Reduction in Acute Stroke Admissions during the COVID-19 Pandemic: Data from a National Stroke Registry

Introduction: The COVID-19 pandemic overwhelmed health-care systems worldwide, and medical care for other acute diseases was negatively impacted. We aimed to investigate the effect of the COVID-19 outbreak on admission rates and in-hospital care for acute stroke and transient ischemic attack (TIA) in Israel, shortly after the start of the pandemic. Methods: We conducted a retrospective observational study, based on data reported to the Israeli National Stroke Registry from 7 tertiary hospitals. All hospital admissions for acute stroke or TIA that occurred between January 1 and April 30, 2020 were included. Data were stratified into 2 periods according to the timing of COVID-19 restrictions as follows: (1) “pre-pandemic” – January 1 to March 7, 2020 and (2) “pandemic” – March 8 to April 30, 2020. We compared the weekly counts of hospitalizations between the 2 periods. We further investigated changes in demographic characteristics and in some key parameters of stroke care, including the percentage of reperfusion therapies performed, time from hospital arrival to brain imaging and to thrombolysis, length of hospital stay, and in-hospital mortality. Results: 2,260 cases were included: 1,469 in the pre-COVID-19 period and 791 in the COVID-19 period. Hospital admissions significantly declined between the 2 periods, by 48% for TIA (rate ratio [RR] = 0.52; 95% CI 0.43–0.64) and by 29% for stroke (RR = 0.71; 95% CI 0.64–0.78). No significant changes were detected in demographic characteristics and in most parameters of stroke management. While the percentage of reperfusion therapies performed remained unchanged, the absolute number of patients treated with reperfusion therapies seemed to decrease. Higher in-hospital mortality was observed only for hemorrhagic stroke. Conclusion: The marked decrease in admissions for acute stroke and TIA, occurring at a time of a relatively low burden of COVID-19, is of great concern. Public awareness campaigns are needed as patients reluctant to seek urgent stroke care are deprived of lifesaving procedures and secondary prevention treatments.

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Development of the Madrid Stroke Programme: Milestones and Changes in Stroke Trends and Mortality from 1997 to 2017

Neuroepidemiology ◽

10.1159/000514077 ◽

2021 ◽

pp. 1-6

Author(s):

Silvia Pastor ◽

Elena de Celis ◽

Itsaso Losantos García ◽

María Alonso de Leciñana ◽

Blanca Fuentes ◽

...

Keyword(s):

Hospital Mortality ◽

Hospital Admissions ◽

Temporal Trends ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Care Organization ◽

Stroke Units ◽

Health Region ◽

Number Of Patients ◽

The Impact

Introduction: Stroke is a serious health problem, given it is the second leading cause of death and a major cause of disability in the European Union. Our study aimed to assess the impact of stroke care organization measures (such as the development of stroke units, implementation of a regional stroke code, and treatment with intravenous thrombolysis and mechanical thrombectomy) implemented from 1997 to 2017 on hospital admissions due to stroke and mortality attributed to stroke in the Madrid health region. Methods: Epidemiological data were obtained from the National Statistics Institute public website. We collected data on the number of patients discharged with a diagnosis of stroke, in-hospital mortality due to stroke and the number of inhabitants in the Madrid health region each year. We calculated rates of discharges and mortality due to stroke and the number of inhabitants per SU bed, and we analysed temporal trends in in-hospital mortality due to stroke using the Daniels test in 2 separate time periods (before and after 2011). Figures representing annual changes in these data from 1997 to 2017 were elaborated, marking stroke care organizational measures in the year they were implemented to visualize their temporal relation with changes in stroke statistics. Results: Hospital discharges with a diagnosis of stroke have increased from 170.3/100,000 inhabitants in 1997 to 230.23/100,000 inhabitants in 2017. However, the in-hospital mortality rate due to stroke has decreased (from 33.3 to 15.2%). A statistically significant temporal trend towards a decrease in the mortality percentage and rate was found from 1997 to 2011. Conclusions: Our study illustrates how measures such as the development of stroke units, implementation of a regional stroke code and treatment with intravenous thrombolysis coincide in time with a reduction in in-hospital mortality due to stroke.

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Abstract TP306: Characteristics and Outcomes Among Patients Transferred to Regional Stroke Centers Across the United States for Specialized Stroke Care

Stroke ◽

10.1161/str.47.suppl_1.tp306 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Syed F Ali ◽

Gregg Fonarow ◽

Eric Smith ◽

Li Liang ◽

Robert Sutter ◽

...

