The impact of COVID-19 on the metrics for stroke care

A recent study published in PLOS ONE evaluated the effects of the coronavirus disease 2019 (COVID-19) pandemic on stroke code (SC) metrics.

Background

Spain is one of the countries affected most by the COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). More than 70,000 COVID-19 cases were recorded in the Community of Madrid (CM) by June 15, 2020. This catastrophe has obscured other pathologies leading to substantial interference in health systems.

Acute stroke is the leading cause of disability among adults and a second-leading cause of mortality worldwide. The therapies developed in the past three decades have lowered mortality in patients with acute ischemic stroke. Nonetheless, clinical outcomes depend on the time elapsed since symptom onset and reperfusion treatment.

Reports suggest that each minute saved in the beginning increases life without sequelae by one week. The detection of calls with the suspicion of acute stroke, dispatch of an ambulance, in-situ patient assessment, selection of appropriate (nearest) hospital, alerting on-duty neurologists, and rapid transfer of patients constitute the SC protocol.

The implementation of the SC protocol has significantly decreased the time to treatment, with consequences on patient outcomes. Disruptions to the SC protocol functionality could impact stroke care and aggravate patient outcomes. Several research groups have warned about a drastic decline in AS cases, ambulance service delays, and the saturation of call centers and hospital emergency departments during the first wave of the COVID-19 pandemic. However, there is limited information on most-affected services in the pre-hospital and hospital phases of urgent AS care.

About the study

In the present study, researchers evaluated the impact of the COVID-19 pandemic on the SC protocol in the CM. The primary objective was to compare the time spent in each phase of SC protocol in the pre-COVID-19 period (February 27 – June 15, 2019) and during the first COVID-19 wave (same period in 2020) in the CM. The secondary objective was the comparison of other fundamental SC aspects (diagnostic accuracy and in-hospital death, among others) between the two periods.

The study included the SC cohort of the Emergency Medical Service of Madrid (SUMMA 112) and discharge summary data from 10 hospitals with a stroke unit. Patients satisfying the SC criteria were eligible for inclusion. Patients were excluded if they lacked a health identification number (HIN) or a minimum basic data set (MBDS) record.

The time elapsed in each step of the pre-hospital SC process was analyzed. Data on sex, age, vital signs, suspicion of large vessel occlusion (LVO), place of patient admission, and Glasgow Coma Scale were collected in the pre-hospital phase. The severity status of patients was evaluated using 1) the Charlson comorbidity index (CCI), 2) the degree of severity and mortality risk, and 3) in-hospital death.

Findings

The SC protocol was activated for 966 patients – 514 in the pre-COVID-19 period and 452 during the pandemic. During the COVID-19 period, the SC protocol activation declined by 6.4% relative to the corresponding pre-pandemic period.

In the COVID-19 period, patients were younger and predominantly male. Vital signs, CCI, the degree of severity, and mortality risk were not statistically different between the two periods. The proportion of patients undergoing pre-hospital electrogram declined by 10% during the pandemic.

In-hospital mortality dropped from 14% to 9% in the pandemic, albeit statistically insignificant. During the pandemic, call management time by the coordinating center and the time spent in situ increased by 9% and 12%, respectively, relative to the pre-pandemic period. The median length of stay (LOS) in the hospital also increased by over 3% during the pandemic.

The differences in the proportion of patients treated with intravenous thrombolysis (IVT) or mechanical thrombectomy (MT) between the two periods were not significant. Similarly, in-hospital mortality was not significantly different between the two periods, albeit lower in the COVID-19 period.  

Conclusions

In summary, the researchers observed that response times of 112 call centers and in-situ time increased over 10% in the first COVID-19 wave, although the ambulance transit duration was not significantly affected. The median hospital LOS increased marginally during the pandemic.

Nevertheless, the diagnostic accuracy of emergency medical services (EMS) professionals was unaffected by the pandemic. The proportion of patients treated with MT or IVT in the pandemic was not significantly different from the pre-pandemic period, underscoring the resilience of the stroke network.