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ANALYSIS OF THE TIME TO HOSPITAL ADMISSION FOR STROKE

PATIENT IN DR SARDJITO HOSPITAL FROM 2011-2013

A graduating paper
Submitted to the board of examiners as partial
fulfillment of the requirement of the sarjana Degree in
Faculty of Medicine, Universitas Gadjah Mada

By
MUHAMMAD NURAZAM BIN AZMAN
10/304645/KU/14064

INTERNATIONAL PROGRAMME
FACULTY OF MEDICINE
GADJAH MADA UNIVERSITY
YOGYAKARTA
2014
i

PREFACE
All praise be to Allah, The God Almighty for the
blessings of His guidance and direction that He showed
me throughout the completion of this research. I would
like to express my deepest gratitude to my material
advisor Dr. dr. Ismail Setyopranoto, Sp.S (K) for his
guidance and time he spent on me during this study. I
also would like to thank my methodology advisor dr. H.
Abdul
Ghofir,
Sp.S
(K)
for
spending
time
for
consultation during the course of study. Special thanks
to dr. Kusumo Dananjoyo, M.Sc.,Sp.S who agreed to be my
expert examiner for this study and contributing his
valuable opinion for a better improvement in this
study. All the valuable opinions given by this great
team of experts has contributed greatly to the
successful and completing of this study.
Thanks and grateful acknowledgement also goes to
all those who were involved in helping me finish this
study successfully, including the administrative staffs
of Faculty of Medicine, Universitas Gadjah Mada, fellow
group mates, family, friends, and to all whose thoughts
and prayers contributed to the successful of this
study. This paper presents the analysis of time to
hospital admission of stroke patients in RSUP Dr.
Sardjito form 2011-2013. This paper primarily addressed
to the health practitioners and the society to be more
alert about the importance of the Golden Hour of the
stroke management. This paper can also be used by those
who wish to use it as a base for future studies. Any
lack of information and inadequacies of this paper are
deeply regretted. May this paper be useful to the
responsible sectors for the improvement of patient care
and advancement of strokes preventions in the future.
Thank you.

iv

Table of Contents

page

Cover Page------------------------------------------i
Approval Page--------------------------------------ii
Authenticity Statement----------------------------iii
Preface--------------------------------------------iv
Table of Contents-----------------------------------v
List of Tables-------------------------------------vi
List of Figures------------------------------------vi
Appendices-----------------------------------------vi
Abstract------------------------------------------vii
Chapter I- Introduction
a) Background-------------------------------------1
b) Formulation of Problems------------------------3
c) Research Objectives ---------------------------3
d) Research Benefits -----------------------------3
e) Research Authenticity -------------------------4
Chapter II- Literature Review
a) Definition of Stroke---------------------------5
b) Type of Stroke---------------------------------5
c) Pathophysiology of Stroke----------------------6
d) Golden Hour of stroke treatment----------------7
page
e) Theoretical Framework--------------------------9
f) Conceptual Framework--------------------------10
Chapter III- Research Methodology
a) Research Design-------------------------------11
b) Research Population---------------------------11
c) Inclusion and Exclusion Criteria--------------11
d) Equipment-------------------------------------12
e) Research Step---------------------------------13
f) Variables and Operational Definition----------13
g) Result Analysis and Approval Study------------14
Chapter IV- Result and Discussion------------------15
- Limitation and Recommendation----------22
Chapter V- Conclusion and Suggestion---------------23
Chapter VI- References-----------------------------25
Appendices-----------------------------------------27