Keyword(s):

Hospital Mortality ◽

Acute Care Hospital ◽

Length Of Hospital Stay ◽

High Volume ◽

Stroke Care ◽

The United States ◽

Large Sample Size ◽

Care Hospital ◽

Stroke Registry ◽

Front Door

Intro: Many patients are transferred to stroke centers for advanced stroke care, especially after IV tPA. We sought to determine differences in the baseline characteristics and outcomes between AIS cases presenting directly to stroke centers’ front doors vs. transfers-in from another regional acute care hospital. Methods: Using data from the national GWTG-Stroke registry, we analyzed 970,390 AIS cases (01/2010 - 03/14). Patients at hospitals with high transfer-in rates (>15%) were selected (284 hospitals, 303,739 patients). Due to large sample size, instead of p-values, standardized differences were reported. Multivariable model (MV) examined the association of transfer-in vs. front door with the primary and secondary outcomes, adjusting for patient and hospital characteristics including NIHSS. Results: High volume transfer-in hospitals admitted 31% of their patients via transfer. Transfer-in patients were younger, more often white and non-Hispanic. They had similar stroke risk factors except for hypertension and previous stroke/TIA which were less common. Transfer-in had worse initial NIHSS, more often had altered consciousness and language disturbance. Transfer-in patients had longer length of hospital stay, higher mRS at discharge, and were less often discharged home. In-hospital mortality was ∼ 3% higher in transfer-in as compared with front-door. Among tPA treated patients, sICH < 36hr was more common in transfer-in patients. On MV, transfer-in patients had overall worse outcomes as shown by the higher odds of in-hospital mortality, longer length of stay, and not able to ambulate independently at discharge (Table). Conclusion: Many hospitals receive high volumes of stroke patients via transfer. Because transfer-in patients have worse outcomes, these patients have the potential to negatively influence institutional outcomes rates. Transfer-in patients should be carefully accounted for in risk adjusted models of hospital outcomes.

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Factors Associated with Shortening of Prehospital Delay among Patients with Acute Ischemic Stroke

Journal of Clinical Medicine ◽

10.3390/jcm8101712 ◽

2019 ◽

Vol 8 (10) ◽

pp. 1712 ◽

Cited By ~ 5

Author(s):

Raúl Soto-Cámara ◽

Josefa González-Santos ◽

Jerónimo González-Bernal ◽

Asunción Martín-Santidrian ◽

Esther Cubo ◽

...

Keyword(s):

Acute Stroke ◽

Public Awareness ◽

Stroke Care ◽

University Hospital ◽

Medical Emergency ◽

Acute Stroke Care ◽

Cross Sectional ◽

Factors Associated ◽

Prehospital Delay ◽

Awareness Campaigns

Background: Despite recent advances in acute stroke care, only 1–8% of patients can receive reperfusion therapies, mainly because of prehospital delay (PHD). Objective: This study aimed to identify factors associated with PHD from the onset of acute stroke symptoms until arrival at the hospital. Methods: A cross-sectional study was conducted including all patients consecutively admitted with stroke symptoms to Burgos University Hospital (Burgos, Spain). Socio-demographic, clinical, behavioral, cognitive, and contextualized characteristics were recorded, and their possible associations with PHD were studied using univariate and multivariable regression analyses. Results: The median PHD of 322 patients was 138.50 min. The following factors decreased the PHD and time until reperfusion treatment where applicable: asking for help immediately after the onset of symptoms (OR 10.36; 95% confidence interval (CI) 4.47–23.99), onset of stroke during the daytime (OR 7.73; 95% CI 3.09–19.34) and the weekend (OR 2.64; 95% CI 1.19–5.85), occurrence of stroke outside the home (OR 7.09; 95% CI 1.97–25.55), using a prenotification system (OR 6.46; 95% CI 1.71–8.39), patient’s perception of being unable to control symptoms without assistance (OR 5.14; 95% CI 2.60–10.16), previous knowledge of stroke as a medical emergency (OR 3.20; 95% CI 1.38–7.40), call to emergency medical services as the first medical contact (OR 2.77; 95% CI 1.32–5.88), speech/language difficulties experienced by the patient (OR 2.21; 95% CI 1.16–4.36), and the identification of stroke symptoms by the patient (OR 1.98; 95% CI 1.03–3.82). Conclusions: The interval between the onset of symptoms and arrival at the hospital depends on certain contextual, cognitive, and behavioral factors, all of which should be considered when planning future public awareness campaigns.

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Abstract 3446: Inpatient Code Stroke Protocol: A Quality Improvement and Knowledge Translation Strategy for a Challenging Scenario

Stroke ◽

10.1161/str.43.suppl_1.a3446 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Jacqueline D Willems ◽

Krsytyna Skrabka ◽

Roseane Nisenbaum ◽

Judith Barnaby ◽

Pawel Kostyrko ◽

...

