Visual stroke symptom triage tool to reduce delays due to limited English proficiency in Emergency department stroke activations

Abstract

Background Limited English proficiency (LEP) may contribute to delays in care and worse outcomes in patients hospitalized with stroke. Limited access to interpreter services leads to delays in triage, code activation, imaging evaluations, and treatment. At our Comprehensive Stroke Center, 20% of patients with stroke have a Chinese dialect as a primary language and LEP. We sought to assess differences in stroke activation process times and IV alteplase treatment (IVT) rates between English and LEP (Chinese dialect) patients before and after implementation of a visual stroke symptom (VSS) triage tool. Methods This was a retrospective cohort study of adult patients presenting to the ED with stroke activation at a tertiary care center in Boston, MA from 1/1/2019-8/31/2019. Data was collected from 1/1/2019-3/31/2019 and from 6/1/2019-8/30/2019. Patients were excluded if they had a language other than English or Chinese as a primary language, prehospital notification, or pre-hospital IVT. All LEP patients were triaged with assistance of the VSS triage tool starting with a training phase from 4/1/2019-5/30/2019. Outcomes included door-to-triage (DTT) time, door-to-stroke activation (DSA) time, door-to-CT (DCT) time, door-to-needle (DTN) time, and proportion treated with IVT. Comparisons were made between the pre-intervention and post-intervention phases with the Wilcoxon rank sum test. A sensitivity analysis included only LEP patients. Results 131 patients were included (language: 104 English, 27 Chinese). There were no differences in overall preintervention versus post-intervention median times for DTT (6 vs 5 min, p=0.41), DSA (22 vs 21 min, p=0.81), DCT (37.5 vs 34 min, p=0.55), or DTN (69 vs 57 min, p=0.84). There were no differences in the LEP-only sensitivity analysis for DSA (21 vs 23 min, p=0.96) or DCT (44 vs 39 min, p=0.55), but there were trends towards reduced times for DTT (6 vs 3.5 min, p=0.19) and DTN (99 vs 62 min, p=0.15). In the preintervention phase, 1/11 (9%) of LEP patients were treated with IV alteplase, whereas 4/16 (25%) were treated in the post-intervention phase. Conclusion A larger proportion of LEP patients were treated with IVT with the use of a VSS triage tool, and there were trends towards lower DTT and DTN times.