List of Tables

page

Result of Time to Hospital Admission,------- 15


percentage and mean of TTHA in 2011
until 2013

List of Figures

page

Theoretical Framework---------------------Conceptual Framework----------------------Comparison of time to hospital admission


of stroke patient between 2011-2013-------Comparison of time to hospital
admission of stroke patients
between<3 hours and >3 hours in 2011------Distribution of reason for late
admission for stroke patients in 2011------Comparison of time to hospital admission
of stroke patients between
<3 hours and >3 hours in 2012--------------Distribution of reason for late
admission for stroke patients in 2012------Comparison of time to hospital admission
of stroke patients between
<3 hours and >3 hours in 2013--------------Distribution of reason for late
admission for stroke patients in 2013------Comparison of percentage of
time to hospital admission
of stroke patients between 2011-2013-------Comparison of mean of time to
hospital admission of stroke
patients from 2011-2013--------------------Appendices

9
10
15

16
17

18
19

19
20

21

21

page

1.Researcher Curriculum Vitae------------------27

vi

THE ANALYSIS OF TIME TO HOSPITAL ADMISSION FOR STROKE PATIENT IN


RSUP Dr. SARDJITO IN 2011-2013
Muhammad Nurazam Bin Azman*
ABSTRACT
Background: Stroke is a cerebrovascular disease that occurs due to
the obstruction of oxygen supply to the brain, causing brain
tissue to die. This in turn resulted in various disabilities to
the patients such as paralysis and cognitive impairment and can
even lead to death. This high number of mortality and morbidity is
partly due to the delayed time to hospital admission after the
onset of stroke in this study, we hope to see the progress of time
to admission of strokes patients in Dr. Sardjito Hospital from the
year 2009-2013 in order to know if the time to admission has
improved for stroke patients over the years as this will greatly
affect the prognosis for the stroke patients. The data from this
study can be used by the hospitals and healthcare office to know
about the current rate of time of admission and for the
improvement of healthcare for stroke patients in the future.
Aim: To analyze the time to admission of stroke in Dr. Sardjito
Hospital from 2011-2013.
Methods:
This
is
a
non-experimental
research;
it
is
an
observational descriptive study using the retrospective method.
All the data from this study will be obtained from secondary data;
the medical record of the stroke patients who have been admitted
to stroke unit of RSUP Dr.Sardjito from 2011-2013.
Results: The percentage of time to admission for stroke patient in
2011 is 22.66%, for 2012 is 30.98% while in 2013 is 17.395. While
the mean for time to admission for 2011 is 23.93 hours, for 2012
is 23.07 hours and for 2013 is 25.79hours
Conclusion: The trend of percentage of time to admission of stroke
patient in less then 3 hours from 2011 to 2013 is fluctuating.
This might be due to the lack of knowledge of the patient and
their family and also the lack in sense of urgency to send the
patient for immediate medical treatment. The percentage of time to
admission in RSUP Dr. Sardjito is almost similar to other places
such as Japan and France but the mean of time to admission is
still falling behind other countries such as United State
Keywords: Time of admission for stroke patient, Golden Hour of
stroke treatment, Sardjito Hospital
*Student of Faculty of Medicine, Gadjah Mada University

vii

CHAPTER 1
INTRODUCTION
A.

Background
Stroke occur 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 classified into 2 major groups
that

are

stroke

ischemic

refers

vessel

to

and
the

ruptures.

hemorrhagic

condition

It

is

aneurysms and arteriovenous

stroke.

where

mostly

in

malformations.

Hemorrhagic

weakened
the

blood

form

of

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

condition

called

Transient

Ischemic

Attack(TIA)

which sometimes called mini-stroke that occurs when the


blood

flow

to

the

brain

is

blocked

for

short

time

usually under 5 minutes. However, it is still an emergency


condition

that

requires

emergency

care

and

may

be

warning sign for future stroke.


1

Stroke had become one of the major cause of death in


recent

years

as

about

6.2

million

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 contribute 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 function and also severe headache
with

no

known

cause

(CDC-DHDSP,

2008).

Some

of

the

complication of strokes are lasting brain damage, longterm disabilities or even death and this is worsen by
delayed hospital admission from the time of stroke onset.
Early
greatly

time

affect

of

admission

after

the

mortality

or

stroke

morbidity

event
of

can

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
2

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.

