Decreased Stroke Presentation Rates at a Comprehensive Stroke Center during COVID-19

Outcomes in patients with acute stroke treated at a comprehensive stroke center using telemedicine versus in-person assessments

INTRODUCTION

Telemedicine has been shown to be a safe and effective modality to assess and treat patients with acute stroke who present to a community hospital. There are no previous reports on using telemedicine to treat patients with acute stroke who present to a comprehensive stroke center. We report here the outcomes of patients with acute stroke treated in 2021 at our comprehensive stroke center using telemedicine versus an in-person assessment.

METHODS

Patients with acute ischemic stroke who were treated after either a telemedicine or in-person assessment at our hospital in 2021 were identified by a retrospective chart review. The primary outcomes collected were door-to-needle (DTN) time for alteplase (tPA) administration, door-to-puncture (DTP) time for endovascular thrombectomy, symptomatic intracranial hemorrhage (sICH) rates and 3-month mortality.

RESULTS

There were 302 patients with acute stroke treated at our hospital in 2021. Of these, 18.2% (n = 55/302) were treated using telemedicine. There were no differences in any of the outcomes between patients treated using telemedicine versus an in-person assessment: DTN (35.5 min (n = 42) vs 33 min (n = 182), p < 0.76), DTP (86.5 min (n = 30) vs 85 min (n = 134), p < 0.97), sICH (0% (n = 0/55) vs 1.6% (n = 4/245, p < 0.59) or 3-month mortality (20.6% (n = 7/34) vs 22.1% (n = 40/181), p < 0.29).

DISCUSSION

To the best of our knowledge, this is the first study to report on outcomes for acute stroke patients treated using telemedicine at a comprehensive stroke center. In this study, there were no differences in outcomes between patients treated using telemedicine versus an in-person assessment.

Impact of the COVID-19 Pandemic on Stroke Subtype Presentation in Patients Without COVID-19 Infection

BACKGROUND & AIMS

It is unknown if the COVID-19 pandemic and public health measures had an immediate impact on stroke subtypes and etiologies in patients not infected with COVID-19. We aimed to evaluate if the proportion of non-COVID-19-related stroke subtypes (ischemic vs. hemorrhagic) and etiologies (cardioembolic, atherosclerosis, small vessel disease, and others) during the pandemic's first wave were different from prepandemic.

METHODS

For this retrospective cohort study, we included patients without COVID-19 with ischemic or hemorrhagic stroke at two large Canadian stroke centers between March-May 2019 (prepandemic cohort) and March-May 2020 (pandemic cohort). Proportions of stroke subtypes and etiologies were compared between cohorts using chi-square tests.

RESULTS

The prepandemic cohort consisted of 234 stroke patients and the pandemic cohort of 207 stroke patients. There were no major differences in baseline characteristics. The proportions of ischemic versus hemorrhagic stroke were similar (ischemic stroke: 77% prepandemic vs. 75% pandemic; hemorrhagic stroke:12% prepandemic vs. 14% pandemic; p > 0.05). There were no differences in etiologies, except for a decreased proportion of ischemic stroke due to atherosclerosis in the pandemic cohort (26% prepandemic vs. 15% pandemic; difference: 10.6%, 95%CI: 1.4-19.7; p = 0.03). Notably, during the pandemic, the cause of ischemic stroke was more often unknown because of incomplete work-up (13.3% prepandemic vs. 28.2% pandemic, difference: 14.9%, 95%-CI: 5.7-24.2; p = <0.01).

CONCLUSIONS

In this study, the pandemic had no clear effect on stroke subtypes and etiologies suggesting a limited impact of the pandemic on stroke triggers. However, the shift from atherosclerosis toward other causes warrants further exploration.

Access to rehabilitation professionals by individuals with stroke one month after hospital discharge from a stroke unit in Brazil is insufficient regardless of the pandemic

OBJECTIVE

To compare access to rehabilitation professionals by individuals with stroke one month after hospital discharge from a stroke unit in Brazil, before and during the COVID-19 pandemic.

