key: cord-0762822-hihxystf
authors: Banfield, W.H.; Elghawy, O.W.; Dewanjee, A.; Brady, W.J.
title: Impact of COVID-19 on emergency department management of stroke and STEMI. A narrative review
date: 2022-05-01
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2022.04.033
sha: 4ae2482606c9de9a183d7285d708f72346b8b757
doc_id: 762822
cord_uid: hihxystf

The novel coronavirus of 2019 (COVID-19) has resulted in a global pandemic; COVID-19 has resulted in significant challenges in the delivery of healthcare, including emergency management of multiple diagnoses, such as stroke and ST-segment myocardial infarction (STEMI). The aim of this study was to identify the impacts of the COVID-19 pandemic on emergency department care of stroke and STEMI patients. In this study a review of the available literature was performed using pre-defined search terms, inclusion criteria, and exclusion criteria. Our analysis, using a narrative review format, indicates that there was not a significant change in time required for key interventions for stroke and STEMI emergent management, including imaging (door-to-CT), tPA administration (door-to-needle), angiographic reperfusion (door-to-puncture), and percutaneous coronary intervention (door-to-balloon). Potential future areas of investigation include how emergency department (ED) stroke and STEMI care has adapted in response to different COVID-19 variants and stages of the pandemic, as well as identifying strategies used by EDs that were successful in providing effective emergency care in the face of the pandemic.

Coronavirus disease of 2019 , caused by Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), has resulted in a global pandemic; the initial outbreak occurred in late 2019 in Wuhan, Hubei Province, China. The virus spread rapidly around the world and was initially declared a pandemic on March 11, 2020. Recent variants, including the Delta and Omicron variants, have resulted in significant increases in cases and a related massive impact on the delivery of healthcare, including emergency management of multiple diagnoses, syndromes, and presentations.

It has become evident that the COVID-19 pandemic has had both direct and indirect impacts on the ability of emergency systems to deliver high quality care in acute settings. With over 69 million COVID-19 cases to date in the United States, it is unsurprising that being forced to isolate, diagnose, and treat these patients while still managing the millions of other emergent cases is taxing on both the healthcare system and healthcare professionals. 1 Resources and staffing have subsequently become a growing concern nationwide as shortage of vital resources such of PPE has greatly increased burden on emergency medicine physicians. 2, 3, 4 In addition to the direct impacts of the COVID-19 pandemic discussed above, to date in the United States there have been over 79 million reported cases of coronavirus infection and nearly 1 million deaths due to the virus. 5 The indirect impacts of the COVID-19 pandemic may not be as evidently clear.

Emergency medicine has long been at notoriously high risk of developing burnout J o u r n a l P r e -p r o o f Journal Pre-proof before the pandemic due to their long hours, shift work, and high emotional burden. 6, 7 The COVID-19 pandemic has been directly shown to increase the amount of healthcare workers suffering from exhaustion and subsequent burnout symptoms in several previous studies. 8, 9 It has been theorized that this increased fatigue and burnout could lead to a decreased quality of care delivered in emergency departments including care to patients with acute life threatening conditons. 10 Additionally, the need for dawning personal protective equipment and general precautions around contracting COVID may delay emergency medical service response time. It is also probable that the acuity of the patients that are seen in the emergency room is higher than ever. Patients with acute, medical events such as stroke and ST-segment elevation myocardial infarction (STEMI) have been shown in several studies to be more reluctant to present to hospitals given the fear of contracting COVID-19 infection from these institutions. 11, 12, 13, 14, 15 When observing the quality of care that an emergency medicine program provides, there are several quality metrics that are usually assessed. For instance, the door to balloon time has become a performance measure of regional and national quality improvement initiatives by measuring the time it takes an emergency room to triage, diagnose and treat an occluded coronary artery causing a STEMI. 16, 17 Similar metrics such as the time to administer tissue plasminogen activator (tPA) in patients with acute ischemic stroke (door-to-needle time) or time to angiographic reperfusion of the ischemic brain (door-to-puncture time) are also used. 17, 18, 19 J o u r n a l P r e -p r o o f

