ANALYSIS OF THE TIME TO ADMISSION TO HOSPITAL FOR STROKE PATIENT IN DR SARDJITO HOSPITAL FROM 2009-2013

THESIS PROPOSAL

“This thesis is presented as partial requirements for the attainment of Bachelor of

Medicine Degree in Gadjah Mada University, Yogyakarta, Indonesia”

MUHAMMAD NURAZAM BIN AZMAN10/304645/KU/14064

FACULTY OF MEDICINE GADJAH MADA UNIVERSITY

YOGYAKARTA

2013

RESEARCH PROPOSAL

ANALYSIS OF THE TIME BETWEEN ONSET OF STROKE AND ADMITTANCE TO HOSPITAL FOR STROKE PATIENT IN DR SARDJITO HOSPITAL

FROM 2009-2013

Submitted by

MUHAMMAD NURAZAM BIN AZMAN10/304645/KU/14064

Approved by

Material advisor Date:

Dr. Ismail Setyopranoto, Sp.S(K) NIP: 196305061989031 002

Methodology advisor Date:

dr. H. Abdul Gofir, Sp.S(K)NIP: 196505061996031 002

Chapter I. INTRODUCTION

a. Background:

Stroke occurs when the blood supply to the

brain is blocked or when a blood vessel in the

brain ruptures, causing brain tissue to die. It is

defined as a sudden, non convulsive loss of

neurological function due to an ischemic or

hemorrhagic intracranial vascular event(Adams et

al., 2003). It can be classifie into 2 major

groups that are ishcemic and hemorrhagic stroke.

Hemorrhagic stroke refers to the condition where

a weakened blood vessel ruptures. It is mostly in

the form of aneurysms and arteriovenous

malformations. However, the most common cause of

hemorrhagic stroke is uncontrolled hypertension.

Ischemic stroke on the other hand occurs as a

result of an obstruction of a blood vessel

supplying blood to the brain causing tissue

hypoxia and later ischemic. It is a biggest type

of stroke as it accounts for 87 percent of all

stroke cases. Meanwhile, there is also a condition

called Transient Ischemic Attack(TIA) which

sometimes called mini-stroke that occur when the

blood flow to the brain is blocked for a short

time usually under 5 minutes. However, it is still

an emergency condition that require emergency care

and may be a warning sign for future stroke.

Stroke had became one of the major cause of

death in recent years as about 6.2 millions or

around 10.6% of deaths worldwide in 2011 are

caused by this disease and this trend continue to

increase as compared to the previous decade. In

Indonesia alone, stroke has become the leading

cause of death among adult contributing up to

15.4% of all deaths among Indonesians over five,

followed by Tuberculosis at 7.5% (IRIN, 2009)

Symptoms of strokes arise due to the

obstruction or rupture of blood supply to the

brain. It include sudden numbness or weakness

of the arms, face or legs, sudden confusion or

trouble speaking or understanding others,

sudden trouble for seeing in one or both eyes,

impairment of motoric and sensoric fuction and

also severe headache with no known cause (CDC-

DHDSP, 2008). Some of the complication of

strokes are lasting brain damage, long-term

disabilities or even death and this is worsen

by delayed hospital admission from the time of

stroke onset. Early time of admission after

stroke event can greatly effect the mortality

or morbidity of stroke patient. A study by the

American Heart Association suggest that stroke

patient who are sent to the hospitals within 90

minutes after the onset and receive

thrombolytic medication stand a greater chance

of surviving with little or no disabilities

within three months as compared to the patient

with longer time to admission. Meanwhile, a

study by European Stroke Organization also

recommend that patient who arrive at hospital

within the golden hour of 3-4.5 hours of onset

could be given recombinant tissue plasminogen

activator alteplase which are shown to reduce

the incidence of stroke-related disability.

b. Formulation of the Problems:

The problems that can arise are:

1. What is the time to admission for stroke patient

in Dr. Sardjito Hospital?

2. What is the appropriate time of admission that

should be used as the Golden Standard for stroke

patient?

3. Is there any changes in the time of admission of

stroke patient in Dr. Sardjto Hospotals during the

year 2009-2013?

c. Research authenticity:

There are several studies that already

conducted in variuos countries to analyzed the

time to admisson of stroke patients in their

respective community.

For example, there is a study in Australia

that involve 284 patients who are admitted to

Royal Adelaide Hospital Stroke Unit, South

Australia between the year 2000 and 2002

(Broadley SA, Thompson PD, 2003)

There is also a study about the time to

hospital admission and start of treatment in

patients with ischemic stroke in northern Italy

which also study about the prediction of delay(

Vidale. S et al, 2013)

In this study, I hope to analyze the time

to admission of stroke patient in Dr. Sardjito

Hosptal between the year 2009-2013 to see

whether there are any improvement in the time

to admission over the years.

d. Objective of the Study:

The main objective of this study is to evaluate

the time to admission of stroke patient in Dr.