MATERIALS AND METHODS

This longitudinal and prospective study included individuals aged 20 years or older without previous disabilities admitted into a stroke unit due to a first stroke. Individuals were divided into two groups: before (G1) and during (G2) the COVID-19 pandemic. Groups were matched for age, sex, education level, socioeconomic status, and stroke severity. One month after hospital discharge, individuals were contacted via telephone to collect data regarding their access to rehabilitation services based on the number of referred rehabilitation professionals. Then, between-group comparisons were conducted (α = 5%).

RESULTS

The access to rehabilitation professionals was similar between groups. Rehabilitation professionals accessed included medical doctors, occupational therapists, physical therapists, and speech therapists. The first consultation after hospital discharge was mainly provided by public services. Despite the pandemic, telehealth was not frequent in any period evaluated. In both groups, the number of accessed professionals (G1 = 110 and G2 = 90) was significantly lower than the number of referrals (G1 = 212 and G2 = 194; p < 0.001).

CONCLUSIONS

Access to rehabilitation professionals was similar between groups. However, the number of accessed rehabilitation professionals was lower than that of referred ones during both periods. This finding indicates a compromised comprehensiveness of care for individuals with stroke, regardless of the pandemic.

Single-step Optimization in Triaging Large Vessel Occlusion Strokes: Identifying Factors to Improve Door-to-groin Time for Endovascular Therapy

INTRODUCTION

Although acute stroke endovascular therapy (EVT) has dramatically improved outcomes in acute ischemic stroke (AIS) patients with large vessel occlusions (LVO), access to EVT-capable centers remains limited, particularly in rural areas. Therefore, it is essential to optimize triage systems for EVT-eligible patients. One strategy may be the use of a telestroke network that typically consists of multiple spoke sites that receive a consultation to determine appropriateness of patient transfer to an EVT-capable hub site. Standardization of AIS protocols may be necessary to achieve target door-to-groin (DTG) times of less than 60 minutes in EVT-eligible patients upon hub arrival. Specifically, the decision to obtain vascular imaging at the transferring hub site vs delaying until arrival at the hub is controversial. The purpose of this study was to identify factors associated with reduced DTG time in LVO-AIS patients.

METHODS

We performed a retrospective chart review for all patients treated over a 3.5-year period at our home hub institution. Patients were classified as telestroke transfers, non-telestroke transfers, and direct-to-hub presentations. We recorded demographic information, DTG time, reperfusion status, length of stay (LOS), functional status at discharge, seven-day mortality, and the site where vascular imaging- computed tomography angiography (CTA)-was obtained. We performed binary logistic regression to identify factors associated with DTG <60 minutes.

RESULTS

In the sample of EVT-eligible patients (n = 383), CTA was performed at the spoke site prior to transfer to the hub institution in 53% of cases. Further, 59% of telestroke transfer cases received a CTA prior to transfer compared to only 40% of non-telestroke transfers (59 vs 40%, P = 0.01). A Door-to-groin time <60 minutes was achieved in 67% of transfer patients who received pre-transfer CTA compared to only 22% of transfer patients who received CTA upon hub arrival and 17% of patients who presented directly to the hub. Ultimately, transfer patients who received CTA prior to transfer were 7.2 times more likely to have a DTG <60 minutes compared to those who did not (OR 7.2, 95% confidence interval 3.5-14.7; P < 0.001).

CONCLUSION

Pre-transfer computed tomography angiography was the only significant predictor of achieving target door-to-groin times of less than 60 minutes. Because DTG time has been well established as a predictor of clinical outcomes, including pre-transfer CTA in a standardized acute ischemic stroke protocol may prove beneficial. Our findings also illustrate the need to optimize direct-to-hub stroke alerts and telestroke relationships to minimize workflow disruptions, which became more apparent during the pandemic.

