke centre.

Methods Patient health-related data were extracted for stroke/TIA discharges for the period 2009–2017. Electronic medical record data were used to determine sociodemographic characteristics and prehospital factors, and their associations with delayed presentation≥4.5 hours from stroke onset were studied.

Results During the 9-year period, population-adjusted stroke/TIA discharge rates increased from 540 to 676 per 100 000. A significant reduction in the proportion of patients presenting to ED<4.5 hours (56% in 2009 versus 46% in 2017, p<0.001) was observed. Younger patients aged 55–64 and 65–74 years, those belonging to Polynesia, South Asia and Mainland Southeast Asia, and those not using state ambulance as the mode of arrival to the hospital were at increased risk of prehospital delay.

Conclusions Comprehensive reappraisal of educational programmes for early stroke recognition is required in our region due to delayed ED presentations of younger and specific CALD communities of stroke/TIA patients.

  • stroke
  • delayed presentation
  • culturally and linguistically diverse (CALD) population
  • health systems
  • health promotion
  • health policy
  • emergency department
  • health equity
  • healthcare access

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Stroke is a leading cause of mortality and long-term morbidity.1 2 In Australia, the financial burden of stroke is estimated to be $A5 billion in 2012.1 The impact of stroke is devastating due to the loss of health-related quality of life and the overall burden of disease costs amounting to $A49.2 billion.1 During the past 15 years, advances in acute stroke therapies, in particular, reperfusion therapy, such as intravenous thrombolysis and more recently endovascular thrombectomy, has seen a significant increase in the proportion of acute ischaemic stroke patients who are functionally independent.2 Initiatives and programmes to promote awareness about the benefits of early presentation is key for delivering improved value care to stroke patients.3–12 Stroke awareness programmes, such as the FAST (face, arm, speech and time) score, have improved paramedic and emergency department (ED) staff recognition of patients who may be suffering from acute ischaemic stroke and/or amenable to acute therapy.3 4 However, the impact of stroke education programmes on improving community stroke awareness of the benefits of early ED presentation is unclear, especially in culturally and linguistically diverse (CALD) population. To this end, examining the trends in ED presentation can provide insights on specific CALD communities who might be at a greater risk of prehospital delay in receiving time-critical acute stroke therapies.

South Western Sydney (SWS) comprises of a CALD and lower socioeconomic status population group within the New South Wales (NSW). The 2016 census of population and housing reported 966 450 people living in the SWS, which accounts for 12% of the NSW population; where 51% speak a language other than English at home and 44% were born overseas.13 The median weekly total household income and education level (bachelor’s degree and above) in the catchment area (Liverpool City, SWS) is lower than that at state (NSW wide) and national levels.14 Geographic location and demographic factors play an important role in access to healthcare and may be crucial in the success of acute stroke intervention.3 4 12 15 The aim of the study was to examine the trends in delayed presentation to ED during the period 2009–2017 and identify the factors associated with prehospital delay in stroke/transient ischaemic attack (TIA) patients admitted to a comprehensive stroke centre (CSC). The findings of the study may help to identify current barriers, and specific CALD patient subgroups, who may be at risk of worse outcomes due to delayed presentation. This may help to develop strategies to mitigate barriers to the early presentation, improve rates of early presentation to the ED and reduce long-term disability.


Study design

Patients with primary discharge diagnoses of stroke and/or TIA were identified from the SWS stroke management data set. The retrieved data set was then linked to the health information exchange (HIE) database, with ICD-10-AM coding as the primary discharge diagnoses of stroke and/or TIA at our hospital. All patients during the study period, between 01 January 2009 and 31 December 2017, were included in this study. HIE is a data warehouse (an online analytical processing database) of patient health and hospital admission records. Liverpool Hospital is a tertiary referral hospital with a CSC covering a large catchment area within the SWS Local Health District. A structured data collection form was used to retrieve the demographic and clinical data from the Cerner Millennium Power Chart System (electronic medical record (eMR)) of our hospital. Since this study involved a retrospective review of the consecutive stroke patients for the study period, all patients satisfying the inclusion criteria and with complete stroke discharge/management data set were included. This would have mitigated the risk of selection bias as no random sampling strategy was employed. The severity of stroke symptoms at the admission was defined on the Scandinavian Stroke Scale (SSS). Patients were categorised as mild (43≤SSS≤58), moderate (26≤SSS≤42) and severe (0≤SSS≤25) depending on the SSS profile.