Problem Formulation

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) Are

there

any

changes

in

the

time

of

admission

of

stroke patient in Dr. Sardjito Hospital during 20112013?


C.

Research Objective
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 2009 to 2013.
D.

Research Benefits
This research can help us to know about the yearly

trend of time to admission and see whether 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
3

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.
E.

Research Authenticity
There are several studies that already conducted in

various countries to analyze the time to admission of


stroke

patients

in

their

respective

community.For

example, there is a study in Australia that involves 284


patients who are admitted to Royal Adelaide Hospital
Stroke Unit, South Australia between the year 2000 and
2002 (Broadley&Thompson, 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 et al., 2013).
In

this

study,

hope

to

analyze

the

time

to

admission of stroke patient in Dr. Sardjito Hospital


between

2009-2013

to

see

whether

there

are

any

improvement in the time to admission over the years.

CHAPTER II
LITERATURE REVIEW
A.

Definition of Stroke
Stroke

is

sudden

focal

neurologic

syndrome;

specifically the type caused by cerebrovascular disease


(Ropper et al., 2009).Brain disease that occurs secondary
to

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).
B.

Types of Stroke

a) Ischemic Stroke
Atherosclerotic

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.

atherosclerotic

lesion

cerebral

arteries.

arteries

coming

This
or

embolism

Embolism

from

the

is

of

other

due

to

at

the

the
more

main
distal

clot

in

the

cerebral

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
5

disease such as chronic hypertension (Truelsen et al.,


2006).
b)

Hemorrhagic Stroke
Hemorrhagic

intracerebral

stroke

occur

due

hemorrhage

which

lead

to
to

spontaneous
increase

of

intracranial pressure and diminished supply of blood to


the brain. There are several factors that can lead to
hemorrhagic
disease,

stroke

such

coagulation

as

arteriolar

hypertensive

vascular

malformation

disorder,

within the brain and malnutrition (Truelsen et al., 2006).


c)

Subarachnoid Hemorrhage
Subarachnoid hemorrhage occurs when there is 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
(Truelsen et al., 2006).
C.

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 (Hinkle et al., 2007).
6

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,

decrease

in

intracranial

thrombus
blood
system

is

developed.

flow
and

in
the

This

the

will

lead

extracranial

function

of

to
and

collateral

circulation is maintained.
Decrease perfusion and cell death will occur when
compensatory mechanism of collateral circulation is failed
and compromised the perfusion(Hinkle et al., 2007).A clot
travels from a distant source and embedded in cerebral
vessel may cause embolic stroke (Hinkle et al., 2007).
D.

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

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.
7

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

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.

E.

THEORETICAL FRAMEWORK

Ischemic

Subarachnoid
haemorrhagic

Haemorrhagic

Stroke

Roughened of endothelial

Forming of plague

Forming of thrombosis

Increase intracranial pressure


damages the brain tissue

Formation of blood clot in the brain

Intracerebral haemorrhage

Adherence of platelet

rupture of brain blood vessels

Activated of coagulation

Hypertension, coagulation
disorder, vascular malformation

Developing of thrombus

Figure 1: Theoretical framework

F.

Conceptual Framework

Time to admission for stroke patient in Dr. Sardjito


Hospital in 2009-2013

<3 hours

>3 hours

Analysis on the time


to admission

Figure 2: Conceptual framework

10

CHAPTER III
RESEARCH METHODOLOGY
A.

Research Design
The

research

retrospective

is

study.

performed

It

will

be

as

conducted

descriptive
at

RSUP

Dr.

Sardjito General Hospital Yogyakarta. The time range of


this study is from year 2013 to 2014.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

2011-2013

in

Dr.

Sardjito

Hospital

Yogyakarta.
The reason for late admission will also be recorded
to know if there is any correlation with the late time to
admission. The data will be used to analyze the trend of
time

to

admission

for

stroke

patient

in

Dr.

Sardjito

Hospital.
B.

