To characterize delays in evaluation and inter-facility transfer among patients presenting with suspected acute stroke at first-level hospitals in Lusaka, Zambia.

Stroke is a leading cause of death among adults in Zambia. Even when patients arrive within clinically meaningful time windows, in-hospital delays in care can eliminate eligibility for time-sensitive interventions and contribute to complications and mortality. Understanding diagnostic and transfer pathways at first-level facilities is essential to strengthening regional stroke systems of care.

We conducted structured observations of consecutive patients presenting with stroke-like symptoms at four first-level hospitals in Lusaka (July to November 2025). Observers followed patients from arrival through triage, initial stroke evaluation (defined as the first clinical assessment with documented neurologic exam or explicit stroke consideration), early management steps, consultation with higher-level care, and disposition decision (admission, transfer, discharge, or death). Descriptive statistics are reported.

A total of 52 patients with suspected stroke were observed. Twenty (38%) arrived within 4.5 hours of last known well, including 16 (31%) within 3 hours. Transport to first-level hospitals occurred primarily via private vehicle (n=23) or taxi (n=18); ambulance transport was uncommon (n=3). Clinical stroke evaluation was frequently delayed or absent: 4% (2/52) had no documented stroke evaluation during observation; among those evaluated (50/52), 40% (20/50) were evaluated >30 minutes after arrival, and 20% (10/50) were evaluated >5 hours after arrival. None of the first-level facilities had computed tomography capability; no patients underwent head CT before disposition decisions were made. Twelve patients (23%) were transferred to a higher-level facility, all by ambulance, and transfers were also frequently delayed. Among transferred patients, the decision-to-departure time (from decision to transfer to ambulance departure) had a mean of 5 hours 19 minutes and median of 4 hours 45 minutes.

A substantial fraction of suspected stroke patients presenting to first-level hospitals in Lusaka arrive within potential treatment windows. However, delays in early clinical evaluation and inter-facility transfer may prevent timely access to definitive stroke care. These findings highlight actionable targets for stroke pathway redesign, triage standardization, and strengthened inter-facility transfer coordination. Interventions targeted at these bottlenecks, such as rapid tele-neurology-supported stroke triage and expedited transfer protocols, warrant evaluation in this setting. Mobile stroke unit strategies may be considered where feasible.