The relevance of a strong healthcare system for acute stroke care during the COVID-19 pandemic

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Blanca Fuentes
María Alonso de Leciñana
Exuperio Díez Tejedor

Blanca Fuentes, María Alonso de Leciñana, and Exuperio Díez Tejedor write about the challenges faced in the management of stroke care throughout the pandemic, and the lessons learned. Fuentes originally presented on this topic at the joint European Stoke Organisation and World Stroke Organization (ESO-WSO) virtual conference (7–9 November, 2020).

The COVID-19 pandemic has disrupted the normal functioning of hospitals, causing an overload of emergency services and hospital wards with patients infected with SARSCOV-2. As a result, many of the human and material resources usually dedicated to stroke care were reallocated to attend COVID-19 patients. This fact might have negatively affected acute stroke care.

A recent web-based survey conducted by the ESO in March 2020, showed the negative impact on the delivery of stroke care. The survey was completed by more than 400 stroke care providers from 55 countries. A reported 77% of responders affirmed that not all stroke patients were receiving usual care, and this proportion was even higher in Italy and Spain, two of the most heavily affected countries by the first wave of the COVID-19pandemic in Europe.1

Extended working hours due to lack of personnel, sleep deprivation, the assignation of stroke physicians to new tasks outside of stroke care, and the shortage of personal protective equipment were frequently reported.1,2 To overcome the challenge of the pandemic, most hospitals in affected countries had to reorganise acute stroke resources, balancing two main objectives: first, to provide timely and effective stroke care; and second, to ensure safety and minimise the risk of infection inside the stroke teams.

It is important to highlight that reorganisation involves every component of the stroke care chain,3 starting with the general public by encouraging them to seek prompt medical attention and avoid staying at home for fear of contagion. At the prehospital level, it is essential to stick with stroke code priority while also ensuring the personal protection of all of the healthcare professionals evaluating the patients. A COVID-19 symptoms checklist should be implemented at this level for early identification of infected patients.

All health providers must be familiar with the code stroke protocol. This is especially important in those settings hiring temporary or external staff because of the pandemic who may not be familiar with local stroke code protocols.

Different pathways should be followed for patients with and without suspected COVID-19, including the use of different emergency wards, inpatient wards, stroke units and critical care units. We should encourage close outpatient management for TIA and minor stroke patients as well as the use telemedicine for follow-up and rehabilitation.

However, the implementation of the expert’s recommendations was not homogenous in the affected regions, since each hospital had to adapt them to their local characteristics and resources.4,5 Therefore, in addition to establishing organisational recommendations, we should evaluate their generalisability and effectiveness in terms of stroke treatment and outcomes.

Several multicentre studies in Europe have reported decrease in stroke admissions, but the good news is that, in the majority of them, the proportions of recanalisation therapies for acute ischemic strokes were kept without significant changes.6–9 even with an increase in the proportion of endovascular treatment in some regions.6 This suggests that the strength of the pre- COVID-19 stroke care systems, along with the implementation of the new organisational measures has played an essential role in affording the pandemic challenge.

Nevertheless, as the COVID-19 pandemic has not yet been fully eradicated, and with some countries undergoing new waves, it is also important to monitor the performance of each of the recommended measures to identify any deviation and correct it in the forthcoming waves.

One of the organisational measures that has come into question is the performance of Chest-computed tomography (CT) scan on acute stroke patients for the early detection of the COVID-19 lung involvement, as it seems to be associated to significant delays in door-to puncture-times.7 That recommendation was given at the beginning of the pandemic, to ensure the better allocation of the acute stroke patients in the COVID or COVID-free wards and pathways. Its rationale was that, at that time, there were large delays in the confirmation of the SARS-COV-2 infection by the polymerase chain reaction (PCR).

The reliability of PCR was initially poor, with many false negatives, which could compromise the safety of the members of the stroke teams and other stroke patients. Fortunately, diagnostic accuracy for the currently available tests is much better now, and there are no reasons for the systematic performance of Chest-CT. This finding is a good example of the importance of monitoring and evaluating the stroke care pathways during COVID-19 pandemic, to identify new needs and to discard some organisational measures that are not needed anymore.

The war against the pandemic is still on-going. The first wave of the pandemic caught us off guard, but we knew how to adapt and deal with it. We have learned our lesson and we may face the new waves with reinforced organisational measures to care for acute stroke.

Blanca Fuentes. Head of the stroke unit, Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ, La Paz University Hospital-Universidad Autónoma de Madrid, Madrid, Spain.

María Alonso de Leciñana. Coordinator of the Stroke Group, Spanish Society of Neurology, Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ, La Paz University Hospital-Universidad Autónoma de Madrid, Madrid, Spain.

Exuperio Díez Tejedor. Coordinator of the Ictus Madrid Program, Department of Neurology and Stroke Centre. Hospital La Paz Institute for Health Research- IdiPAZ, La Paz University Hospital- Universidad Autónoma de Madrid, Madrid, Spain.

References:

  1. Aguiar de Sousa D, van der Worp HB, Caso V, et al. Maintaining stroke care in Europe during the COVID-19 pandemic: Results from an international survey of stroke professionals and practice recommendations from the European Stroke Organisation. Eur Stroke J. Epub ahead of print 2020. DOI: 10.1177/2396987320933746.
  2. Alonso de Leciñana-Cases M, Castellanos M, Ayo-Martín Ó, et al. Stroke care during the COVID-19 outbreak in Spain. The experience of Spanish stroke units. Stroke Vasc Neurol. Epub ahead of print 2020. DOI: 10.1136/svn-2020-000678.
  3. Rodríguez-Pardo J, Fuentes B, Alonso de Leciñana M, et al. Acute stroke care during the COVID-19 pandemic. Ictus Madrid Program recommendations. Neurologia 2020; 35: 258–263.
  4. Bersano A, Kraemer M, Touzé E, et al. Stroke care during the COVID‐19 pandemic: experience from three large European countries. Eur J Neurol 2020; 27: 1794–1800.
  5. Fuentes B, Alonso de Leciñana M, Calleja-Castaño P, et al. Impact of the COVID-19 pandemic on the organisation of stroke care. Madrid Stroke Care Plan. Neurologia 2020; 35: 363–371.
  6. Sacco S, Ricci S, Ornello R, et al. Reduced admissions for cerebrovascular events during COVID-19 outbreak in Italy. Stroke 2020; 51: 3746–3750.
  7. Fuentes B, Alonso de Leciñana M, García-Madrona S, et al. Stroke acute management and outcomes during the COVID-19 outbreak: a cohort study from the madrid stroke network. Stroke (in Press).
  8. Tejada Meza H, Lambea Gil Á, Sancho Saldaña A, et al. Impact of COVID-19 outbreak on ischemic stroke admissions and in-hospital mortality in North-West Spain. Int J Stroke 2020; 15: 755–762.
  9. Tejada Meza H, Lambea Gil Á, Sancho Saldaña A, et al. Impact of COVID‐19 outbreak in reperfusion therapies of acute ischaemic stroke in northwest Spain. Eur J Neurol 2020; 27: 2491–2498.

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