Acute Stroke Care during the COVID-19 Pandemic: Reduction in the Number of Admissions of Elderly Patients and Increase in Prehospital Delays

Introduction: We analyzed whether the coronavirus disease 2019 (COVID-19) crisis affected acute stroke care in our center during the first 2 months of lockdown in Spain. Methods: This is a single-center, retrospective study. We collected demographic, clinical, and radiological data; time course; and treatment of patients meeting the stroke unit admission criteria from March 14 to May 14, 2020 (COVID-19 period group). Data were compared with the same period in 2019 (pre-COVID-19 period group). Results: 195 patients were analyzed; 83 in the COVID-19 period group, resulting in a 26% decline of acute strokes and transient ischemic attacks (TIAs) admitted to our center compared with the previous year (p = 0.038). Ten patients (12%) tested positive for PCR SARS-CoV-2. The proportion of patients aged 65 years and over was lower in the COVID-19 period group (53 vs. 68.8%, p = 0.025). During the pandemic period, analyzed patients were more frequently smokers (27.7 vs. 10.7%, p = 0.002) and had less frequently history of prior stroke (13.3 vs. 25%, p = 0.043) or atrial fibrillation (9.6 vs. 25%, p = 0.006). ASPECTS score was lower (9 [7–10] vs. 10 [8–10], p = 0.032), NIHSS score was slightly higher (5 [2–14] vs. 4 [2–8], p = 0.122), onset-to-door time was higher (304 [93–760] vs. 197 [91.25–645] min, p = 0.104), and a lower proportion arrived within 4.5 h from onset of symptoms (43.4 vs. 58%, p = 0.043) during the COVID-19 period. There were no differences between proportion of patients receiving recanalization treatment (intravenous thrombolysis and/or mechanical thrombectomy) and in-hospital delays. Conclusion: We observed a reduction in the number of acute strokes and TIAs admitted during the COVID-19 period. This drop affected especially elderly patients, and despite a delay in their arrival to the emergency department, the proportion of patients treated with recanalization therapies was preserved.

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

Cerebrovascular Diseases ◽

10.1159/000516309 ◽

2021 ◽

pp. 1-9

Author(s):

Anna Ramos-Pachón ◽

Álvaro García-Tornel ◽

Mònica Millán ◽

Marc Ribó ◽

Sergi Amaro ◽

...

Keyword(s):

Acute Stroke ◽

Functional Outcome ◽

Stroke Care ◽

Care Quality ◽

Point Of View ◽

Stroke Severity ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Prehospital Delays ◽

The Impact

Introduction: The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system’s bottlenecks from a territorial point of view. Methods: Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15–May 2, 2020) and an immediate prepandemic period (January 26–March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days. Results: Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = −0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05–2.4], p 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4–0.9], p 0.015) during the pandemic period. Conclusion: During the COVID-19 pandemic, Catalonia’s stroke system’s weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system’s analysis is crucial to allocate resources appropriately.

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The Dutch Acute Stroke Audit: Benchmarking acute stroke care in the Netherlands

European Stroke Journal ◽

10.1177/2396987318787695 ◽

2018 ◽

Vol 3 (4) ◽

pp. 361-368 ◽

Cited By ~ 8

Author(s):

Laurien S Kuhrij ◽

Michel WJM Wouters ◽

Renske M van den Berg-Vos ◽

Frank-Erik de Leeuw ◽

Paul J Nederkoorn

Keyword(s):

Acute Stroke ◽

Best Practice ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Favourable Outcome ◽

Hospital Level ◽

Acute Stroke Care ◽

Related Factors ◽

Variation In Care

Introduction In the nationwide Dutch Acute Stroke Audit (DASA), consecutive patients with acute ischaemic stroke (AIS) and intracranial haemorrhage (ICH) are prospectively registered. Acute stroke care is a rapidly evolving field in which intravenous thrombolysis (IVT) and intra-arterial thrombectomy (IAT) play a crucial role in increasing odds of favourable outcome. The DASA can be used to assess the variation in care between hospitals and develop ‘best practice’ in acute stroke care. Patients and methods: We describe the initiation and design of the DASA as well as the results from 2015 and 2016. Results In 2015 and 2016, 55,854 patients with AIS and 7727 patients with ICH were registered in the DASA. Treatment with IVT was administered to 10,637 patients (with an increase of 1.3% in 2016) and 1740 patients underwent IAT (with an increase of 1% in 2016). Median door-to-needle time for IVT and median door-to-groin time for IAT have decreased from 27 to 25 min and 66 to 64 min, respectively. Mortality during admission was 4.9% in patients with AIS, whereas 26% of patients with ICH died. Modified Rankin Scale score at three months was registered in 49% of AIS patients and 45% of ICH patients. Discussion During the nationwide DASA, time to treatment is reduced for IVT as well as IAT. With the rapidly evolving treatment of acute stroke care, the DASA can be used to monitor the quality provided on patient- and hospital level. Conclusion Increasing completeness of registration of the outcome, in combination with adjustment for patient-related factors, is necessary to define and further improve the quality of the acute stroke care.