Statistical analyses

Given that the distribution of the prehospital delay was positively skewed, it was summarised by the median and upper and lower quartiles. The differences in median time between sociodemographic and prehospital variable subgroups were analysed with the Wilcoxon rank-sum or Mann-Whitney U test. For two or more groups of an independent variable on a continuous or ordinal dependent variable, a rank-based non-parametric Kruskal-Wallis H test was used. ORs and 95% CIs were used to describe associations of sociodemographic and prehospital factors with prehospital delay (≥4.5 hours) using univariate logistic regression analyses. Subsequent to univariate logistic regression analysis, variables with p<0.1 in univariate logistic regression were included in a multivariate logistic regression model. The multivariate regression model included age, year, region of birth, marital status, mode of arrival to the hospital, triage category, time of day, living status in an aged care facility or nursing home, basic hospital cover health insurance, stroke severity at admission and medical risk factors, such as atrial fibrillation (AF), AF on admission and previous TIA. All patients with onset of stroke between 2009 and 2017 were included in these analyses. Patients with missing data were excluded from the logistic regression analysis. All analyses were performed with STATA V.13.0 SE software.


There were 5313 patients with a discharge diagnosis of stroke/TIA registered between January 2009 and December 2017. Of these, 3537 patients who had their stroke separations documented by completed eMR referrals were included in the study. The mean age was 69.46 (SD 14.14) years, and 1611 (45.5%) of patients were women.

Between 2009 and 2017, a total of 1495 (42.3 %) patients arrived within 3 hours of symptom onset and 1825 (51.6 %) within 4.5 hours. Significant differences in the proportion of patients who arrived within 3 versus ≥3 hours (p=0.0001), and those who arrived within 4.5 versus ≥4.5 hours were observed (p=0.0001).

Table 1 presents the median prehospital delay time to ED for all patients by selected sociodemographic and prehospital characteristics. The overall median prehospital delay to presentation time was 4.22 (IQR 1.43–13.68) hours and was longer in patients for following groups: age groups 55–64 and 65–74 years and those with the global region of birth in Mainland Southeast Asia, Polynesia and South Asia. No significant differences in prehospital delay were observed by gender.

Table 1

Median time from onset of stroke to emergency department arrival and univariate logistic regression analysis for delayed presentation (≥4.5 hours) by selected sociodemographic characteristics and prehospital variables

A linear trend in the population-adjusted stroke separations by diagnosis and completed eMR referrals were observed during the period 2009–2017 reflecting a steady increase in stroke/TIA presentations in the region (see figure 1) (p=0.0001). Age-adjusted and population-adjusted stroke separations also showed a linear increasing trend. A similar significant increase was observed in patients with a delayed presentation to ED (≥4.5 hours). Conversely, a linear downward trend in proportion of early presenters to ED was observed (see figure 2). In our study, 36.6% of stroke patients were born in Australia in 2009, which increased marginally to 37.3% in 2017.

Figure 1

Population-adjusted stroke separation by diagnosis and completed electronic medical record (eMR) referrals from 2009 to 2017 presenting to the Liverpool Hospital in South Western Sydney.

Figure 2

Trends in stroke onset to emergency department (ED) presentation.

Delayed presentation to ED was significantly associated with age (p=0.0001). In comparison to the age group 85 and above, patients in the age groups of 55–64 (OR 1.60 (1.27–2.03), median time in hours 5.07 (IQR 1.55–17.83), p<0.001)) and 65–74 (OR 1.75 (1.41–2.18), median time in hours 5.34 (IQR 1.58–17.15), p<0.001)) were at higher odds of delayed presentation to the ED, respectively.

Global region of birth influenced time to presentation. Patients born in Mainland Southeast Asia (OR 1.28 (1.03–1.59); median time in hours 5.47 (IQR 1.73–15.9)) and Polynesia (OR 1.58 (1.15–2.18); median time in hours 7.03 (IQR 1.8–24.83)) were significantly more likely to have a delayed presentation to ED in comparison to those born in Australia.

Marital status was significantly associated with time to presentation. Patients who were ‘separated’ (OR 1.66 (1.14–2.41); median time in hours 7.51 (IQR 1.88–20.28)) or ‘never married’ (OR 1.17 (0.91–1.50); median time in hours 5.06 (IQR 1.65–19.36)) were more likely to have delayed presentation to ED or showed a trend towards delayed presentation, respectively, in comparison to married patients (median time in hours 4.12 (IQR 1.4–13.42) (p=0.0767)).

Mode of arrival was significantly associated with the risk of delayed presentation to ED (p<0.0001). Patients arriving at ≥4.5 hours to ED with private vehicle (OR 2.79 (2.39–3.25); median time in hours 8.85 (IQR 2.42–30.7)) were significantly greater than those arriving by state ambulance vehicle (median time in hours 3.02 (IQR 1.25–9.12)). A histogram of patients arriving by ambulance stratified by their region of birth is shown in figure 3. The proportion of patients arriving to hospital on state ambulance was lower in those born in Polynesia (50%), South America (51%) and South Asia (52%) in comparison to those born in Australia (68%).