Population and Subject


The target population for this research is stroke

patient, and the accessible population is stroke patients


who are treated in RSUP Dr. Sardjito General Hospital,
Yogyakarta and has the medical record data kept in the
system.
Subject inclusion criteria:
1)

Medical record which shows the first event of stroke

2)

Patients with transient ischemic attack (TIA)


11

3)

Patients with thrombotic and embolic

4)

Primary intracerebral hemorrhage of any cause

5)

Medical record date from January 2011 until December


2013.

Subject exclusion criteria:


1)

Children patients which is 16 years old and under

2)

Patients with subarachnoid hemorrhage

3)

Incomplete data on the medical record or the record is


not clear.

C.

Equipment
The

medical

data
record

for
of

this

study

stroke

will

patient

be
from

taken

from

medical

the

record

department in Dr. Sardjito Hospital Yogyakarta


D.

Research Material (Sample Size)

N= (Z)^2 (P)(lP)
D^2
Where,
N= minimal sample size
Z= 1.96 the Confidence Interval is 95%
P= proportion of cases in the population, which is 0.27
(Triono, 2007)
D= level of error tolerance (0.087)
With this formula applied to the study, the minimal sample
size is 100.04, rounded off to 100 samples. The sample
selection method will be random consecutive sampling.
12

E.

Research Step

1)

Consultation with research supervisor

2)

Research preparation

3)

Obtaining the ethical clearance and permission letter


for the research

4)

Data collection on patients medical record

5)

Data calculation and data analysis.

F.

Variables

Independent

variable:

Time

to

hospital

admission

for

stroke patient from 2011-2013


Dependent variable:

Patient with first event of stroke

from year 2011-2013


G.

Operational Definition

- Stroke:

WHO

clinical

defines

signs

of

stroke

focal

as

(or

rapidly

global)

developing

disturbance

of

cerebral function, with symptoms lasting 24 hours or


longer or leading to death, with no apparent cause other
than of vascular origin. So, this sample is the patient
who has been diagnosed with stroke in RSUP Dr. Sardjito.
Ischemic

and

hemorrhagic

stroke

patients

will

be

included.
- Age: the age of patient is ranging from 17 until 90
- First Stroke event: in this study, the data will be
taken only from patient with first event of stroke.

13

H.

Result Analysis
The time to hospital admission for the first stroke

event patient from RSUP Dr. Sardjito will be taken and


grouped into each consecutive from 2011 until 2013. This
data will be analyzed and assessed into each year and
compared to the other years using descriptive statistics
such as table and bar chart to describe the trend of the
time to hospital admission for stroke patient in RSUP Dr.
Sardjito.
I.

Approval Study
The study will be approved by Biomedical Research Ethics

Commissions of Faculty of Medicine of Gadjah Mada University


and permission letter from Director of Dr. Sardjito General
Hospital, Yogyakarta.

14

CHAPTER IV
RESULTS AND DISCUSSION
A.

Result and Discussion


The data that are taken in this research are stroke

patients

from

the

Neurology

Department

of

RSUP

Dr.

Sardjito that were first evaluated for the inclusion and


exclusion criteria in the 2011-2013. The data from medical
record that did not meet the criteria were dismissed and
the one that meet the criteria was taken. The data are
shown in the Table 1 below
Table 1.Result of Time to Hospital Admission, percentage
and mean of TTHA in 2011 until 2013

Year

Time to hospital
admission(TTHA)

total

Percentage of
TTHA <3hours

Mean
TTHA(hours)

<3hours

>3hours

2011

17

58

75

22.66%

23.93

2012

22

49

71

30.98%

23.02

2013

20

97

115

17.39%

25.79

Figure 3. Comparison of
stroke between 2011-2013

time

to

hospital

admission

of

15

In 2011, there are a total of 75 stroke patients that


meet the criteria and the data are recorded. Out of these
75 patients, only 17 (22.67%)were arrived and admitted to
the hospital within 3 hours after the onset of stroke
while the rest 58 (77.33%) were admitted after the 3 hours
window period

as shown in

Figure

4. The mean time to

hospital admission for this year is 23.93 hours with the


shortest time to admission is 1 hour and the longest time
to admission is 6 days.