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Maintenance of Acute Stroke Care Service During the COVID-19 Pandemic Lockdown

Stroke ◽

10.1161/strokeaha.120.032176 ◽

2021 ◽

Vol 52 (5) ◽

pp. 1693-1701

Author(s):

Valerian L. Altersberger ◽

Lotte J. Stolze ◽

Mirjam R. Heldner ◽

Hilde Henon ◽

Nicolas Martinez-Majander ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Performance Measures ◽

Care Service ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

National Institutes Of Health ◽

Reference Period ◽

Acute Stroke Care ◽

Symptomatic Intracranial Hemorrhage

Background and Purpose: Timely reperfusion is an important goal in treatment of eligible patients with acute ischemic stroke. However, during the coronavirus disease 2019 (COVID-19) pandemic, prehospital and in-hospital emergency procedures faced unprecedented challenges, which might have caused a decline in the number of acute reperfusion therapy applied and led to a worsening of key quality measures for this treatment during lockdown. Methods: This prospective multicenter cohort study used data from the TRISP (Thrombolysis in Ischemic Stroke Patients) registry of patients with acute ischemic stroke treated with reperfusion therapies, that is, intravenous thrombolysis or endovascular therapy. We compared prehospital and in-hospital time-based performance measures (stroke-onset-to-admission, admission-to-treatment, admission-to-image, and image-to-treatment time) during the first 6 weeks after announcement of lockdown (lockdown period) with the same period in 2019 (reference period). Secondary outcomes included stroke severity (National Institutes of Health Stroke Scale) after 24 hours and occurrence of symptomatic intracranial hemorrhage (following the ECASS [European-Australasian Acute Stroke Study]-II criteria). Results: Across 20 stroke centers, 540 patients were treated with intravenous thrombolysis/endovascular therapy during lockdown period compared with 578 patients during reference period (−7% [95% CI, 5%–9%]). Performance measures did not change significantly during the lockdown period (2020/2019 minutes median: onset-to-admission 133/145; admission-to-treatment 51/48). Same was true for admission-to-image (20/19) and image-to-treatment (31/30) time in patients with available time of first image (n=871, 77.9%). Median National Institutes of Health Stroke Scale on admission (2020/2019: 11/11) and after 24 hours (2020/2019: 6/5) and percentage of symptomatic intracranial hemorrhage (2020/2019: 6.2/5.7) did not differ significantly between both periods. Conclusions: The COVID-19 pandemic lockdown resulted in a mild decline in the number of patients with stroke treated with acute reperfusion therapies. More importantly, the solid stability of key quality performance measures between the 2020 and 2019 period may indicate resilience of acute stroke care service during the lockdown, at least in well-established European stroke centers.

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Abstract T P37: Routine CT Angiography in Acute Stroke Does Not Delay Acute Stroke Care

Stroke ◽

10.1161/str.46.suppl_1.tp37 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Gisele S Silva ◽

