Decreased Ischemic Stroke Admissions and Telestroke Consultations During Pandemic

Mark Etherton, MD, PhD

Data from a recent study suggest that the COVID-19 pandemic has led to decreasing telestroke consultations, decreased ischemic stroke (IS) admissions, and reduced performance on stroke quality of care.

Researchers found that telestroke consultations were reduced by 1.32% per week (P = .004) and IS patient admissions decreased from 13.3 patients per week prior to March 1, 2020 to 10.3 patients per week afterward (P = .04). Patient presentation and care delivery time metrics were unchanged, but rates of adherence to dysphagia screening, early antithrombotic initiation, and early venous thromboembolism were reduced.

First author Mark Etherton, MD, PhD, associate director, acute stroke service, Massachusetts General Hospital, and instructor, Harvard Medical School, and colleagues wrote that “many physicians and health care leaders have expressed concern about the potential consequences of delayed care for time-critical diagnoses like stroke and acute myocardial infarction. Understanding the influence of the COVID-19 pandemic on stroke patient presentation, and systems and quality of care, holds potential to improve stroke care moving forward.

Etherton and colleagues analyzed data from 1248 patient presentations—844 telestroke consultations and 404 comprehensive stroke center admissions—at 2 academic hub hospitals and 24 urban, suburban, and rural spoke hospitals across 3 New England states that make up the Partners TeleNeurology Network. There was a maximum of 16% (65 of 404 admissions) overlap in cases between the 2 cohorts as 125 telestroke consultations had documentation of plan to transfer and 52% (n = 65) indicated a plan to transfer to comprehensive care centers.

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The researchers found decreasing telestroke consultations over the 6-month study period, but no differences in the mean number of consultations prior to (33.7 per week) and after March 2020 (29.8 per week; P = .11) or the mean number of stroke cases per week prior to March (23.9) and after (21.2). All stroke admissions decreased from 16.7 patients per week prior to March to 12.9 patients per week after March (P = .02).

Etherton and colleagues saw that final diagnoses of IS after telestroke consultation decreased by 1.24% cases per week (P = .02). Transient ischemic attack (TIA) cases decreased from 3.5 cases per week prior to March 2020 to 1.8 cases per week after (P = .02) and made up a smaller proportion of telestroke consultations after March (10.5%) as compared to before (5.4%; P = .02).

The researchers found that rates were also reduced for alteplase administrated within 3.5 hours of last known well (LKW) time and treated by 4.5 hours, decreasing from 100% (n = 15) to 55.6% (n = 5) pre- and post-March, respectively (P = .01). Dysphagia screening similarly decreased from 94.6% (n = 210) of cases to 66.7% (n = 94; P <.001), early antithrombotic initiation decreased from 100% (n = 134) to 70.4% (n = 50; P <.001), and early venous thromboembolism prophylaxis decreased from 99.6% (n = 242) to 70.9% (n = 90; P <.001). Rates of stroke education also decreased from 98.3% (n = 114) to 87.0% (n = 60; P = .002). 

No significant changes were found in the number of patients treated with alteplase. No significant change was seen in the number of cases eligible for endovascular thrombectomy (EVT), or cases with large vessel occlusion (LVO), although EVT was performed in 4.26% fewer cases per week (P = .03).

No significant changes were seen in patients’ age or National Institutes of Health Stroke Scale (NIHSS) score. No differences were observed in time from LKW or symptom discovery to presentation or treatment.

“These findings suggest that the reorganization efforts of stroke systems of care in preparation for the COVID-19 surge were successful in mitigating the potential impact on delays in acute stroke treatment but that continued emphasis on optimizing stroke quality care is essential. For the purposes of population awareness and recognition of stroke and TIA symptoms, a continued national emphasis will be important for stroke prevention and public health,” Etherton and colleagues concluded.

NeurologyLive previously talked to James Grotta, MD, about the impact of the COVID-19 pandemic on stroke care. Grotta discussed the considerable toll on emergency medical services (EMS) providers and critical care workers, and how the pandemic could lead to clinician burnout and a dwindling EMS pool. Watch that interview below.

REFERENCE

Etherton MR, Zachrison KS, Yan Z, et al. Regional changes in patterns of stroke presentation during the COVID-19 pandemic. Stroke. 2021; 52. doi: 10.1161/STROKEAHA.120.031300