Changes in the clinico-functional characteristics of stroke patients in the acute phase during the COVID-19 pandemic

OBJECTIVE

To compare the sociodemographic and clinico-functional characteristics of patients admitted to a stroke unit immediately before and during two different COVID-19 pandemic phases.

METHODS

This exploratory study was conducted in the stroke unit of a public hospital in Brazil. Patients consecutively admitted to a stroke unit for 18 months with primary stroke aged ≥20 years were included and divided into three groups: G1: Pre-pandemic; G2: Early pandemic; and G3: Late pandemic. The sociodemographic and clinico-functional characteristics of the groups were compared (α=0.05).

RESULTS

The study included 383 individuals (G1=124; G2=151; G3=108). The number of risk factors (higher in G2; p≤0.001), smoking (more common in G2; p≤0.01), type of stroke (ischemic more common in G3; p=0.002), stroke severity (more severe in G2; p=0.02), and level of disability (more severe in G2: p≤0.01) were significantly different among the groups.

CONCLUSION

A greater number of serious events and risk factors including smoking and higher level of disability was observed in patients in the beginning of the pandemic than in the late phases. Only the occurrence of ischemic stroke increased in the late phase. Therefore, these individuals may have an increased need for rehabilitation services monitoring and care during their lifespan. Additionally, these results indicate that health promotion and prevention services should be strengthened for future health emergencies.

Barriers leading to increased disability in neurologically challenged populations during COVID-19 pandemic: a scoping review

PURPOSE

The objective of this scoping review was to get an overview of barriers emerging across the globe from the pandemic that are likely to increase the level of pre-existing disability status of neurologically challenged populations.

METHODS

Database searches (PubMed/MEDLINE, CINAHL, ProQuest, Ovid, Scopus, and Web of Science) updated to December 2020 were conducted. Articles that identified challenges or barriers to neuro-rehabilitation, impact on disability status and health care services were included. Full-text articles limited to the English language with no restrictions on study design were included. Data was synthesized based on recurrent themes that were identified.

RESULTS

Thirty-seven studies were included in this review. Neurological populations considered: stroke, multiple sclerosis, amyotrophic lateral sclerosis, parkinson's disease, autism, developmental disabilities, and those who required neurosurgical care. Barriers were grouped into categories as increased disease risk and complications, delayed or restricted access to neuro-rehabilitation, limited hospital access, telerehabilitation limitations, and shutdown of special centers of aid.

CONCLUSIONS

COVID-19 pandemic has given rise to barriers that affect almost every aspect of healthcare and rehabilitation in neurologically challenged populations prompting an increase in their disability level. This can assist policymakers in designing mitigation strategies to minimize the detrimental effects on this vulnerable population.Implications for rehabilitationPandemic has led to the worsening of existing motor and non-motor symptoms, which need to be monitored, assessed and managed medically, and through rehabilitation in neurologically challenged populations.Notable decline of cognition and physical activity in neurologically challenged populations needs to be assessed and efforts to reverse these outcomes should be attempted.Rehabilitation services, hospital care and centers of aid need to be made more accessible for neurologically challenged populations with COVID-19 precautionary measures.Telemedicine and telerehabilitation need to be upgraded to enhance further face to face like interactions and for tracking of progressive disease.

Survey of the Impact of COVID-19 on Chronic Liver Disease Patient Care Experiences and Outcomes

Background

The COVID-19 pandemic has a secondary impact on the health of patients with chronic liver disease (CLD). Our objective was to study this impact on care provision, telemedicine, and health behaviours in CLD patients.

Methods

CLD patients of an urban gastroenterology clinic who attended a telemedicine appointment between March 17, 2020 and September 17, 2020, completed an online survey on care delays, health behaviours, and experience with telemedicine. Chart review was conducted in 400 randomly selected patients: 200 charts from during the pandemic were compared to 200 charts the previous year. Data were extracted for clinicodemographic variables, laboratory investigations, and clinical outcomes.

