Timeliness and Effectiveness of Stroke Care in the Emergency Department

Abstract

Background: Acute stroke outcomes are critically dependent on time to diagnosis and treatment, with each minute of delay leading to irreversible neuronal loss. Despite international benchmarks emphasizing door-to-imaging ≤25 minutes and door-to-needle ≤60 minutes, delays remain widespread in low- and middle-income countries, including Pakistan. Objective: To assess the timeliness and effectiveness of acute stroke management in the Emergency Department of Lady Reading Hospital, Peshawar, focusing on prehospital and in-hospital time intervals and their association with early neurological outcomes. Methods: A prospective observational study was conducted from October 2024 to January 2025, enrolling 300 adults presenting within 24 hours of stroke onset. Time intervals—onset-to-door, door-to-imaging, and door-to-needle—were recorded. Effectiveness was evaluated by adherence to international targets and early neurological improvement (NIHSS reduction ≥4). Data were analyzed using SPSS 26, applying t-tests, χ² tests, and multivariate logistic regression. Results: The median onset-to-door time was 160 minutes, and mean door-to-imaging and door-to-needle times were 38 ± 18 and 62 ± 19 minutes, respectively. Only 52% achieved imaging ≤25 minutes, and 46.6% received thrombolysis within 60 minutes. Door-to-imaging ≤25 minutes (OR 2.83, 95% CI 1.43–5.61) and door-to-needle ≤60 minutes (OR 2.32, 95% CI 1.09–4.94) independently predicted early neurological improvement. Conclusion: Significant prehospital and imaging delays limited timely reperfusion despite efficient triage. Implementing structured stroke-fast-track pathways, EMS prenotification, and prioritized neuroimaging could substantially enhance both timeliness and early outcomes in tertiary emergency care in Pakistan.