Keyword(s):

Quality Improvement ◽

Acute Stroke ◽

Robust Regression ◽

Stroke Care ◽

Initial Assessment ◽

Stroke Severity ◽

Care Hospital ◽

Presenting Symptoms ◽

Number Of Patients ◽

Assessment And Treatment

Background: Stroke care faces a clinical challenge in treating inhospital strokes, which account for about 15% of all strokes. Prior studies showed an inequity in the assessment and treatment of inpatients who suffer a stroke versus out-of hospital. For example, inpatients have longer time to initial assessment, CT and are less likely (wait longer) to receive tissue plasminogen activator (t-PA). There is limited research evaluating the efficacy of inpatient code stroke protocols (ICSP) on access to and quality of hyper-acute stroke care. Objective: To evaluate the efficacy of the ICSP in a large tertiary care hospital. Methods: This prospective study evaluated a quality improvement strategy involving ICSP implementation at St Michael’s Hospital in 2009. The ICSP focuses on the identification of stroke symptoms and timely notification of most responsible physician, then leverages the Emergency Department code stroke process. A 3-month hospital-wide implementation period involved 60 min. education sessions with a minimum of 2 sessions per unit. Demographic factors, presenting symptoms, stroke severity, vascular risk factors as well as time of: symptoms onset, CT; and physician assessment were collected by chart abstraction after ethics approval. The primary outcomes was time from last seen normal (LSN) to CT scan. Secondary outcomes include time from LSN to initial assessment (IA), medical complications and number of patients receiving endovascular interventions or intravenous thrombolysis. The analysis was completed by comparing unadjusted and adjusted outcomes pre and post implementation of the ICSP. Descriptive statistics and robust regression was completed using SAS 9.0. Results: Overall, there were 245 inhospital strokes during the study period (152 pre and 93 post ICSP implementation). Mean age was 69.8 yrs, 60% were male. Most inpatient strokes occurred on cardiovascular services (42.9%). Main results summarized in table . There was no difference in the number of patients receiving thrombolysis or endovascular treatment. After adjustment for covariates, the ICS was associated with a significant reduction of 288 minutes (95%CI -566, -10) in time from LSN to CT. Similarly, there was significant reduction of 307 (95%CI -532, -82) in time from LSN to IA. Conclusions: Implementation of the ICSP resulted in improvements in the process indicators related to assessment and treatment of hyper-acute stroke. Similar quality improvement strategies can be implemented to ameliorate disparities between care for inpatients and outpatient presenting with an acute ischemic stroke.

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Epidemiological Surveillance of the Impact of the COVID-19 Pandemic on Stroke Care Using Artificial Intelligence

Stroke ◽

10.1161/strokeaha.120.031960 ◽

2021 ◽

Author(s):

Raul G. Nogueira ◽

Jason M. Davies ◽

Rishi Gupta ◽

Ameer E. Hassan ◽

Thomas Devlin ◽

...

Keyword(s):

Artificial Intelligence ◽

Acute Stroke ◽

Systems Of Care ◽

Ct Perfusion ◽

Stroke Care ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Number Of Patients ◽

The Impact

Background and Purpose: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform. Methods: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (−22.8%; 1.39–1.07 patients/day per hospital, P <0.001) and CT perfusion (−26.1%; 0.50–0.37 patients/day per hospital, P <0.001) as well as in the incidence of large vessel occlusion (−17.1%; 0.15–0.13 patients/day per hospital, P <0.001) and severe strokes on CT perfusion (−16.7%; 0.12–0.10 patients/day per hospital, P <0.005). The sampled cohort showed similar declines in the rates of large vessel occlusions versus thrombectomy (18.8% versus 19.5%, P =0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P =0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

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Sex Differences in Acute Stroke Care in a Statewide Stroke Registry

Stroke ◽

10.1161/strokeaha.107.493262 ◽

2008 ◽

Vol 39 (1) ◽

pp. 24-29 ◽

Cited By ~ 81

Author(s):

Julia Warner Gargano ◽

Susan Wehner ◽

Mathew Reeves

Keyword(s):

Sex Differences ◽

Acute Stroke ◽

Stroke Care ◽

Acute Stroke Care ◽

Stroke Registry

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Changes in Stroke Patients’ Health-Seeking Behavior by COVID-19 Epidemic Regions: Data from the Korean Stroke Registry

Cerebrovascular Diseases ◽

10.1159/000519093 ◽

2021 ◽

pp. 1-9

Author(s):

