Impact of COVID-19 on Stroke Caseload in a Major Hyperacute Stroke Unit

The impact of the COVID-19 pandemic on delayed care of cardiovascular diseases in Europe: a systematic review

AIMS

Cardiovascular diseases (CVD) are the leading cause of death worldwide. The coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare systems, causing delays in essential medical services, and potentially impacting CVD treatment. This study aims to estimate the impact of the pandemic on delayed CVD care in Europe by providing a systematic overview of the available evidence.

METHODS AND RESULTS

PubMed, Embase, and Web of Science were searched until mid-September 2022 for studies focused on the impact of delayed CVD care due to the pandemic in Europe among adult patients. Outcomes were changes in hospital admissions, mortality rates, delays in seeking medical help after symptom onset, delays in treatment initiation, and change in the number of treatment procedures. We included 132 studies, of which all were observational retrospective. Results were presented in five disease groups: ischaemic heart diseases (IHD), cerebrovascular accidents (CVA), cardiac arrests (CA), heart failures (HF), and others, including broader CVD groups. There were significant decreases in hospital admissions for IHD, CVA, HF and urgent and elective cardiac procedures, and significant increases for CA. Mortality rates were higher for IHD and CVA.

CONCLUSION

The pandemic led to reduced acute CVD hospital admissions and increased mortality rates. Delays in seeking medical help were observed, while urgent and elective cardiac procedures decreased. Adequate resource allocation, clear guidelines on how to handle care during health crises, reduced delays, and healthy lifestyle promotion should be implemented. The long-term impact of pandemics on delayed CVD care, and the health-economic impact of COVID-19 should be further evaluated.

Association of the COVID-19 pandemic on stroke admissions and treatment globally: a systematic review

OBJECTIVES

The COVID-19 pandemic has highlighted insufficiencies and gaps within healthcare systems globally. In most countries, including high-income countries, healthcare facilities were over-run and occupied with too few resources beyond capacity. We carried out a systematic review with a primary aim to identify the influence of the COVID-19 pandemic on the presentation and treatment of stroke globally in populations≥65 years of age.

DESIGN

A systematic review was completed. In total, 38 papers were included following full-text screening.

DATA SOURCES

PubMed, MEDLINE and Embase.

ELIGIBILITY CRITERIA

Eligible studies included observational and real-world evidence publications with a population who have experienced stroke treatment during the COVID-19 pandemic. Exclusion criteria included studies comparing the effect of the COVID-19 infection on stroke treatment and outcomes.

DATA EXTRACTION AND SYNTHESIS

Primary outcome measures extracted were the number of admissions, treatment times and patient outcome. Secondary outcomes were severity on admission, population risk factors and destination on discharge. No meta-analysis was performed.

RESULTS

This review demonstrated that 84% of studies reported decreased admissions rates during the COVID-19 pandemic. However, among those admitted, on average, had higher severity of stroke. Additionally, in-hospital stroke treatment pathways were affected by the implementation of COVID-19 protocols, which resulted in increased treatment times in 60% of studies and increased in-hospital mortality in 82% of studies by 100% on average. The prevalence of stroke subtype (ischaemic or haemorrhagic) and primary treatment methods (thrombectomy or thrombolysis) did not vary due to the COVID-19 pandemic.

CONCLUSIONS

During the COVID-19 pandemic, many populations hesitated to seek medical attention, decreasing hospital admissions for less severe strokes and increasing hospitalisation of more severe cases and mortality. The effect of the pandemic on society and healthcare systems needs to be addressed to improve stroke treatment pathways and prepare for potential future epidemics.

PROSPERO REGISTRATION NUMBER

CRD42021248564.

Effects of the COVID-19 pandemic on stroke response times: a systematic review and meta-analysis

OBJECTIVES

COVID-19 presents a risk for delays to stroke treatment. We examined how COVID-19 affected stroke response times.

METHODS

A literature search was conducted to identify articles covering stroke during COVID-19 that included time metrics data pre- and post-pandemic. For each outcome, pooled relative change from baseline and 95% CI were calculated using random-effects models. Heterogeneity was explored through subgroup analyses comparing comprehensive stroke centers (CSCs) to non-CSCs.

