Recommendations for Prehospital Stroke Care During COVID-19 Published

Mayank Goyal, MD

Recommendations created by an international group of stroke specialists, on behalf of the American Heart Association (AHA) and American Stroke Association (ASA) Stroke Council Science Subcommittees, have been published, seeking to minimize the risk of infectious exposure of COVID-19 for emergency medical service (EMS) providers when transferring patients with acute stroke.¹

While the COVID-19 pandemic has broad implications on stroke patient triage, there are still unanswered questions and protocols to follow to minimize safety concerns. The recommendations note that EMS providers need to access a patient with acute stroke’s history and neurological status and determine the likelihood of a large vessel occlusion (LVO), all in a safe manner. Controlling infectious disease and determining the likelihood of the need for intensive care due to a potential COVID-19 infection are 2 additional factors that have come into play during this pandemic.

The authors, led by Mayank Goyal, MD, clinical professor, department of radiology, University of Calgary, and colleagues, laid the conceptual framework for acute stroke patient triage and transfer during the COVID-19 pandemic and similar healthcare emergencies in the future with challenges, resolutions to those challenges, and other take-home points.

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The proposed challenges and their resolutions included:

• Need for additional screening and enhanced communication between EMS and hospitals in the triage phase. The recommendations suggest that in order to overcome the challenge of limited data on travel history and respiratory symptoms available at the time of EMS arrival, several agencies have made COVID-19 screening tools for paramedics available online free of charge. If a patient is screened as positive, EMS can inform the receiving hospital with information to streamline proper protocol. In the setting of interfacility stroke transfer, EMS providers should be notified about COVID-19 status by the transferring hospital.
• Adequate use of personal protection equipment (PPE) and other methods to prevent spread. PPE is intended to reduce the risk of infectious exposure of healthcare personnel and should be donned before arrival at the patient’s location. The guidance suggests that EMS providers and hospital staff should be fit-tested and trained on how to effectively and safely use PPE. EMS and other frontline healthcare workers should be the first to receive vaccination when it becomes available.
• Need for advanced clinical monitoring and respiratory status management. Monitoring oxygen saturation, blood pressure, heart rate, and respiratory rate are crucial in patients with suspected or confirmed cases of COVID-19. The recommendations state that paramedics who utilize aerosol-generating procedures such as nebulized medications or cardiopulmonary resuscitation should wear a fit-tested N95 mask and a facial shield. Patient family members and other EMS team members should distance themselves during the procedure.
• Staff shortages and new responsibilities. Loss of personnel due to quarantining or illness can occur in a hospital setting, so individuals may be forced to take on new roles and responsibilities. Goyal et al. noted that simulation training may help individuals identify latent safety threats and modify the local protocols after being put in a position in which they are not accustomed to. As well, EMS employers should consider monitoring EMS providers for post-traumatic stress symptoms and provide appropriate assistance if needed.
• Choosing the right hospital. If a patient requires intubation and poststroke intensive care, they may be directly transferred to a comprehensive stroke center (CSC). To ensure patients are filtered to the correct facilities, the establishment of local coordination centers is encouraged. The authors suggest that telestroke systems should be used to facilitate patient and neuroradiological assessment between primary stroke centers (PSCs) or acute stroke ready hospitals (ASRHs) and CSCs.
• Challenges in patient transfer such as additional time delays. Due to additional screening and the use of PPE, it is anticipated that workflow times will increase, thus prompting the need to monitor them along with traffic patterns. The guidance recommends that EMS employers should establish proper cleaning protocols for ambulances as well as formulate simulation runs and heighten communication to minimize time delays.
• Minimizing infectious exposure and PPE shortages. Limiting person-to-person contact can ultimately prevent the spread of infectious disease. Especially during an interfacility transfer, a direct-to-mothership paradigm should eliminate delays and avoid infectious exposure. Patients should also consider direct transfer to Cath Lab, which can avoid the infectious spread while preserving PPE.

“The principles presented in this statement paper are intended as suggestions rather than strict rules and might serve as a framework to establish and optimize local protocols. As this conceptual framework is preliminary in nature, it will require adaptation to the ongoing COVID-19 crisis and future pandemics,” Goyal and colleagues concluded.

These recommendations come on the heels of another stroke-care guidance published earlier in May 2020, which highlighted the possible issues and their solutions regarding stroke care amid the COVID-19 pandemic. The authors offered advice and specifically addressed the potential impact of the pandemic on the quality of care, ethical considerations, safety and logistic issues, and research in stroke.²

REFERENCE

1. Goyal M, Ospel JM, Southerland AM, et al. Prehospital triage of acute stroke patients during the COVID-19 pandemic. Stroke. Published online May 13, 2020. doi: 10.1161/STROKEAHA.120.030340

2. Leira EC, Russman AN, Biller J, et al. Preserving stroke care during the COVID-19 pandemic: Potential issues and solutions. Neurology. Published online May 8, 2020, doi: 10.1212/WNL.0000000000009713