Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

Establishing a hyperacute stroke service during the COVID-19 pandemic: our institution's one year experience

BACKGROUND AND AIMS

The corononavirus 2019 (COVID-19) pandemic resulted in modifications in the workflow and redistribution of human resources, causing challenges in setting up of an acute stroke service. We would like to share our preliminary outcome amid this pandemic, to determine if the implementation of COVID-19 standard operating procedures (SOPs) affected the delivery of our hyperacute stroke service.

METHODS

We retrospectively analyzed one-year data from our stroke registry that began with the establishment of our hyperacute stroke service at Universiti Putra Malaysia Teaching Hospital from April 2020 until May 2021.

RESULTS

Setting up acute stroke services during the pandemic with constrained manpower and implementation of COVID-19 SOPs, was challenging. There was a significant dip of stroke admission from April to June 2020 due to the Movement Control Order (MCO) implemented by the government to curb the spread of COVID-19. However, the numbers of stroke admission steadily rose approaching 2021, after the implementation of recovery MCO. We managed to treat 75 patients with hyperacute stroke interventions i.e. intravenous thrombolysis (IVT), mechanical thrombectomy (MT) or both. Despite implementing COVID-19 SOPs and using magnetic resonance imaging (MRI) as our first line acute stroke imaging modality, clinical outcomes in our cohort were encouraging; almost 40% of patients who underwent hyperacute stroke treatment had early neurological recovery (ENR), and only 33% of patients had early neurological stability (ENS). In addition, we were able to maintain our door-to-imaging (DTI) and door-to-needle (DTN) time in line with international recommendations.

CONCLUSIONS

Our data reflects that COVID-19 SOPs did not deter successful delivery of hyperacute stroke services in our center. However, bigger and multi center studies are required to support our findings.

Quality in stroke care during the early phases of the COVID-19 pandemic: A nationwide study

Introduction:

Evidence-based early stroke care as reflected by fulfillment of process performance measures, is strongly related to better patient outcomes after stroke and transient ischemic attack (TIA). Detailed data on the resilience of stroke care services during the COVID-19 pandemic are limited. We aimed to examine the quality of early stroke care at Danish hospitals during the early phases of the COVID-19 pandemic.

Materials and methods:

We extracted data from Danish national health registries in five time periods (11 March, 2020–27 January, 2021) and compared these to a baseline pre-pandemic period (13 March, 2019–10 March, 2020). Quality of early stroke care was assessed as fulfilment of individual process performance measures and as a composite measure (opportunity-based score).

Results:

A total of 23,054 patients were admitted with stroke and 8153 with a TIA diagnosis in the entire period. On a national level, the opportunity-based score (95% confidence interval [CI]) at baseline for ischemic patients was 81.1% (80.8–81.4), for intracerebral hemorrhage (ICH) 85.5% (84.3–86.6), and for TIA 96.0% (95.3–96.1). An increase of 1.1% (0.1–2.2) and 1.5% (0.3–2.7) in the opportunity-based score was observed during the first national lockdown period for AIS and TIA followed by a decline of −1.3% (−2.2 to −0.4) in the gradual reopening phase for AIS indicators. We found a significant negative association between regional incidence rates and quality-of-care in ischemic stroke patients implying that quality decreases when admission rates increase.

Conclusion:

The quality of acute stroke/TIA care in Denmark remained high during the early phases of the pandemic and only minor fluctuations occurred.

Telestroke’s Role Through the COVID-19 Pandemic and Beyond

Purpose of review

The goal of this paper is to discuss the role and utilization of telestroke services through the COVID-19 pandemic and to suggest future directions to sustain and increase patients’ access to stroke expertise.

Recent findings

Telestroke is an innovative and effective tool that has been shown to improve access, quality of care, and outcomes of patients with acute stroke syndromes in resource-limited areas for the last two decades. The COVID-19 pandemic posed a significant challenge and strained healthcare systems worldwide, but it created novel and unique opportunities to expand and increase the utilization of telehealth and telestroke services to deliver personalized healthcare across the continuum of stroke care outside of traditional settings. This rapid and widespread increase in telestroke use was facilitated by the removal of many legislative and regulatory barriers which have limited patients’ access to stroke expertise for many years.

Summary

As the public health emergency ends, there exists a unique opportunity to optimize and expand upon the pandemic-related rapid growth of telestroke care. Optimal utilization of telehealth and telestroke services will depend on maintaining and improving required infrastructure, laws, and regulations, particularly those governing reimbursement and licensing.

Comparing Emergency Medical Services Processing Times for Stroke Patients Before and During COVID-19 Pandemic; A Cross-sectional Study

INTRODUCTION

Coronavirus disease 2019 (COVID-19) has directly affected global healthcare, especially the front-line of healthcare provision, including emergency medical services (EMS). The present study aimed to compare EMS processing times and the number of acute stroke patients serviced by EMS before and during COVID-19 pandemic.