RESULTS

38 included studies reported on 6109 patients during COVID-19 and 14 637 patients during the pre-COVID period. Pooled increases of 20.9% (95% CI 5.8% to 36.1%) in last-known-well (LKW) to arrival times, 1.2% (-2.9% to 5.3%) in door-to-imaging (DTI), 0.8% (-2.9% to 4.5%) in door-to-needle (DTN), 2.8% (-5.0% to 10.6%) in door-to-groin (DTG), and 19.7% (11.1% to 28.2%) in door-to-reperfusion (DTR) times were observed during COVID-19. At CSCs, LKW increased by 24.0% (-0.3% to 48.2%), DTI increased by 1.6% (-3.0% to 6.1%), DTN increased by 3.6% (1.2% to 6.0%), DTG increased by 4.6% (-5.9% to 15.1%), and DTR increased by 21.2% (12.3% to 30.1%). At non-CSCs, LKW increased by 12.4% (-1.0% to 25.7%), DTI increased by 0.2% (-2.0% to 2.4%), DTN decreased by -4.6% (-11.9% to 2.7%), DTG decreased by -0.6% (-8.3% to 7.1%), and DTR increased by 0.5% (-31.0% to 32.0%). The increases during COVID-19 in LKW (p=0.01) and DTR (p=0.00) were statistically significant, as was the difference in DTN delays between CSCs and non-CSCs (p=0.04).

CONCLUSIONS

Factors during COVID-19 resulted in significantly delayed LKW and DTR, and mild delays in DTI, DTN, and DTG. CSCs experience more pronounced delays than non-CSCs.

Trends in Stroke Presentations before and during the COVID-19 Pandemic: A Meta-Analysis

Background and Purpose There are reports of decline in the rates of acute emergency presentations during coronavirus disease 2019 (COVID-19) pandemic including stroke. We performed a meta-analysis of the impact of COVID-19 pandemic on rates of stroke presentations and on rates of reperfusion therapy.Methods Following the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines, we systematically searched the literature for studies reporting changes in stroke presentations and treatment rates before and during the COVID-19 pandemic. Aggregated data were pooled using meta-analysis with random-effect models.Results We identified 37 observational studies (n=375,657). Pooled analysis showed decline in rates of all strokes (26.0%; 95% confidence interval [CI], 22.4 to 29.7) and its subtypes; ischemic (25.3%; 95% CI, 21.0 to 30.0), hemorrhagic (27.6%; 95% CI, 20.4 to 35.5), transient ischemic attacks (41.9%; 95% CI, 34.8 to 49.3), and stroke mimics (45.6%; 95% CI, 33.5 to 58.0) during months of pandemic compared with the pre-pandemic period. The decline was most evident for mild symptoms (40% mild vs. 25%–29% moderate/severe). Although rates of intravenous thrombolytic (IVT) and endovascular thrombectomy (EVT) decreased during pandemic, the likelihood of being treated with IVT and EVT did not differ between the two periods, both in primary and in comprehensive stroke centers (odds ratio [OR], 1.08; 95% CI, 0.94 to 1.24 and OR, 0.95; 95% CI, 0.83 to 1.09, respectively).Conclusions Rates of all strokes types decreased significantly during pandemic. It is of paramount importance that general population should be educated to seek medical care immediately for stroke-like symptoms during COVID-19 pandemic. Whether delay in initiation of secondary prevention would affect eventual stroke outcomes in the long run needs further study.

Quality of care indicator performance was minimally changed in 2020 despite the COVID-19 pandemic

BACKGROUND

In 2020, the COVID-19 pandemic affected healthcare systems throughout the world, including the management of patients and compliance rates of quality indicators.

OBJECTIVE

To measure the impact in Israel of the COVID-19 pandemic on the indicator-relevant caseload and compliance rates of the quality indicators reported by medical services providers within the Israeli National Program for Quality Indicators (NPQI).

METHODS

Data was collected from the reports made to the NPQI by participating hospitals and medical service providers. The indicator results for the number of cases and compliance rates for 2019 were compared to those from 2020. We assessed and compared the results of the quality indicators in general hospitals, geriatric hospitals and departments, psychiatric hospitals and departments, emergency medical services (EMS), and Mother and Baby health centers.

RESULTS

We found a decrease in measurable cases in 2020 relative to 2019, especially in geriatric hospitals. In most indicators, compliance rates rose in 2020. Few indicators had lower compliance rates associated with COVID-19 pandemic regulations.

CONCLUSIONS AND POLICY IMPLICATIONS

Routine medical activity decreased in Israel in 2020 in comparison to 2019, as reflected by a decrease in cases, but compliance rates were better in most indicators. The results of our study imply that the functioning of healthcare quality measurement programs should not be interrupted during a pandemic. This not only allows measuring of the healthcare system's performance during a crisis, but also may assist in maintaining a high level of healthcare quality.