Sardjito Hospital and to see is there any

improvement in the yearly trend of time to

admission from year 2009 to 2013

e. Research benefits:

This research can help us to know about the yearly

trend of time to admission and see wheather there

is any improvement of time of admission for stroke

patient in Dr. Sardjito. This information could

help the Healthcare Office, Dr. Sardjito Hospital

management and the doctors to formulate the

appropriate guideline and procedure in managing

stroke patient. This research is also important

for the Healthcare Office in educating the public

on the importance of getting the stroke patient to

the hospital as soon as possible.

f. Ethical clearance:

This study will be conducted with the ethical

clearance letter approved by Komisi Etik Penelitian

Kedokteran dan Kesehatan Fakultas Kedokteran,

Universitas Gadjah Mada.

Chapter II.LITERATURE REVIEW

a. Literature review:

a.i.Definition of stroke

Stroke is a sudden focal neurologic syndrome,

specifically the type caused by cerebrovascular

disease (Ropper et. al, 2009).

Brain disease that occurs secondary to a

pathological disorder of blood vessels (usually

arteries) or blood supply is defined as

cerebrovascular disease. It is due to occlusion by

rupture or disease of vessel wall, thrombus or

embolus, and disturbance of normal properties of

blood. There are two types of stroke which are

hemorrhagic stroke and ischemic stroke. (Linslay et.

al, 2002).

a.ii. Types of stroke

a) Ischemic stroke (infarction)

Artherosclerotic obstructions of big cervical

and cerebral arteries, with ischemia in all parts or

part of the territory of the occluded artery lead to

thrombotic cerebral infarction. This is due to the

main artherosclerotic lesion or embolism at the more

distal cerebral arteries. Embolism of a clot in the

cerebral arteries coming from the other parts of the

arterial system can cause embolic cerebral infection.

Small deep infarcts in the small penetrating artery

explained the lacunar cerebral infarction. Usually it

is caused by local disease such as chronic

hypertension (Thomas Truelsen et. al, 2006).

b) Hemorrhagic stroke

Hemorraghic stroke occur due to spontaneous

intracerebral hemorrhage which lead to increase of

intracranial pressure and diminished supply of blood

to the brain. There are several factors that can lead

to hemorrhagic stroke such as arteriolar hypertensive

disease, coagulation disorder, vascular malformation

within the brain and malnutrition (Thomas Truelsen

et. al, 2006).

c) Subarachnoid hemorrhage

Subarachnoid hemorrhage occur when there are

rupture of aneurysms at the bifurcations of large

arteries at the inferior surface of brain. Some

studies just exclude this type of stroke because it

is not often to cause direct damage to the brain.

However, symptoms in accordance to stroke definition

maybe developed in person with this type of stroke

and make it should be counted as stroke too (Thomas

Truelsen et. al, 2006).

a.i v . Pathophysiology of stroke

In ischemic stroke, the blood supply to the brain

is disturbed causing the decreasing supply of oxygen

and glucose supply to the brain. Small or large

artery (45%) embolic in origin (20%) and others

unknown causes are the causes of ischemic stroke

(Janice L. Hinkle et. al, 2007).

When intima is roughened and plague forms along

the injury vessel, thrombosis in extracranial and

intracranial can be formed. Platelet will adhere and

aggregate at the injured endothelial, activates the

coagulation at the site of plague, thrombus is

developed. This will lead to decrease in blood flow

in the extracranial and intracranial system and the

function of collateral circulation is maintained.

Decrease perfusion and cell death will occurred when

compensatory mechanism of collateral circulation is

failed and compromised the perfusion(Janice L. Hinkle

et. al, 2007).

A clot travels from a distant source and embedded

in cerebral vessel may cause embolic stroke (Janice

L. Hinkle et. al, 2007).

a.i v . Golden Hour of stroke treatment

Stroke patients who arrive at the hospitals within

a short period of time after the onset of stroke and

receive IV thrombolytic therapy show better prognosis

as compare to those who have longer time to admission

to hospital. However, there is a certain time window

where administration of IV thrombolytic therapy could

provide affective result to the patient. A study by the

NINCDS has provide the evidence of IV rtPA benefits

when given within 3 hours of the symptoms onset of

which the result shows an increase of 30% in the number

of patients who show little or no neurologic deficit

when re-examined after 3 months.

This 3 hours time window or also called the “Golden

Hours” for stroke treatment is also used by the United

States, Canada and Europe as a benchmark for the

administration of IV rtPA for stroke patients where the

onset of stroke is defined as the time when the stroke

began of the last time where the patient was seen

normal.

b.theoritical framework

hemorrhagicischemicsubarachnoid

hemorrhagic

stroke

roughened of

endothelial

forming of plague

forming of

thrombosis

adherence of

platelet

activated of

coagulation

developing of

thrombus

hypertension, coagulation

disorder, vascular malformation

bursting of brain blood vessels

intracerebral hemorrhage

Formation of blood clot in the brain

Increase intracranial

pressure damages the brain tissue

C.Conceptual framework:

Time to admission for stroke patient in Dr. Sardjito Hospital in 2009-2013

< 3 hours

Analysis on the time to admission

< 90 minutes > 3 hours

Chapter III. Methodology

a.Research design:

This research will use the observational

descriptive study design. The data is collected from

the secondary data which is the medical record of the

patient who have ischemic or hemorrhagic stroke for

the first time in 2009-2013 in Dr Sardjito Hospital

in Yogyakarta. The data will be used to analyze the

trend of time to admission for stroke patient in Dr.

