title: Factors associated with delayed evaluation of patients with potential stroke in US EDs.
abstract: BACKGROUND
  The American Heart Association/American Stroke Association guidelines recommend all patients presenting to emergency departments (EDs) with a potential stroke be seen within 10 minutes of arrival, although this may not be achieved in all patients. We sought to identify factors associated with delayed evaluation of ED patients with potential stroke.
  
  
  METHODS
  Using the National Hospital Ambulatory Medical Care Survey, we identified all patient ED visits from 2003 to 2010 and further identified those patients with strokes or stroke-like symptoms using International Classification of Disease, Ninth Revision codes. Visits were classified as those evaluated within 10 minutes of ED arrival or those where evaluation by the treating provider was 10 minutes or greater (delayed evaluation). We stratified visits, compared proportions, and calculated the unadjusted and adjusted odds ratios (ORs) in a multivariable model.
  
  
  RESULTS
  We identified 743 cases in the database representing an estimated 2.3 million ED visits for patients with strokes. Of these, 600000 were seen within 10 minutes and 1.7 million visits with delayed evaluation. Visits at nonmetropolitan statistical area hospitals were associated with decreased odds of delayed evaluation (OR, 0.41 [95% confidence interval, 0.26-0.64]; P < .001). Being triaged to a less urgent emergency severity index category was associated with increased odds of delayed evaluation (OR 3.08 (95% CI 1.94-4.89) p < 0.001). Other factors were not associated with delayed evaluation.
  
  
  CONCLUSIONS
  In this national sample of patients presenting with strokes to US EDs, patient visits to metropolitan statistical area hospitals and those triaged to less urgent categories were associated with delayed evaluation.
authors.affiliation: Department of Emergency Medicine, Allegheny Health Network, Erie, PA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Taylor
authors.affiliation: Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Ken
authors.initials: K
authors.lastname: Uchino
authors.affiliation: Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: M Shazam
authors.initials: MS
authors.lastname: Hussain
authors.affiliation: Department of Emergency Medicine, Allegheny Health Network, Erie, PA; Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA. Electronic address: jcarlson@svhs.org.
authors.forename: Jestin N
authors.initials: JN
authors.lastname: Carlson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017598:Efficiency, Organizational; D004636:Emergency Service, Hospital / Q000592:standards* / Q000706:statistics & numerical data*; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000175:diagnosis* / Q000453:epidemiology; D061665:Time-to-Treatment; D014218:Triage / Q000592:standards*; D014481:United States / Q000453:epidemiology