Figure 3

Distribution of patients arriving on state ambulance by region of birth.

Triage category at the admission was significantly associated with an early presentation to ED (p<0.001) (figure 4). The proportion of patients presenting early (<4.5 hours) under resuscitation (median time in hours 2.23 (IQR 0.87–5.62)) or emergency triage category (median time in hours 2.28 (IQR 1.12–7.05)) were significantly higher than those admitted under urgent (median time in hours 6.98 (IQR 2.08–21.92)), semi-urgent (median time in hours 9.38 (IQR 1.18–52.45)) or non-urgent (median time in hours 9.56 (IQR 4.22–69.9)) triage category. Time of the stroke (daytime/night-time) and English language background had no association with delayed presentation.

Figure 4

Histogram of onset to emergency department (ED) presentation by triage category.

Living alone or with others per se was not significantly associated with prehospital delay. However, patients from aged care or nursing home facility were more likely to present early (median time in hours 3.82 (1.37–10.67)). Patients with basic hospital cover health insurance were significantly associated with prehospital delay (median time in hours 5.22 (IQR 1.99–18.29)).

In terms of stroke severity, patients with mild stroke are more likely to have a delayed presentation to the hospital (median time in hours 4.95 (IQR 1.55–17.08)). Severe strokes were more likely to present early to the ED. Medical risk factors, such as history of AF, AF on admission and previous TIA, were significantly associated with early ED presentation.

In the multivariate model (table 2), the following factors were associated with increased risk of prehospital delay to the ED: younger patients from 65 to 74 versus 85 and above age subgroup, patients from specific communities, such as Polynesia, Mainland Southeast Asia and South Asia versus those from Australia, patients who were unmarried, widowed, divorced or separated versus those who were married, patients who used private vehicle or no transport (walk-in) versus those who used public ambulance, patients presenting at night-time versus those presenting during the day, patients at aged care or nursing facility versus those who were living alone at the time of stroke and patients with basic hospital cover health insurance versus those who had premium health cover.

Table 2

Multivariate regression analysis showing an association of demographic, socioeconomic and clinical factors with prehospital delay to the emergency department


This study found a significant linear increase in the proportion of patients with prehospital delay (≥4.5 hours) presenting to the ED at our hospital, covering a substantial catchment area of Liverpool or SWS, over the study period 2009–2017 (see figure 1). The data strongly suggest that different patient subpopulations in our health region are failing to recognise the potential benefits of early arrival after the onset of stroke symptoms. During this period, the age-adjusted stroke hospitalisations for Liverpool Hospital also significantly rose whereas the figures for the entire NSW state did not (see online supplementary figure 1). This may conversely reflect a growing awareness in our patient population of the importance of hospital attendance but more likely represents a rise in the prevalence of stroke in SWS. Our findings raise concern that primary prevention strategies for vascular risk factor management in a CALD population, such as in SWS, need to be further optimised.

The increased patient numbers with delayed time to presentation comes on a background of various stroke awareness programmes or educational initiatives, such as FAST (Facial drooping, Arm weakness, Speech difficulties and Time to call emergency services), that were introduced by the NSW Health and government health agencies in 2009. Despite such initiatives, general population awareness on aspects, such as ‘time is brain’ vis a vis prehospital delay, remains poor.16

SWS has a rich diversity of multicultural or CALD communities. Given the cultural diversity in SWS population the priorities and health challenges, including access to appropriate health information, access to equitable and quality health services that recognise and respect the specific needs of CALD communities, vary between communities.17 The understanding and sensitivity around health priorities and challenges of CALD communities is important in designing services, policy and programmes that addresses the relevant needs.17

One important finding of this study is the increasing proportion of prehospital delay in patients of younger subgroups (55–64 and 65–74 years), and those born in Polynesia and Mainland Southeast Asia. These findings have important ramifications from a public policy perspective and warrant a targeted stroke awareness programme for people from these regions. Appropriate public health and education campaigns to raise awareness on the importance of recognising stroke symptoms and early time to ED presentation will empower members of these communities. Moreover, we also found that members of specific communities, such as those born in Polynesia, South America and South Asia, are less likely to arrive to the hospital via ambulance. Mode of arrival using state ambulance is associated with shorter prehospital delay. Therefore, in addition to awareness on stroke, it is equally important to design educational programmes for these communities on seeking state ambulance services as soon as symptoms of a stroke are observed rather than arriving to the hospital on their own. Ambulance practice is an important element in the continuum of the comprehensive stroke care pathway.18 19 Stroke recognition by paramedics and hospital prenotification is associated with reduced prehospital delay and in-hospital time from ED/hospital arrival to first medical assessment.18 Our NSW ambulance team are equipped with the state-of-the-art facilities and capable paramedic staff for immediate medical attention following stroke. Moreover, given that the ambulance drivers are trained to take the shortest route and minimise the prehospital delay, the benefits of taking NSW ambulance are immense. Marital status was also a significant variable contributing to the prehospital delay. Patients with a marital status of divorced, never married or separated were significantly at a higher risk of prehospital delay. Patients presenting at night-time were at significantly increased risk of prehospital delay. Severity of stroke symptoms at baseline also impacted prehospital delay. Patients with mild stroke (defined by SSS score between 43 and 58) are at an increased risk of prehospital delay.