Sardjito Hospital.

b.Sample size:

The sample size include all patients who

experienced the first event of stroke from January 2009

until December 2013 in Dr. Sardjito Hospital.

c.Subject:

The data collection will take place in Dr.

Sardjito Hospitals in Yogyakarta from January 2009 to

December 2013. The subject will be the medical record

of patient who suffered stroke from January 2009 to

December 2013.

The inclusion criteria of this research are (1)

medical record which shows the first event of stroke

(2) patients with transient ischemic attack (TIA) (3)

patients with thrombotic and embolic (4) primary

intracerebral hemorrhage of any cause (5) medical

record date from January 2009 until December 2013.

The exclusion criteria of this research are (1)

children patients which is 16 years old and under (2)

patients with subarachnoid hemorrhage.

d.Tool and material:

The data for this study will be taken from the

medical record from neurology department in a Dr.

Sardjito Hospitals in Yogyakarta.

e.Data Collection Method:

The data will be obtained from medical record of

patients with first event of stroke. The information

on the onset and time to admission of stroke patient

will be recorded.

f.Research framework:

Data collection

Identify medical record of patients with first event of

stroke from January 2009 to December 2013

Fits research criteria

Data input

Data analyse

g.Variable:

Independent variable: time to admission for stroke

patient from 2009-2013.

Dependent variable : patient with first event of

stroke

h.Operational definition:

Age : the age of the patient is ranging from

16 until 90

Type of stroke: type of stroke that will be

analyzed are ischemic stroke and hemorrhagic

stroke.

Subarachnoid is not included because it falls

under the population that is not covered in

the guideline by National Institute of Health

and Care Excellent (NICE) (National Institute

of Health and Care Excellent,2013).

i.Result analysis:

The collected data will be put in the table by

using the Microsoft excel. The transferred data is

then will be analyzed.

Table 1 : Data of the time to admission of stroke

patient in Dr. Sardjito Hospital

variab

les

Time to admission Percentage Mean

< 3 hours > 3 hours

2009

2010

2011

2012

2013

Chapter IV. Reference

1. Allan H. Ropper, Martin A. Samuels, 2009, Cerebrovascular Disease, Adams and Victor’s Principle of Neurology, ninth edition, Mc Graw Hill, page 746, 781-782

2. Stephen L. Hauser, Scott A. Josephson, 2010, Cerebrovascular Disease, Harrison’s Neurology In Clinical Medicine, second edition, McGraw Hill, page 249

3. Emily McFadden, Robert Luben, Nicholas Wareham, Sheila Bingham and Kay-Tee Khaw, Social Class, Risk Factors, and Stroke Incidence in Men and Women: A Prospective Study in the European Prospective Investigation Into Cancer in Norfolk Cohort, 2009;40:1070-107

4. Broadley SA and Thompson PD., Time To Hospital Admission For Acute Stroke: An Observational Study, 2003; 178 (7): 329-331

5. Jeffrey L. Saver, Eric E. Smith, Gregg C. Fonarow, Mathew J. Reeves, Xin Zhao, DaiWai M. Olson and Lee H. Schwamm, The ''Golden Hour'' and Acute Brain Ischemia: Presenting Features and Lytic Therapy in>30 000 Patients Arriving Within 60 Minutes of Stroke Onset,2010;41:1431-1439

6. Vidale S. Beghi E. Gerardi F. DePiazza C. Proserpio S. Arnaboldi M. Bezzi G. Bono G. Grampa G. Guidotti M. Perrone P. Porazzi D. Zarcone D. Zoli A. Agostoni E, Time to Hospital Admission and Start of Treatment in Patients with Ischemic Stroke in Northern Italy and Predictors of Delay, 2013;70:349-355

7. Sapna E. Sridharan, J.P. Unnikrishnan, Sajith Sukumaran, P.N. Sylaja, S. Dinesh Nayak, P. Sankara Sarma and Kurupath Radhakrishnan, Incidence, Types, Risk Factors, and Outcome of Stroke in a Developing Country: The Trivandrum Stroke Registry, 2009;40:1212-1218

8. Janice L. Hinkle, PhD RN CNRN, Mary McKenna Guanci, MS RN CNRN,Acute Ischemic Stroke Review, 2007;39(5):285-293, 310. 

http://www.medscape.com/viewarticle/567653_2

9. National Institute of Health and Care Excellent (NICE), Stroke: Diagnosis and initial management of acute stroke and transient ischemic attack (TIA), July 2008,http://publications.nice.org.uk/stroke-cg68/guidance

10. World Health Organization(WHO), Fact Sheets: Top 10 Leading Cause Of Death In The World 200-2011, July 2013,http://who.int/mediacentre/factsheets/fs310/en/index.html

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