Results

Of 399 patients invited to participate, 135 (34%) completed the online survey. Fifty (39%) patients reported 83 care delays due to the COVID-19 pandemic, with the majority (71%) of delays persisting beyond 2 months. Ninety-five (75%) patients were satisfied with telemedicine appointments. There was a longer delay between lab work and appointments in patients seen during the pandemic compared to 2019 (P = 0.01). Compared to the year prior, during the COVID pandemic, there was a similar number of cases of cirrhosis decompensation (n = 26, 13% versus n = 22, 11%) and hospitalization (n = 12, 6% versus n = 5, 3%).

Conclusion

The COVID-19 pandemic has led to care delays for CLD outpatients, with most delays on the scale of months. These patient-reported experiences and clinical observations can direct optimization of CLD care as effects from the pandemic evolve.

Considerations for the Implementation of a Telestroke Network: A Systematic Review

The application of telestroke has matured considerably since its inception in 1999. The use of telestroke is now recommended in several published guidelines. Consequently, jurisdictions without a telestroke service are seeking practical information on the best approach to implement telestroke. French et al. (2013) reviewed the challenges of implementing a telestroke network including studies between 2000 and 2010. At the time, telestroke networks were largely limited to the UK, USA, Canada and Europe and only one process evaluation had been conducted. Given the prolific expansion of telestroke services since 2010, we conducted a systematic review to determine factors associated with successful establishment, management, and sustainability of a contemporary telestroke services. A comprehensive search of telestroke studies was conducted in July 2021. Empirical studies published between 2010 and 2021 were included if they contained descriptive, evaluation or operational data on the implementation of a telestroke network. Studies were subsequently evaluated using the Consolidated Framework for Implementation Research (CFIR). The initial literature search revealed a total of 7415 potential studies; 38 of which met the inclusion criteria. The past decade of process evaluation studies has enabled a more nuanced investigations into how to implement and sustain a telestroke network. Pre-implementation planning is crucial to ensure clear telestroke processes, governance structures and stakeholder engagement. Sustainability of networks relies on securing long-term investment, providing adequate resources, and maintaining staff motivation and willingness. Recommendations are provided to overcome commonly identified barriers related to technology, staffing, planning and standardisation of processes, evaluation, and sustainability and scale-up. Further research needs to explore how new advancements in stroke care such as endovascular clot retrieval (EVT) and advanced brain imaging can be considered and planned for during the implementation of a new telestroke service.

Impact of the COVID-19 Pandemic on Acute Stroke Care, Time Metrics, Outcomes, and Racial Disparities in a Southeast Michigan Health System

BACKGROUND

COVID-19 has impacted acute stroke care with several reports showing worldwide drops in stroke caseload during the pandemic. We studied the impact of COVID-19 on acute stroke care in our health system serving Southeast Michigan as we rolled out a policy to limit admissions and transfers.

METHODS

in this retrospective study conducted at two stroke centers, we included consecutive patients presenting to the ED for whom a stroke alert was activated during the period extending from 3/20/20 to 5/20/20 and a similar period in 2019. We compared demographics, time metrics, and discharge outcomes between the two groups.

RESULTS

of 385 patients presented to the ED during the two time periods, 58% were African American. There was a significant decrease in the number of stroke patients presenting to the ED and admitted to the hospital between the two periods (p <0.001). In 2020, patients had higher presenting NIHSS (median: 2 vs 5, p = 0.012), discharge NIHSS (median: 2 vs 3, p = 0.004), and longer times from LKW to ED arrival (4.8 vs 9.4 h, p = 0.031) and stroke team activation (median: 10 vs 15 min, p = 0.006). In 2020, stroke mimics rates were lower among African Americans. There were fewer hospitalizations (p <0.001), and transfers from outside facilities (p = 0.015).

CONCLUSION

a trend toward faster stroke care in the ED was observed during the pandemic along with dramatically reduced numbers of ED visits, hospitalizations and stroke mimics. Delayed ED presentations and higher stroke severity characterized the African American population, highlighting deepening of racial disparities during the pandemic.