Previous studies on temporal trends in public awareness of stroke have indicated elevated stroke risks factors and significant lack of awareness of reperfusion treatment (intravenous thrombolysis and endovascular thrombectomy (EVT)) options in minority patient populations, such as in Blacks compared with the Caucasian population.1 4–6 10 11 20–26 This has led to calls on urgent need for targeted campaigns focussing on awareness of stroke warning signs and risk factors and time-dependent benefits of reperfusion therapies in minority populations.5 11 Increased knowledge of acute stroke signs and risk factors, treatment options, pathways and benefits of early presentation may empower public in general, and minority/CALD population groups, in particular, to minimise prehospital delay and avail optimal benefits of reperfusion treatments.7 27 Such targeted strategies customised for specific CALD communities have a potential to reduce delay in presentation to ED and improve reperfusion therapy rates—thereby reducing overall long-term morbidity and mortality due to stroke in SWS or similar demographics.8 9 25

In light of these findings, we postulate that hospital presentation patterns can be useful in identifying specific communities or subpopulations who might be at an increased risk of prehospital delay and access to quality stroke care services. This may be useful in developing targeted community-based intervention programmes to improve awareness about time-critical (speed) stroke therapies and use of public ambulance (mode) to arrive at ED following an acute stroke event, among specific communities. Future education programmes in diverse populations, such as in SWS, with large CALD communities and potentially unique social and cultural barriers, should be designed with special focus on sensitising these specific communities on implications of delayed presentation to the hospital following a stroke.

Limitations of our study include the retrospective study design and standard constraints of using administrative data sets. However, given the large number of patients included in the study, it is more likely to reflect the case-mix of the general population.


Our findings suggest that stroke patients from specific communities and younger subgroups are at significantly increased risk of preup hospital delay to the ED. Community-specific and targeted public health and education campaigns on reducing prehospital delays and sensitivity to prehospital factors, such as using public ambulance facilities to arrive to the hospital, may reduce time to ED presentation in CALD populations. Potential impact of sociodemographic and prehospital factors on stroke awareness and prehospital delays in other populations warrant consideration. In light of these findings, we suggest a comprehensive reappraisal of stroke awareness and education programmes in SWS .

Main messages

  • Geographic location and demographic factors play an important role in access to health care and may be crucial in the success of acute stroke intervention.

  • Our study suggests that specific culturally and linguistically diverse (CALD) and younger subgroups of stroke patients may be at higher risk of worse outcomes due to delayed emergency department (ED) presentations.

  • Comprehensive reappraisal of educational programs for early stroke recognition, targeted at these subgroups of stroke patients, is required.

What is already known on the subject?

  • Geographic location and demographic factors play an important role in access to healthcare in general, and in access to emergency services in particular. These factors may be crucial in the success of acute stroke interventions.

Current research questions

  • Can public health & education campaigns or interventions improve time to ED presentation following an acute stroke event?

  • Should such programs be targeted at specific subgroups or communities relevant to the population?

  • Is there a need of comprehensive reappraisal of health policy based on variations in access to health care in acute settings?


We would like to acknowledge our administrative and nursing staff for their service and commitment to stroke.



  • Presented at Stroke 2018, the Stroke Society of Australasia (SSA) 28th Annual Scientific Meeting; 7-10 August, 2018; Sydney, Australia

  • Contributors SB contributed to the planning, ethics submission, data analysis and writing of the manuscript. SB wrote the first draft of the paper. PT contributed to the planning, data management, data analysis and revision of the manuscript. DC, AM and SH contributed to the planning and revision of the manuscript. PT, QC and NC contributed to the ethics submission and procurement/analysis of eMR data.

  • Funding Seed funding from the UNSW Medicine, Neuroscience, Mental Health and Addictions Theme and SPHERE Collaborative Research 2018 Round is acknowledged.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the South West Sydney Human Research Ethics Committee (LNR/18/LPOOL/94).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.