Renata C Miranda ◽

Rodrigo M Massaud ◽

Andreia M Vacari ◽

Miguel Cendoroglo Neto

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Tertiary Hospital ◽

Acute Stroke Care ◽

Time Intervals ◽

Radiology Report ◽

Group 2

Introduction: Vascular imaging is increasingly used for diagnosis of arterial occlusions in acute ischemic stroke. Hypothesis:We hypothesized that time intervals using a CTA based acute ischemic stroke protocol are not increased when compared to an earlier non-CTA based protocol. Methods: We evaluated a database of consecutive patients admitted to a Brazilian tertiary hospital with acute ischemic stroke from February 2009 to March 2014 and reviewed our stroke quality measures data to determine if the time required to obtain CTA prolonged door-to-neuroimaging, door to radiology report and door-to-needle times. Patients were categorized into: Group 1 (February 2009 to October 2013) (Non-contrast CT Scan based acute stroke protocol) and Group 2 (November 2013 to August 2014) (CTA based acute stroke protocol). Time intervals were compared between the two groups.Results: We evaluated 415 consecutive patients, 20 of whom (4.8%) had a CTA in the acute phase (Group 2). Patients in groups 1 and 2 had similar onset-to-door times (1.86 [0.75-3.58] versus 2.75 hours [1.0-8.49], p=0.09); door to neuroimaging times (27.6 [18.6-46.8] versus 37.8 minutes [23.4-46.2], p=0.28 ) and door to radiology report intervals (39 [27-60.6] versus 53.4 minutes[35.4-61.2], p=0.09). The frequency of treatment with recanalization therapies ( either intravenous thrombolysis or endovascular procedures) was similar between groups 1 (30%) and 2 (21%), p=0.33, as well as door to needle times (p=0.09). Conclusions: CTA based acute stroke care does not significantly delay time to neuroimaging or thrombolysis in routine clinical practice.

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Gender disparity in the access of elderly patients to acute stroke care

Aktuelle Neurologie ◽

10.1055/s-2007-988080 ◽

2007 ◽

Vol 34 (S 2) ◽

Author(s):

M Sitzer ◽

C Foerch ◽

T Neumann-Haefelin ◽

H Steinmetz

Keyword(s):

Elderly Patients ◽

Acute Stroke ◽

Stroke Care ◽

Gender Disparity ◽

Acute Stroke Care

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Malpractice litigation in acute stroke care – where are we now?

Medico-Legal Journal ◽

10.1177/0025817217750494 ◽

2018 ◽

Vol 86 (3) ◽

pp. 134-139 ◽

Cited By ~ 2

Author(s):

Gilberto KK Leung ◽

Gerard Porter

Keyword(s):

Acute Stroke ◽

Scientific Evidence ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Healthcare Personnel ◽

Acute Stroke Care ◽

The United Kingdom ◽

Legal Implications ◽

Legal Challenges ◽

Improvement Measures

Acute stroke care has undergone momentous changes in recent years with the introduction of intravenous thrombolysis, mechanical thrombectomy and integrated stroke services. While these are welcome developments, they also carry unique medico-legal challenges. In 2015, a patient from Greater Manchester was awarded over £1 million in compensation after ambulance paramedics failed to admit her to a specialist unit. This paper explores the medico-legal implications of this first but over looked thrombolysis-related claim in the United Kingdom. It is submitted that the highly time-dependent and multidisciplinary nature of acute stroke care may expose a host of healthcare personnel, both medical and non-medical, to risks of legal pursuit for failing to provide appropriate care, and that available scientific evidence will likely support such claims. The situation calls for an urgent and concerted effort at implementing improvement measures at national levels. A reminder of the legal consequences of substandard acute stroke care is timely and necessary.

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Stroke Intervention: Geographic Disparities in Acute Stroke Care and the Role of Interventional Cardiology

EMJ Interventional Cardiology ◽

10.33590/emjintcardiol/20-00009 ◽

2020 ◽

Keyword(s):

Acute Stroke ◽

Case Series ◽

Intravenous Thrombolysis ◽

Interventional Cardiology ◽

Stroke Care ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Geographic Disparities

Stroke is the second-leading cause of death and a major cause of disability worldwide. The majority of strokes are ischaemic, and effective therapy to achieve reperfusion includes intravenous thrombolysis and, for proximal large vessel occlusion strokes, endovascular mechanical thrombectomy (MT). There has been a paradigm shift in acute stroke care, driven by a series of randomised controlled trials demonstrating that timely reperfusion with MT results in superior outcomes compared to intravenous thrombolysis in patients with large vessel occlusion strokes. There are significant geographic disparities in delivering acute stroke care because of the maldistribution of neurointerventional specialists. There are now several case series demonstrating the feasibility and safety of first medical contact MT by carotid stent-capable interventional cardiologists and noninvasive neurologists working on stroke teams, which is a solution to the uneven distribution of neurointerventionalists and allows stroke interventions to be delivered in local communities.

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Implementation of regional Acute Stroke Care Map increases thrombolysis rates for acute ischaemic stroke in Chinese urban area in only 3 months

Stroke and Vascular Neurology ◽

10.1136/svn-2020-000332 ◽

2020 ◽

pp. svn-2020-000332

Author(s):

Yi Sui ◽

Jianfeng Luo ◽

Chunyao Dong ◽

Liqiang Zheng ◽

Weijin Zhao ◽

...