The Impact of COVID-19 Pandemic During Lockdown on the Veterinary Profession in Romania: A Questionnaire-Based Survey

The lockdown period in Romania lasted for 60 days and had the purpose of limiting the spread of SARS-CoV-2 virus outbreak and manage its consequences through emergency measures on many important areas of activity. This study aimed to gather, assess, analyze and disseminate relevant social, economic, and medical aspects on the impact of COVID-19 pandemic during lockdown on the veterinary profession in Romania. A survey was created using an online questionnaire platform, and disseminated. The survey was completed by a total of 409 individuals. A high number of respondents (71.64%; n = 293) felt exposed to medium or high risk of infection with SARS-CoV-2 at their workplace and many (56.97%; n = 233) felt that their professional environment was more stressful than usual during lockdown. Almost all respondents (89.73%; n = 367) declared the implementation of several control measures recommended by FECAVA and FVE (e.g., social distancing, wearing protective equipment, hand washing), but few mentioned the opportunity of remote work or visiting restrictions. Overall, the results show that the impact of lockdown lies directly on four main categories of importance on veterinarian professional's life-human resource, activity management, relationship between veterinarian and authorities, and continuing education.

Medical Students Learning on the COVID-19 Front Line

In this viewpoint, we share our perspectives, as medical students at Imperial College London, on our experiences during our Infectious Diseases placement at Northwick Park Hospital, touching upon other students' experiences at other sites as well. We highlight some of the main drivers of and barriers to medical students seeing patients with COVID-19.

Consequences of COVID-19 pandemic lockdown on emergency and stroke care in a German tertiary stroke center

BACKGROUND

COVID-19 pandemic caused a decline in stroke care in several countries. The objective was to describe lockdown stroke care in a tertiary stroke center in Düsseldorf, Germany near Heinsberg, a German hot spot for COVID-19 in spring 2020.

METHODS

In a retrospective, observational, single-center study, we compared all patients treated in our emergency department (ED), patients seen by a neurologist in the ED, ED patients suffering from ischemic and hemorrhagic strokes and transient ischemic attacks (TIAs) as well as stroke patients admitted to our stroke unit during lockdown in spring 2020 (16 March 2020-12 April 2020) to those cared for during the same period in 2019 and lockdown light in fall 2020 (2 November - 29 November 2020).

RESULTS

In spring 2020 lockdown the mean number of patients admitted to our ED dropped by 37.4%, seen by a neurologist by 35.6%, ED stroke patients by 19.2% and number of patients admitted to our stroke unit by 10% compared to the same period in 2019. In fall lockdown light 2020 effects were comparable but less pronounced. Thrombolysis rate was stable during spring and fall lockdown, however, endovascular treatment (EVT) rate declined by 58% in spring lockdown and by 51% in fall lockdown compared to the period in 2019.

CONCLUSIONS

Our study indicates a profound reduction of overall ED patients, neurological ED patients and EVT during COVID-19 pandemic caused lockdowns. Planning for pandemic scenarios should include access to effective emergency therapies.

Impact of National Lockdown on the Hyperacute Stroke Care and Rapid Transient Ischaemic Attack Outpatient Service in a Comprehensive Tertiary Stroke Centre During the COVID-19 Pandemic

Background: The COVID-19 pandemic is having major implications for stroke services worldwide. We aimed to study the impact of the national lockdown period during the COVID-19 outbreak on stroke and transient ischemic attack (TIA) care in London, UK. Methods: We retrospectively analyzed data from a quality improvement registry of consecutive patients presenting with acute ischemic stroke and TIA to the Stroke Department, Imperial College Health Care Trust London during the national lockdown period (between March 23rd and 30th June 2020). As controls, we evaluated the clinical reports and stroke quality metrics of patients presenting with stroke or TIA in the same period of 2019. Results: Between March 23rd and 30th June 2020, we documented a fall in the number of stroke admissions by 31.33% and of TIA outpatient referrals by 24.44% compared to the same period in 2019. During the lockdown, we observed a significant increase in symptom onset-to-door time in patients presenting with stroke (median = 240 vs. 160 min, p = 0.020) and TIA (median = 3 vs. 0 days, p = 0.002) and a significant reduction in the total number of patients thrombolysed [27 (11.49%) vs. 46 (16.25%, p = 0.030)]. Patients in the 2020 cohort presented with a lower median pre-stroke mRS (p = 0.015), but an increased NIHSS (p = 0.002). We registered a marked decrease in mimic diagnoses compared to the same period of 2019. Statistically significant differences were found between the COVID and pre-COVID cohorts in the time from onset to door (median 99 vs. 88 min, p = 0.026) and from onset to needle (median 148 vs. 126 min, p = 0.036) for thrombolysis whilst we did not observe any significant delay to reperfusion therapies (door-to-needle and door-to-groin puncture time). Conclusions: National lockdown in the UK due to the COVID-19 pandemic was associated with a significant decrease in acute stroke admission and TIA evaluations at our stroke center. Moreover, a lower proportion of acute stroke patients in the pandemic cohort benefited from reperfusion therapy. Further research is needed to evaluate the long-term effects of the pandemic on stroke care.