Han-Yeong Jeong ◽

Eung-Joon Lee ◽

Min Kyoung Kang ◽

Ki-Woong Nam ◽

Jeonghoon Bae ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Patient Characteristics ◽

Stroke Care ◽

Health Seeking ◽

Stroke Patients ◽

Stroke Registry ◽

Care Services ◽

Health Seeking Behaviors ◽

Number Of Patients ◽

Using Data

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has led to changes in stroke patients’ healthcare use. This study evaluated changes in Korean stroke patients’ health-seeking behaviors and stroke care services using data from the Korean Stroke Registry (KSR). Methods: We reviewed data from patients with acute stroke and transient ischemic attack (TIA) during 2019 (before COVID-19 period) and 2020 (COVID-19 period). Outcomes included patient characteristics, time from stroke onset to hospital arrival, and in-hospital stroke pathways. Subgroup analyses were performed for an epidemic region (Daegu city and Gyeongsangbuk-do region, the D-G region). Results: The study included 1,792 patients from the pre-COVID-19 period and 1,555 patients from the COVID-19 period who visited hospitals that contribute to the KSR. During the COVID-19 period, the D-G region had two-thirds the number of cases (vs. the pre-COVID-19 period) and a significant decrease in the proportion of patients with TIA (9.97%–2.91%). Unlike other regions, the median onset-to-door time increased significantly in the D-G region (361 min vs. 526.5 min, p = 0.016), and longer onset-to-door times were common for patients with mild symptoms and who were in their 60s or 70s. The number of patients who underwent intravenous thrombolysis also decreased during the COVID-19 period, although the treatment times were not significantly different between the 2 periods. Discussion/Conclusion: Korean stroke patients in a COVID-19 epidemic region exhibited distinct changes in health-seeking behaviors. Appropriate triage system and public education regarding the importance of early treatment are needed during the COVID-19 pandemic.

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Admissions for Stroke and Strategies to Optimize Healthcare Delivery During the COVID-19 Pandemic - Experience from a Tertiary Care Hospital in South India

Journal of Evidence Based Medicine and Healthcare ◽

10.18410/jebmh/2021/599 ◽

2021 ◽

Vol 8 (36) ◽

pp. 3300-3305

Author(s):

Kevin John John ◽

Rhea Anne Roy ◽

Bincy Baby ◽

Deep P. Pillai ◽

Anilkumar Sivan ◽

...

Keyword(s):

Hospital Mortality ◽

Hospital Admissions ◽

Tertiary Care ◽

Care Hospital ◽

Hospital Type ◽

Stroke Incidence ◽

Nihss Score ◽

Number Of Patients ◽

Significant Difference ◽

Time Periods

BACKGROUND COVID-19 is associated with a hypercoagulable state and stroke is one of its most common neurological complications. The current study is aimed at investigating the effect of the COVID-19 pandemic on hospital admissions for stroke. METHODS We conducted a retrospective observational study to determine if there was a significant difference in the number of hospital admissions for stroke during the 2 months of lockdown and the two preceding months, (starting on 24 March 2020). The numbers were also compared with the figures during the same months in the previous year. The numbers were also compared to the same months one year prior. The secondary objectives were to compare the time between the onset of stroke and presentation to the hospital, type of strokes that presented to the hospital, severity of stroke, number of code activations, number of thrombolysis conducted, and in-hospital mortality between the same time periods. RESULTS The total number of patients admitted for stroke during the time periods from 25th March 2019 to 24th May 2019, 25th January 2020 to 24th March 2020 and 25th March 2020 to 24th May 2020 were 82, 72 and 75 respectively, and there was no statistically significant difference between these numbers. However, there was a significant increase in the proportion of stroke cases when compared to total hospital admissions. This suggests that an increase in stroke incidence may have been masked by a reduction in the total number of patients presenting to the hospital. The National Institutes of Health Stroke Scale (NIHSS) score of the patients who presented during the lockdown were higher. There were no significant differences in the time between the onset of stroke and presentation to the hospital, type of strokes that presented to the hospital, severity of stroke, number of code activations, number of thrombolysis conducted, and in-hospital mortality between the periods under study. CONCLUSIONS The present study suggests that there may be a relative increase in the incidence of stroke in the community, as a result of the COVID-19 pandemic. The patients who presented with stroke during the lockdown period had a higher NIHSS score. KEYWORDS COVID-19, Stroke, Lockdown

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Abstract 2734: Thrombolytics, Treatment, Transfer, and Triage: Improving Access to Stroke Care in Eastern North Carolina

Stroke ◽

10.1161/str.43.suppl_1.a2734 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Cristine W Small ◽

