key: cord-310105-a4fzp6bn
authors: Kamdar, Hera A.; Senay, Blake; Mainali, Shraddha; Lee, Vivien; Gulati, Deepak Kumar; Greene-Chandos, Diana; Hinduja, Archana; Strohm, Tamara
title: Clinician's Perception of Practice Changes for Stroke During the COVID-19 Pandemic: Perception of Practice Changes for Stroke During COVID-19
date: 2020-07-22
journal: J Stroke Cerebrovasc Dis
DOI: 10.1016/j.jstrokecerebrovasdis.2020.105179
sha: 
doc_id: 310105
cord_uid: a4fzp6bn

BACKGROUND: Approach to acute cerebrovascular disease management has evolved in the past few months to accommodate the rising needs of the 2019 novel coronavirus (COVID-19) pandemic. In this study, we investigated the changes in practices and policies related to stroke care through an online survey. METHODS: A 12 question, cross-sectional survey targeting practitioners involved in acute stroke care in the US was distributed electronically through national society surveys, social media and personal communication. RESULTS: Respondants from 39 states completed 206 surveys with the majority (82.5%) from comprehensive stroke centers. Approximately half stated some change in transport practices with 14 (7%) reporting significant reduction in transfers. Common strategies to limit healthcare provider exposure included using personal protective equipment (PPE) for all patients (127; 63.5%) as well as limiting the number of practitioners in the room (129; 64.5%). Most respondents (81%) noted an overall decrease in stroke volume. Many (34%) felt that the outcome or care of acute stroke patients had been impacted by COVID-19. This was associated with a change in hospital transport guidelines (OR 1.325, P=0.047, 95% CI: 1.004-1.748), change in eligibility criteria for IV-tPA or mechanical thrombectomy (MT) (OR 3.146, P=0.052, 95% CI: 0.988- 10.017), and modified admission practices for post IV-tPA or MT patients (OR 2.141, P=0.023, 95% CI: 1.110-4.132). CONCLUSION: Our study highlights a change in practices and polices related to acute stroke management in response to COVID-19 which are variable among institutions. There is also a reported reduction in stroke volume across hospitals. Amongst these changes, updates in hospital transport guidelines and practices related to IV-tPA and MT may affect the perceived care and outcome of acute stroke patients.

A 12 question, cross-sectional survey targeting practitioners involved in acute stroke care in the US was distributed electronically through national society surveys, social media and personal communication. 

Our study highlights a change in practices and polices related to acute stroke management in response to COVID-19 which are variable among institutions. There is also a reported reduction in stroke volume across hospitals. Amongst these changes, updates in hospital transport guidelines and practices related to IV-tPA and MT may affect the perceived care and outcome of acute stroke patients.

Acute stroke care is time sensitive and requires a prompt multidisciplinary approach for effective management. The essential components involve rapid decision making for the need of thrombolytic therapy and/or endovascular intervention, and then transfer to a center with a higher level of care as described in the "Hub and Spoke" model 1 . This model of practice allows for timely intervention for patients presenting at remote community hospitals and improves overall patient outcomes 2 .

As the 2019 novel coronavirus (COVID-19) pandemic continues to evolve, hospitals across the nation have implemented new policies and protocols to ensure the safety of patients and practitioners, and to conserve or reallocate resources. We sought to survey the stroke community across the nation to understand the current changes in stroke systems of care.

The primary objective of this survey is to understand the changes in practices and policies related to acute stroke care during the COVID-19 pandemic. The secondary objective is to analyze the effect of these changes on the perceived impact of acute stroke care and patient outcome.

This is an IRB exempt, observational, population-based study led by researchers at The Ohio State University. A cross-sectional survey of twelve questions (Table 1) 

The intended participants for this survey were practicing and training physicians and advanced practice providers (APPs) on the front lines of stroke care. This included multiple specialties such as neurology, neurosurgery, internal medicine, and emergency medicine.

To minimize recall bias we created a descriptive and detailed set of questions that were internally peer-reviewed prior to distribution. We also targeted health care professionals that would be the most informed about these practice changes.

Data were analyzed with SPSS 26 for windows. Descriptive statistics were used to report the characteristics of survey respondents. Attitudes about hospital transport, specialty unit utilization, stroke volume and patient outcomes were compared to demographic characteristics with a Chi-squared test. Binomial logistic regression analysis was conducted using questions regarding change in stroke practice as independent variables to identify factors associated with perceived change in outcome or care. Regression diagnostics were performed for each analysis.

The statistical significance was set at p < 0.05 (two-sided). Odds ratios (ORs) and their 95% confidence intervals were used to quantify the associations between variables.

We received a total of 206 responses with a 100% completion rate. Six surveys were excluded since the respondents were outside the target population (3 RNs, 2 pharmacists, one neuroscience coordinator). The respondents included 153 (76.5%) attending/practicing physicians, 75 (37.5%) vascular neurologists, and 56 (28%) neurocritical care specialists ( Table   Perception of Practice Changes for Stroke During COVID-19 7 2). The majority (82.5%) identified themselves as working in the setting of a comprehensive stroke center (Table 2) . Survey respondents represented 39 states.