Keyword(s):

Ischaemic Stroke ◽

Acute Stroke ◽

Urban Area ◽

Acute Ischaemic Stroke ◽

Urban Areas ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Care Quality ◽

Acute Stroke Care ◽

Tertiary Hospitals

BackgroundThe rate of intravenous thrombolysis for acute ischaemic stroke remains low in China. We investigated whether the implementation of a citywide Acute Stroke Care Map (ASCaM) is associated with an improvement of acute stroke care quality in a Chinese urban area.MethodsThe ASCaM comprises 10 improvement strategies and has been implemented through a network consisting of 20 tertiary hospitals. We identified 7827 patients with ischaemic stroke admitted from April to October 2017, and 506 patients underwent thrombolysis were finally included for analysis.ResultsCompared with ‘pre-ASCaM period’, we observed an increased rate of administration of tissue plasminogen activator within 4.5 hours (65.4% vs 54.5%; adjusted OR, 1.724; 95% CI 1.21 to 2.45; p=0.003) during ‘ASCaM period’. In multivariate analysis models, ‘ASCaM period’ was associated with a significant reduction in onset-to-door time (114.1±55.7 vs 135.7±58.4 min, p=0.0002) and onset-to-needle time (ONT) (169.2±58.1 vs 195.6±59.3 min, p<0.0001). Yet no change was found in door-to-needle time. Clinical outcomes such as symptomatic intracranial haemorrhage, favourable functional outcome (modified Rankin Scale ≤2) and in-hospital mortality remained unchanged.ConclusionThe implementation of ASCaM was significantly associated with increased rates of intravenous thrombolysis and shorter ONT. The ASCaM may, in proof-of-principle, serve as a model to reduce treatment delay and increase thrombolysis rates in Chinese urban areas and possibly other highly populated Asian regions.

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A brief history of acute stroke care

Aging ◽

10.18632/aging.101542 ◽

2018 ◽

Vol 10 (8) ◽

pp. 1797-1798 ◽

Cited By ~ 4

Author(s):

Rahul Damani

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Acute Stroke Care ◽

History Of

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Abstract 2: Acute Stroke Care During The Covid-19 Pandemic: The Society Of Vascular And Interventional Neurology Collaboration

Stroke ◽

10.1161/str.52.suppl_1.2 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

James E Siegler ◽

Alicia Zha ◽

Alexandra L Czap ◽

Santiago Ortega-Gutierrez ◽

Mudassir Farooqui ◽

...

Keyword(s):

Acute Stroke ◽

Treatment Time ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Independent Effect ◽

Continuous Variables ◽

Acute Stroke Care ◽

Delayed Treatment ◽

Collateral Effect ◽

Transferred Patients

Background: We sought to evaluate whether the coronavirus disease 2019 (COVID-19) pandemic may have contributed to delays in acute stroke management at Comprehensive Stroke Centers (CSCs). Methods: Pooled clinical data of consecutive adult stroke patients from 12 U.S. CSCs (1/1/2019-5/31/2020) were queried. The rate of thrombolysis for non-transferred patients within the Target: Stroke goal of 60min was compared between patients admitted 3/1/2019-5/31/2019 (pre-COVID-19) and 3/1/2020-5/31/2020 (COVID-19). The time from arrival to imaging and treatment with thrombolysis or thrombectomy, as continuous variables, were also assessed. Results: Of the 7906 patients included, 1319 were admitted pre-COVID-19 and 933 were admitted during COVID-19, 15% of whom underwent intravenous thrombolysis. There was no difference in the rate of thrombolysis within 60min during COVID-19 (OR 0.88, 95%CI 0.42-1.86, p=0.74), despite adjustment for variables associated with earlier treatment (adjusted OR 0.82, 95%CI 0.38-1.76, p=0.61). There was no significant overall delay to thrombolysis during the COVID-19 period vs. pe-COVID-19 (p=0.42), even after multivariable adjustment (p=0.63) or after comparison across months leading to COVID-19 (Figure). The only independent predictor of delayed treatment time between periods was the use of emergency medical services (adjusted β=-6.93, 95%CI -12.83 - -1.04, p=0.03). There was no significant delay from hospital arrival to imaging in all patients, or imaging to skin puncture in patients who underwent thrombectomy. Conclusions: There was no independent effect of the COVID-19 period on delays in acute care with respect to thrombolysis or thrombectomy in this multicenter observational cohort. Further studies are warranted to externally validate these findings, and determine if site volume or center accreditation may mediate a collateral effect of the pandemic on stroke care paradigms.

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