METHODS

This is a retrospective observational review of Bangkok Surgico Medical Ambulance and Rescue Team (S.M.A.R.T.) EMS data from 2018 to 2021. The EMS processing times and the number of acute strokes were compared between pre-COVID-19 era (January 1st, 2018, and December 31st, 2019) and during COVID-19 pandemic (January 1st, 2020, and December 31st, 2021).

RESULTS

The number of stroke patients transported by EMS in one year, before and during COVID-19 pandemic was 128 and 150 cases, respectively (Change difference = 17.2%, 95% CI: 11.1-24.9). However, the average number of acute stroke patients per week was not significantly different (p = 0.386). The mean total EMS processing times before and during COVID-19 era were 25.59 ± 11.12 and 45.47 ± 14.61 minutes, respectively (mean difference of 19.88 (95% CI: 16.77-22.99) minutes; p < 0.001). The mean time from symptom onset to EMS arrival (p < 0.001), the mean call time (p < 0.001), the mean response time (p < 0.001), and the mean scene time (p < 0.001) were significantly higher during COVID-19 period. The mean transportation times for stroke patients was similar before and during COVID-19 pandemic (10.14 ± 6.28 and 9.41 ± 6.31 minutes, respectively; p = 0.338).

CONCLUSIONS

During COVID-19 pandemic, the number of acute stroke patients serviced by EMS increased substantially, but there was no difference in the average number of patients per week. During the pandemic, EMS processing times markedly increased.

Impact of COVID-19 on emergency department management of stroke and STEMI. A narrative review

The novel coronavirus of 2019 (COVID-19) has resulted in a global pandemic; COVID-19 has resulted in significant challenges in the delivery of healthcare, including emergency management of multiple diagnoses, such as stroke and ST-segment myocardial infarction (STEMI). The aim of this study was to identify the impacts of the COVID-19 pandemic on emergency department care of stroke and STEMI patients. In this study a review of the available literature was performed using pre-defined search terms, inclusion criteria, and exclusion criteria. Our analysis, using a narrative review format, indicates that there was not a significant change in time required for key interventions for stroke and STEMI emergent management, including imaging (door-to-CT), tPA administration (door-to-needle), angiographic reperfusion (door-to-puncture), and percutaneous coronary intervention (door-to-balloon). Potential future areas of investigation include how emergency department (ED) stroke and STEMI care has adapted in response to different COVID-19 variants and stages of the pandemic, as well as identifying strategies used by EDs that were successful in providing effective emergency care in the face of the pandemic.

Global burden of the COVID-19 associated patient-related delay in emergency healthcare: a panel of systematic review and meta-analyses

Background

Apart from infecting a large number of people around the world and causing the death of many people, the COVID-19 pandemic seems to have changed the healthcare processes of other diseases by changing the allocation of health resources and changing people’s access or intention to healthcare systems.

Objective

To compare the incidence of endpoints marking delayed healthcare seeking in medical emergencies, before and during the pandemic.

Methods

Based on a PICO model, medical emergency conditions that need timely intervention was selected to be evaluated as separate panels. In a systematic literature review, PubMed was quarried for each panel for studies comparing the incidence of various medical emergencies before and during the COVID-19 pandemic. Markers of failure/disruption of treatment due to delayed referral were included in the meta-analysis for each panel.

Result

There was a statistically significant increased pooled median time of symptom onset to admission of the acute coronary syndrome (ACS) patients; an increased rate of vasospasm of aneurismal subarachnoid hemorrhage; and perforation rate in acute appendicitis; diabetic ketoacidosis presentation rate among Type 1 Diabetes Mellitus patients; and rate of orchiectomy among testicular torsion patients in comparison of pre-COVID-19 with COVID-19 cohorts; while there were no significant changes in the event rate of ruptured ectopic pregnancy and median time of symptom onset to admission in the cerebrovascular accident (CVA) patients.

Conclusions

COVID-19 has largely disrupted the referral of patients for emergency medical care and patient-related delayed care should be addressed as a major health threat.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00836-2.

Impact of COVID-19 on Emergency Medical Services for Patients with Acute Stroke Presentation in Busan, South Korea

The purpose of this retrospective observational study was to identify the impact of COVID-19 on emergency medical services (EMS) processing times and transfers to the emergency department (ED) among patients with acute stroke symptoms before and during the COVID-19 pandemic in Busan, South Korea. The total number of patients using EMS for acute stroke symptoms decreased by 8.2% from 1570 in the pre-COVID-19 period to 1441 during the COVID-19 period. The median (interquartile range) EMS processing time was 29.0 (23–37) min in the pre-COVID-19 period and 33.0 (25–41) minutes in the COVID-19 period (p < 0.001). There was a significant decrease in the number of patients transferred to an ED with a comprehensive stroke center (CSC) (6.37%, p < 0.001) and an increase in the number of patients transferred to two EDs nearby (2.77%, p = 0.018; 3.22%, p < 0.001). During the COVID-19 pandemic, EMS processing time increased. The number of patients transferred to ED with CSC was significantly reduced and dispersed. COVID-19 appears to have affected the stroke chain of survival by hindering entry into EDs with stroke centers, the gateway for acute stroke patients.