Respondents reported the following: no change in hospital transport practices in 95 (47.5%), transferring most patients in 53 (26.5%), transferring only some patients in 20 (10%), and significantly limiting the number of patients transferring in 14 (7%). Other responses included "We went on Neuro-divert" and "Yes, EMS stopped bringing us patients altogether".

Most responded that mechanical thrombectomy (MT) (96.5%), ruptured aneurysm (88.5%), ICH intervention (86%), and hemicraniectomy monitoring (81.5%) warranted transport to a higher level of care.

Participants from many institutions reported implementation of new policies regarding acute stroke management to limit healthcare provider exposure, and these practices varied widely (Table 3) . Common strategies to ensure patient and provider safety included using personal protective equipment (PPE) during evaluation of all patients (63.5%) and limiting the number of practitioners in the room (64.5%). Despite increased precautions, most respondents (89.5%) did not report change in eligibility criteria for interventional therapies such as IV-tPA or MT. Other responses included elective intubation for MT patients to "reduce exposure in the angiography suite", and more conservative criteria for MT with regards to age and baseline Modified Rankin 

The COVID-19 pandemic has multifactorial impact on the logistics of stroke care and has required rapid adaptation at stroke centers nationally. Special considerations include: maximizing safety of healthcare workers and patients (appropriate PPE and adjustment in protocols to include enhanced screening of patients for COVID-19), effect of mitigation policies on stroke volumes, and changes in protocols that would potentially add delays to time sensitive acute treatments.

Our study demonstrated the rapidly changing environment surrounding stroke patients in the era of COVID-19. Stroke volumes were reported to be decreased. Many respondents also felt that the outcome or care of stroke patients at his or her institution had been impacted by the COVID-19 pandemic.

Based on our multicenter survey, it can be gleaned that across the country a majority of centers are seeing lower stroke volumes compared to pre-pandemic numbers. Several centers noted that, despite the lower overall volumes, large vessel occlusion and major strokes have been on the rise. Our findings are in alignment with several other reports 3-5 .

One hypothesis for this phenomenon is patients' fearing or avoiding the emergency department due to the risk of COVID-19 infection 4 Additionally, an argument can be made for proactive public education regarding the feasibility of safe delivery of acute stroke care despite the ongoing pandemic 7 . Although the COVID-19 pandemic has redirected the healthcare focus and resources as a public health emergency, stroke continues to be a cause of neurologically devastating injury and remains an important cause of morbidity and mortality across the USA. Hence continued efforts to ensure delivery of effective and evidenced based stroke care is critical.

Ultimately, nationwide procedural changes have been implemented to ensure the safety of patients, healthcare providers and hospital staff to allow for continued effective care throughout this pandemic. These necessary efforts can be streamlined in ways to decrease a delay in emergent care, as in the case of acute stroke patients. Suggestions to consider include: expanding the availability and expediting the result processing of Rapid RT-PCR SARS-CoV-2 testing both in the emergency department and from transferring hospitals to allow for efficient triaging; dedicating a single CT Scanner and/or Angiogram Suite to limit cross contamination of patient's and streamline the turnover process; and/or intubating all patients requiring MT if COVID-19 status is pending to ensure safety of providers without delaying door to groin puncture times.

Survey responses limit our data to subjective interpretations of stroke care at individual institutions. Stroke quality metrics and objective outcomes were not incorporated into this study.

While we did have survey respondents from almost every state in the USA, many have only 1-3 respondents, and several states appeared oversampled (California, Michigan, Ohio) which may limit external validity. Sample size was also not prioritized because of the rapidly escalating disease burden within the United States and the need to report our results in a timely fashion. A majority of respondents were from comprehensive stroke centers, which may also limit application to primary stroke centers and community-based hospitals.

The significance seen with change in stroke volumes dependent on area of speciality may potentially be confounded by the level of training and/or differing exposure rates to acute stroke care. Similar significance seen in regards to region may reflect regional practices, though small Perception of Practice Changes for Stroke During COVID-19 13 sample size limits utility of this finding. Prior studies suggested differences in patterns of care and hospital characeristics based on location 17 .

It is evident from our questionnaire that change in practices for acute stroke care including hospital transport guidelines and policies regarding interventional therapies may impact perceived stroke outcome or care. As emphasized in the AHA guidelines, hospital systems should make efforts to limit changes in established stroke practices. This is a pressing concern as current national and state wide restrictions may not lift for some time. What procedures are still considered essential requiring transport to a comprehensive stroke center during the COVID-19 pandemic?* Have stroke alert practices changed at your institution during the COVID-19 pandemic?* Is there any change in eligibility criteria for tPA or thrombectomy to limit staff exposure and save resources for PUI or +COVID-19 patients? Have you changed admission practices for post-tPA or thrombectomy patients during the COVID-19 pandemic?* Has your Stroke and/or Neuro Intensive Care Unit been affected by the COVID-19 pandemic?* Do you believe there has been a change in stroke volume at your institution in the setting of the COVID-19 pandemic? Do you believe the outcome or care of stroke patients at your institution has been impacted in the setting of the COVID-19 pandemic? *Select all that apply 0.754 *Responses included "yes", "no" or "other"

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