Figure 4. Comparison of time to hospital admission


stroke patients between <3 hours and >3 hours in 2011
The

patient

who

arrive

late

at

the

hospital

of

were

asked patients who arrived at the hospital for more than 3


hours were asked about the reason for late admission and
recorded

into

categories

which

are;(1)due

to

16

transportation,

(2)waiting

for

family

members,(3)

long

distance from the hospital, (4)economic factors, (5)lack


of awareness and knowledge and (6)other factors.
In 2011, the majority of stroke patient who arrive
late at hospital or about 51.67% of them gave lack of
awareness and knowledge about the stroke sign and symptoms
as the main reason for late hospital admission. This is
followed by others factors at 21.67%, waiting for family
members

at

15%,

long

distance

from

hospital

at

5%,

transportation at 5% and economic factors at 1.67%. The


distribution of reason of delayed admission is shown in
Figure 5.

Figure 5.Distribution of reason for late admission for


stroke patients in 2011
In

2012,

the

number

of

stroke

patient

who

are

admitted to the RSUP Dr. Sardjito that meet the inclusion


and exclusion criteria is 71. Out of this 71 patients 22
of them (30.98%) are admitted to the hospital under 3

17

hours while 49 (69.02%) arrive after the 3 hours Golden


Period as shown in figure 6. The mean time to hospital
admission

for

the

year

2012

is

23.02

hours

with

the

shortest time to admission is 30 minutes and the longest


time to admission is 6 days.

Figure 6.Comparison of time to hospital admission of


stroke patients between <3 hours and >3 hours in 2012
In this year, the highest reason of delayed hospital
admission

is

still

due

to

the

lack

of

awareness

and

knowledge which stands at 51.85% followed by other factors


at

24.07%,

waiting

for

family

members

at

11.11%,

transportation at 9.26% and long distance from hospitals


and economic factors both at 1.85%.The distribution of
reason for late admission for stroke patients in 2012 is
shown in Figure 7.

18

Figure 7.Distribution of reason for late admission for


stroke patients in 2012
In 2013, there are 115 patient who meet the criteria
and

taken

as

sample.

Out

of

these

115

patients,

only

21(18.26%) of them arrived at the hospitals within the 3


hours period while the rest 94(81.74%) of them were only
admitted 3 hours after the onset of stroke as shown in
Figure 8. The mean of time to hospital admission for this
year is 25.79 hours with the shortest time to admission is
30 minutes and the longest time to admission is 5 days.

Figure 8. Comparison of time to hospital admission


stroke patients between <3 hours and >3 hours in 2013

of

19

For the reason of hospital admittance of more than 3


hours,

the

factors

of

lack

of

awareness

and

knowledge

still became the number one reason for delay in hospital


admittance with 52.11%, followed by waiting for family at
22.54%, other factors at 18.31%, transportation at 4.23%,
while long distance to hospitals at and economic factors
are

both

at

1.41%.The

distribution

of

reason

for

late

admission for stroke patients in 2012 is shown in Figure


9.

Figure 9.Distribution of reason for late admission for


stroke patients in 2013
Figure 10 shows the comparison of percentage of time
to hospital admission <3 hours between the year 2011-2013.
In 2011, the percentage of time to hospital admission <3
hours is 22.66%. This number increase in 2012 when 30.98%
of all patients were admitted to the hospital less than 3
hours. However, in 2013, there is a significant drop of

20

patient who

was

admitted in less than 3 hours to the

hospital which is only 17.39% of all the stroke cases.

