Abstract
Background: Acute stroke is a time-critical emergency where diagnosis and acute management are highly dependent upon the accuracy of the patient’s history. We hypothesised that the language barrier is associated with delayed onset time to thrombolysis and poor clinical outcomes. This study aims to evaluate the effect of language barriers on time to thrombolysis and clinical outcomes in acute ischemic stroke. Concerning the method, this is a retrospective study of all patients admitted to a metropolitan stroke unit (Melbourne, Victoria, Australia) with an acute ischemic stroke treated with tissue plasminogen activator between 1/2013 and 9/2017. Baseline characteristics, thrombolysis time intervals, length of stay, discharge destination, and in-hospital mortality were compared among patients with and without a language barrier using multivariate analysis after adjustment for age, sex, stroke severity, premorbid modified Rankin Scale (mRS), and Charlson Comorbidity Index (CCI). Language barriers were defined as a primary language other than English. A total of 374 patients were included. Our findings show that 76 patients (20.3%) had a language barrier. Mean age was five years older for patients with language barriers (76.7 vs. 71.8 years, p = 0.004). Less non-English speaking patients had premorbid mRS score of zero (p = 0.002), and more had premorbid mRS score of one or two (p = 0.04). There was no statistically significant difference between the two groups in terms of stroke severity on presentation (p = 0.06). The onset to needle time was significantly longer in patients with a language barrier (188 min vs. 173 min, p = 0.04). Onset to arrival and door to imaging times were reassuringly similar between the two groups. However, imaging to needle time was 9 min delayed in non-English speaking patients with a marginal p value (65 vs. 56 min, p = 0.06). Patients with language barriers stayed longer in the stroke unit (six vs. four days, p = 0.02) and had higher discharge rates than residential aged care facilities in those admitted from home (9.2% vs. 2.3%, p = 0.02). In-hospital mortality was not different between the two groups (p = 0.8). In conclusion, language barriers were associated with almost 14 min delay in thrombolysis. The delay was primarily attributable to imaging to needle time. Language barriers were also associated with poorer clinical outcomes.
Highlights
Stroke is a leading cause of death and a substantial disability globally [1]
This was a retrospective observational study of a cohort of patients admitted to a metropolitan stroke unit of Western Health, Melbourne, Victoria, Australia, with an acute ischemic stroke and treated with tissue plasminogen activator (tPA) between January 2013 and September 2017
We propose that shifting the main components of acute stroke assessment, including history taking and examination, together with obtaining consent for thrombolysis to the time interval, i.e., imaging to needle time, was the source of delay in this time interval and the onset to needle time in patients from culturally and linguistically diverse (CALD) backgrounds
Summary
Stroke is a leading cause of death and a substantial disability globally [1]. Approximately 80% of incident strokes are ischemic [2], where time-critical acute care is heavily dependent upon an accurate history and examination.Rising global migration has led to cultural and linguistic diversification of communities and introduced new challenges to the healthcare system in Australia along withother immigration nations. 2016 census in Australia showed that 26% of the population was born overseas, with a 1% increase from the last census in 2011, while more than one-fifth (21%) speak a language other than English at home [3]. This study aimed to determine the influence of language barriers on relevant thrombolysis timing intervals and clinical outcomes (mortality, discharge destination, and length of stay) within a consecutive series of stroke patients who received tissue plasminogen activator (tPA). This study aims to evaluate the effect of language barriers on time to thrombolysis and clinical outcomes in acute ischemic stroke. Concerning the method, this is a retrospective study of all patients admitted to a metropolitan stroke unit (Melbourne, Victoria, Australia) with an acute ischemic stroke treated with tissue plasminogen activator between 1/2013 and 9/2017. Our findings show that 76 patients (20.3%) had a language barrier
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