Susan D Freeman ◽

Dawn K Becker ◽

Katie A McGrath ◽

Alexandria B Gullette

Keyword(s):

North Carolina ◽

Thrombolytic Therapy ◽

Acute Stroke ◽

Clinical Outcomes ◽

Feedback Loop ◽

Stroke Care ◽

List Type ◽

Immediate Feedback ◽

Number Of Patients ◽

Eastern North Carolina

Background: We are a Certified Primary Stroke Center (PSC) at a regional health system serving 29 counties in eastern North Carolina. High poverty rates, socioeconomic, and demographics factors, create challenges for access to care in the heart of the stroke buckle. Purpose: This endeavor promotes best practice for acute stroke care and optimizes outcomes for patients. The PSC serves as the hub, offering supportive resources to community hospitals with an immediate feedback loop that fosters a seamless transfer process through a drip and ship model. As a result of outreach efforts in the region, an increased number of patients will receive thrombolytic therapy. Implementation of this model creates a community network that is well prepared to become a true stroke system of care. Methods: Development of a comprehensive transfer protocol that includes an algorithmic decision tree and continuous quality feedback loop Ongoing data analysis and sharing Key stakeholder collaboration 24/7 resource availability Immediate feedback loop to include phone calls Results: Regional transfers to our facility after t-PA, increased steadily each year from six in 2006 to 52 in 2010, illustrating a significant increase in t-PA utilization. Clinical outcomes were tracked throughout the hospital course to identify stroke severity and disposition. This resulted in a comprehensive analysis of all regional transfers post t-PA, prompting evaluation of t-PA utilization based on phone consults and the feasibility of triage for admission to an ICU or IU based on 18 months of clinical data. Last NIHSS < 12, favorable outcomes 71% of regional transfers had a last NIHSS < 12, 61% were discharged home, 34% Rehab, 5% SNF Regional and PSC average NIHSS comparison: Regional first NIHSS was13, last NIHSS - 9.9; PSC first NIHSS -11.5, last NIHSS 5.2 Conclusions: An increased number of patients are receiving thrombolytic therapy in our community hospitals as a result of outreach efforts in the region. Regional partnerships continue to grow. With growth comes an increased responsibility to explore every aspect of acute stroke treatment that may impact overall clinical outcomes. While the clinical efficacy of t-PA for stroke has been proven in numerous clinical trials, we are obligated as a PSC to take stroke care to the next level and continuously evaluate opportunities for improvement that will guide us to maximize EVERY patient’s outcome.

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Abstract WMP96: Stroke Warning Signs In Spanish Speaking Communities: Camaleon Strategy Proposal

Stroke ◽

10.1161/str.48.suppl_1.wmp96 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Miguel A Barboza ◽

Cinthya Agüero ◽

Paola Bastos ◽

Huberth Fernández

Keyword(s):

Acute Stroke ◽

English Language ◽

Early Recognition ◽

Public Awareness ◽

Warning Signs ◽

Medical Professionals ◽

Awareness Campaigns ◽

Spanish Speaking ◽

The World ◽

Informative Content

Introduction: early recognition of stroke signs lead to a better opportunity for acute management, to decrease morbidity and mortality impact. Public awareness campaigns have been developed with English language acronyms for recognition of these signs, but language and cultural differences should be taken into account for these educational strategies. Hypothesis: we assessed the hypothesis that there is a need for a validated tool for Spanish speaking population for early recognition of stroke warning signs. Material and methods: a 12-item electronic and paper-based survey for non-health related professionals evaluated the knowledge of early stroke signs in a Costa Rican sample. Using data from the FAST acronym, we developed a Spanish based acronym focused on the 3 most common symptoms, which was evaluated with medical professionals and non-medical population for clarity of message and informative content through a 10-item survey. Results: 706 non-medical professional subjects answered the evaluation survey (56.7% female, median age 33 years [IQR 24-43 years]), with 76.2% answering that they were not capable of diagnose an acute stroke, and 97.2% considering the necessity of develop an educational campaign for acute stroke signs recognition. CAMALEON acronym (CAra [face], MAno/brazo [hand/arm], LEnguaje [language] and teléfONo [telephone]) was created adapting FAST acronym to Spanish. 25 medical professionals evaluated the medical content of the Spanish acronym (based on an educational video) with a 95% of acceptance of its content to explain medical symptoms; also 91% of 100 non-medical subjects were able to recognize adequately the symptoms after viewing the video material. This academic initiative is endorsed by the World Stroke Academy from the World Stroke Organization. Conclusion: CAMALEON strategy is an adequate acronym for early recognition of acute stroke signs for Spanish speaking countries that should be validated in stroke awareness campaigns.

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