Figure 10.Comparison of percentage of time to


admission of stroke patients between 2011-2013

hospital

Meanwhile, the mean time to hospital admission from


the year 2011 until 2013 follows the same progression as
the percentage of the time to admission where it started
at 23.93 hours in 2011 and improves to 23.02 hours in 2012
before

rising

significantly

to

25.79

hours

in

2013

as

shown in Figure 11 below.

Figure 11.Comparison of mean of time to hospital admission


of stroke patients from 2011-2013

21

B.

Limitation and Recommendation


This

study

(Neurology
findings

was

conducted

Department
cannot

be

RSUP

Dr.

generalized

at

only

one

Sardjito),
to

all

of

location
so

these

Yogyakarta

society. I hope that in the future this research will be


done in the population based.
The number of sample in the year 2011 and 2012 was
also less than the sample size needed due to the lack of
suitable

cases

after

going

through

the

inclusion

and

exclusion criteria process.


I hope that the length of study is extended not only
3 years from 2011-2013 but more than 5 years span if
possible.

22

CHAPTER V
CONCLUSION AND SUGGESTION
C.

Conclusion
As a conclusion, the data shows that trend of the

percentage
hospital

of

stroke

within

patient

hours

after

that
the

were
onset

admitted
of

stroke

to
is

irregular and fluctuate between 2011 to 2013. There are


several factors that may play a key role in determining
the

cause

of

the

fluctuation

such

as

the

level

of

awareness and knowledge of the stoke patient and their


family about the sign and symptoms of stroke and the sense
of urgency for the patient to seek medical treatment upon
the onset of stroke.
However, stroke patient who wait for their family
member before seeking medical treatment shows proportional
correlation
admission

with

the

percentage

fluctuating

where

it

is

trend
at

15%

of

time

to

in

2011

and

decrease at 11.11% in 2012 before soaring to 18.31% in


2013.
D.

Suggestions
This suggests that there is still a vast majority of

patient and their family that doesnt aware about the sign
and symptoms of stroke and the severity of this disease if
they

do

not

receive

the

medical

treatment

as

soon

as

possible. There is also lack of the sense of urgency as


23

the stroke patient still waits for their family members to


send them to the hospital rather than using the ambulance
service or other transportation.
We

also

found

out

that

the

percentage

of

stroke

patient who arrive at the hospital within the 3 hours


period after onset is more of less the same with other
developed and developing countries. However, the mean of
time to admission of stroke patient in RSUP Dr. Sardjito
is 23 hours to 26 hours. This suggests that there is still
a barrier between patients in urban and rural setting in
seeking treatment. These barriers might include the long
distance to the nearest hospitals, level of knowledge and
also economic factors.
Based

on

the

outcome

of

this

study,

it

can

be

concluded that the Healthcare Department in Yogyakarta and


Indonesia will need to step up the effort to spread the
awareness about the sign and symptoms of stroke and also
the benefits of admitting the stroke patient as soon as
possible to the hospital. Better emergency medical service
should also be provided so that the time from onset to
treatment can be reduced hence increasing the probability
of better outcome.

