What Factors Drive Pre-hospital Delay?

This article was contributed by Philip Beckley, PhD, Atrial Fibrillation Clinical Specialist, Society of Chest Pain Centers

The following are findings from the review of 13 journal articles, published between 1995 and 2010, that reported the factors that are associated with a patient's decision to delay seeking care for chest pain (either calling 911 or self-transport). Collectively, the median delay time from symptom onset to hospital arrival in these studies ranged from 1.5 to 6.0 hours with overall time ranges between 6 minutes and 48 hours.

Findings:

• Patients who had longer delay times tended to be female, older, from an ethnic minority background, and from a lower socioeconomic status and educational level.
• Patients delayed if they felt their symptoms were mild or moderate in intensity, were considered non-severe, appeared gradually or evolved over time, or varied from what they understood typical symptoms to be. Patients waited longer if they didn't feel vulnerable to their symptoms. They also waited longer if they didn't feel their symptoms were heart related. Interestingly, patients who did not sweat with their symptoms waited longer than those who did.
• Conversely, when symptoms were severe, were perceived as being serious, were accompanied with hemodynamic instability, or were immediately attributed to a cardiac event, the time delay was shorter.
• Oddly, patients who had a history of smoking, hyperlipidemia, angina, prior MI, hypertension, diabetes, and heart failure tended to wait longer than those without those experiences.
• Patients who considered their symptoms a new experience tended to have shorter delay times.
• Patients who consulted with family members or healthcare providers had longer delay times. Spouses often recommended strategies that increased delay. In some studies, consultation with a primary care physician accounted for more time delay than individual patient factors. Patients apparently feel that calling their doctor, not 911, is the right thing to do.
• Patients who consulted with co-workers or companions who were not relatives tended to have shorter delay times.
• If patients were at home, alone, resting, or asleep when symptoms first appeared they tended to wait longer.
• If symptoms appeared while engaged in physical activity, the delay was shorter.
• Delays were associated with the fear of inconveniencing or troubling others, appearing foolish or being embarrassed, abusing hospital resources, or the consequences of seeking help when it is not really needed.
• If the patient engaged in control behaviors such as taking medication, resting, trying to relax, praying, or wishing symptoms would go away, the delay was longer.

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