Skripsi Analysis Of The Time To Hospital Admission For Stroke Patient In Dr. Sardjito Hospital From 2011-2013

i

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

iv

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.

v

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

vi

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---------------------- 9

Conceptual Framework----------------------- 10

Comparison of time to hospital admission of stroke patient between 2011-2013-------- 15

Comparison of time to hospital admission of stroke patients

between3 hours in 2011------- 16

Distribution of reason for late admission for stroke patients in 2011------- 17

Comparison of time to hospital admission of stroke patients between

3 hours in 2012--------------- 18


Comparison of time to hospital admission of stroke patients between

3 hours in 2013--------------- 19


Comparison of percentage of time to hospital admission

of stroke patients between 2011-2013-------- 21

Comparison of mean of time to hospital admission of stroke

patients from 2011-2013--------------------- 21

Appendices page

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

vii

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

1

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 ischemic 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 occurs 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 requires emergency care and may be a

warning sign for future stroke.

2

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, 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 affect 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

3

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 2011-

2013?

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

4

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, I 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.

5

CHAPTER II

LITERATURE REVIEW

A. 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).

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. This is due to the main

atherosclerotic 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

6

disease such as chronic hypertension (Truelsen et al.,

2006).

b) Hemorrhagic Stroke

Hemorrhagic 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 (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).

7

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 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 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.

8

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.

9

E. THEORETICAL FRAMEWORK

Figure 1: Theoretical framework

Haemorrhagic Ischemic Subarachnoid

haemorrhagic

Stroke

Roughened of endothelial

Forming of plague

Forming of thrombosis

Adherence of platelet

Activated of coagulation

Developing of thrombus

Hypertension, coagulation

disorder, vascular malformation

rupture of brain blood vessels

Intracerebral haemorrhage

Formation of blood clot in the brain

Increase intracranial pressure

damages the brain tissue

10

F. Conceptual Framework

Figure 2: Conceptual framework

Time to admission for stroke patient in Dr. Sardjito

Hospital in 2009-2013

3 hours

11

CHAPTER III

RESEARCH METHODOLOGY

A. Research Design

The research is performed as a descriptive

retrospective study. It will be conducted 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)

12

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 data for this study will be taken from the

medical record of stroke patient from medical 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.

13

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 defines stroke as a rapidly developing

clinical signs of focal (or global) 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.

14

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.

15

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

16

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 of

stroke patients between 3 hours in 2011

The patient who arrive late at the hospital were

asked patients who arrived at the hospital for more than 3

hours were asked about the reason for late admission and

recorded into 5 categories which are;(1)due to

17

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

18

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


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.

19



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 of


20

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 10 shows the comparison of percentage of time

to hospital admission

21

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 hospital

admission of stroke patients between 2011-2013

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

22

B. Limitation and Recommendation

This study was conducted at only one location

(Neurology Department RSUP Dr. Sardjito), so these

findings cannot be generalized to all of 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.

23

CHAPTER V

CONCLUSION AND SUGGESTION

C. Conclusion

As a conclusion, the data shows that trend of the

percentage of stroke patient that were admitted to

hospital within 3 hours after the onset of stroke 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 with the fluctuating trend of time to

admission percentage where it is at 15% 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

24

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.

25

CHAPTER VI

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27

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 : [email protected]

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 International Programme of Gadjah

Mada University Yogyakarta, Indonesia

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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)

COVER PAGEAPPROVAL PAGEAUTHENTICITY STATEMENTPREFACETABLE OF CONTENTLIST OF TABLELIST OF FIGURESAPPENDICESABSTRACTCHAPTER 1 INTRODUCTIONA. BackgroundB. Problem FormulationC. Research ObjectiveD. Research BenefitsE. Research Authenticity

CHAPTER II LITERATURE REVIEWA. Definition of StrokeB. Types of StrokeC. Pathophysiology of StrokeD. Golden Hour of Stroke TreatmentE. THEORETICAL FRAMEWORKF. Conceptual Framework

CHAPTER III RESEARCH METHODOLOGYA. Research DesignB. Population and SubjectC. EquipmentD. Research Material (Sample Size)E. Research StepF. VariablesG. Operational DefinitionH. Result AnalysisI. Approval Study

CHAPTER IV RESULTS AND DISCUSSIONA. Result and DiscussionB. Limitation and Recommendation

CHAPTER V CONCLUSION AND SUGGESTIONC. ConclusionD. Suggestions

CHAPTER VI REFERENCESAPPENDICES

Skripsi Analysis Of The Time To Hospital Admission For Stroke Patient In Dr. Sardjito Hospital From 2011-2013

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