24

CHAPTER VI
References
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Admission for Acute Stroke: An Observational Study,
2003; 178 (7): 329-331.
Derex, L., Adeleine, P., Nighoghossian, N., Honnorat, J.,
and Trouillas, P., 2002. Factors Influencing Early
Admission in a French Stroke Unit.Stroke;33:153-15.
Foulkes, M.A., Wolf, P.A., Price, T.R., Mohr, J.P., and
Hier, D.B., 1988. The Stroke Data Bank: design,
methods,
and
baseline
characteristics.
Stroke,
19:547-554.
Hauser, S.L., and Josephson, S.A., 2010.Cerebrovascular
Disease, Harrisons Neurology in Clinical Medicine,
second edition, McGraw Hill, page 249.
Hinkle,
J.L.,
and
Guanci,
M.M.,
2007.
Acute
IschemicStroke Review, 2007; 39(5): 285-293, 310.
Kaneko, C., Goto, A., Watanabe, K., Yasumura, S.,
2011.Time
to
presenting
to
hospital
and
associatedfactors in stroke patients, a hospitalbased study in Japan.
McFadden, E., Luben, R., Wareham, N., Bingham,S., and
Khaw, K.T., 2009.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.
http://www.medscape.com/viewarticle/567653_2
National Institute of Health and Care Excellent (NICE),
2008. Stroke: Diagnosis and initial management of
acute stroke and transient ischemic attack (TIA).
http://publications.nice.org.uk/stroke-cg68/guidance
Ropper, A.H., and Samuels, M.A., 2009. Cerebrovascular
Disease, Adams and Victors Principle of Neurology,
ninth edition, McGraw Hill, page 746, 781-782.
Sacco, R.L., Kasner, S.E., Broderick, J.P., Caplan, L.R.,
Connors, J.J., Culebras, A., Mitchell, S.V.,Elkind,
M.G., et al., 2013.An Updated Definition of Stroke
for the 21st Century: A Statement for Healthcare
Professionals
From
the
American
Heart
Association/American
Stroke
Association.
Stroke;44:2064-2089.
Sapna,
E.,Sridharan,
J.P.,Krishnan,
U.,
Sukumaran,
P.N.,Sylaja,
S.,
Dinesh,
N.P.,Sarma,
S.,
and
Radhakrishnan, K., 2009. Incidence, Types, Risk
Factors, and Outcome of Stroke in a Developing
Country: The Trivandrum Stroke Registry,40:1212-1218.

25

Saver, J.L., Smith, E.E., Fonarow, G.C., Reeves, M.J.,


Zhao, X., Olson, M., and Schwamm, L.H., 2010.The
Golden Hour and Acute Brain Ischemia: Presenting
Features
and
Lytic
Therapy
in>30.000
Patients
Arriving Within 60 Minutes of Stroke Onset. Page
41:1431-1439.
Thomas, T., Begg, S., and Mathers, C., 2000.The global
burden of cerebrovascular disease.
Triono, S., 2007.Riset Kesehatan Dasar (RISKESDAS).
Vidale, S., Beghi, E., Gerardi, F., DePiazza, C., Proserp
io, S., Arnaboldi, M., Bezzi, G., Bono, G., Grampa,
G., Guidotti, M., Perrone, P., Porazzi, D., Zarcone
D., Zoli, A.,
and
Agostoni, E,
2013. Time
to
Hospital
Admission
and
Start
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Predictors of Delay, 70:349-355.
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Leading Cause of Death in The World 200-2011.
http://who.int/mediacentre/factsheets/fs310/en/index.
html

26

APPENDICES
CURICULUM VITAE

IDENTITY
Full Name

Muhammad Nurazam bin Azman

Nick Name

Azam

Address

No.35, Jl. Narodo, RT1/RW55/CC17, Condongcatur,


Depok, Sleman

Zip Code

55283

Phone Number

: 087839782845

Email

: azam_mna90@yahoo.com

Place of Birth

: Terengganu, Malaysia

Date of Birth

: 08 October 1990

Sex

: Male

Nationality

: Malaysia

Religion

: Islam

Hobby

: Reading and browsing internet

GPA

: 2.92

EDUCATION
1997-2002

Sekolah Kebangsaan Seri Budiman II

2003-2007

Sekolah Menengah Kebangsaan Sultan Sulaiman

2008-2010

Management Science University (A-level)

2010-now

Medical

Faculty

Mada University

International

Programme

of

Gadjah

Yogyakarta, Indonesia

27

ORGANIZATION EXPERIENCE
2007

President

of

Bahasa

Melayu

Society,

Sekolah

Menengah Kebangsaan Sultan Sulaiman


2011

Head of Islamic Bureau for Persatuan Kebangsaan


Pelajar Malaysia di Indonesia(PKPMI) Cawangan
Yogyakarta

2012

Head

of

Ukhuwah

Pelajar

Islam

Malaysia

Indonesia(Yogyakarta)

28