While it is assumed that the strain of the pandemic has negatively impacted the care of all patients as outlined above, the exact impact of the COVID-19 pandemic on these quality metrics is not yet clear. This review aims to directly quantify the impact of the COVID-19 pandemic on the care of stroke and STEMI patients in emergency departments (ED) by assessing quality metrics door-to-balloon time and door-to-needle time, and door-to-puncture time. treatment")))) OR ("treatment outcome*" OR "Morbidity" OR "Mortality" OR "Clinical Effectiveness" OR "Outcome assessment" OR "Outcome*"))) AND ((("stroke" OR "CVA") OR ("Stroke"[Mesh]))). The final search regarding STEMI was ((((("emergency services" OR "Emergency Room*" OR "Emergency Department*") OR ("Emergency Service, Hospital"[Mesh])) AND (covid 19)) AND ((((("Mortality"[Mesh]) OR ("Treatment Outcome"[Mesh])) OR (("Time-to-Treatment"[Mesh]) OR ("time to treatment")))) OR ("treatment outcome*" OR "Morbidity" OR "Mortality" OR "Clinical Effectiveness" OR "Outcome assessment" OR "Outcome*"))) AND (covid 19)) AND (("ST Elevation Myocardial Infarction"[Mesh]) OR ("ST elevation myocardial infarction")).

Articles were excluded if they did not contain primary data in emergency department settings, did not make distinctions between pre-and pandemic periods, did not reported quality measures such as time to intervention, had no mortality metrics, and were not written in English. Case reports, review articles, meta-analyses, and letters were also excluded. Data from the included articles was summarized by disease type. Details about each study included are included in the following sections (Table 1) .

Primary data extracted for strokes were the number of strokes presenting to EDs, doorto-needle time, and door-to-puncture-time in the pre-pandemic and pandemic periods.

Door-to-needle time was defined as time from initial presentation to time of thrombolytic administration. Door-to-puncture time was defined as time from presentation to start of thrombectomy procedure. Secondary outcomes included onset-to-door time, door-to-CT time, and mortality for stroke patients presenting to emergency departments in the prepandemic and pandemic periods. Onset-to-door time was denied as time from when a patient first became symptomatic to presentation, while door-to-CT time was defined as time from a patient's initial presentation to obtaining a non-contrast CT head.

Primary data extracted in regards to STEMIs were number of cases presenting to EDs and door-to-balloon time in the pre-pandemic and pandemic periods. Secondary outcomes were onset-to-door time and mortality in both periods. Door-to-balloon time was defined as the time form presentation to percutaneous coronary intervention.

Onset-to-door time was defined as the time from first reported symptom to prestation. 

Across included articles with data pertaining to ED stroke presentations there were a total of 2,596 confirmed stroke presentations in the pre-pandemic period with mean of 185.43 (range 17 to 536). In the pandemic period a total of 1,863 were reported with a mean of 133.1 (range 18 to 298). This constitutes a negative 28.24 percent change between the pre-pandemic and pandemic study periods. The difference between the means was 52.36 (95% CI -103.66 to -1.05). There was a statically significant difference in the mean number of stroke presentations between the two periods with t= -2.21 (p-value= .046). 

A total of 2,819 and 201 STEMI patients were reported across all included articles in the pre-pandemic and pandemic periods respectively. The mean number of pre-pandemic STEMI cases presenting to EDs was 313.22 while the mean number of pandemic period STEMI cases was 100.11. This constitutes a percent change of -68.04, with a difference between the means of -213.11 (95% CI -466.7 to 40.48). Two-tailed test between the means showed no significant difference (t = -1.94, p-value= 0.089).

Door-to-balloon time was reported in 7 of the 9 articles included pertaining to ED STEMI presentations. The mean door-to-balloon time in the pre-pandemic period was 57.97 min (range 29.0 to 119.0), compared to 61.94 min (range 22.7 to 122.0) in the pandemic period. Percent change between the means was calculated to be 6.85. Difference between the means was found to be 3.87 (95% CI -15.54 to 23.48). There was no significant difference between the mean door-to-balloon times in the two study periods 

While direct clinical outcomes related to COVID-19, such as case incidence rate, mortality, and morbidity, have been closely tracked; the indirect effects of the pandemic are multifactorial and less clearly established. Various reports and previous studies have demonstrated that the public fear regarding contracting the virus, especially in early stages of the pandemic, resulting in decreased utilization of emergency medical services. 12, 37, 38 Other studies have reported significant delays in acute care for a variety of emergent medical conditions, such as stroke and STEMI. 41, 42, 43, 44, 45 Finally, it has been well established that the COVID-19 pandemic has led to increased burnout for healthcare workers due to emotional exhaustion and decreased staff availability. 44 In this narrative review we set out to quantify the extent to which the pandemic affected the acute management of stroke and STEMI in the ED setting using commonly used quality measures.

Multiple previous studies have reported decreased numbers of stroke and STEMI cases presenting to EDs since the start of the pandemic. 39,40 While we did not find a statically significant decrease in the number of STEMI cases, there was an absolute decrease in the number of both STEMI and stroke cases seen between the pre-pandemic and pandemic periods. However, we did find a statistically significant decrease in the number of stroke cases presenting to EDs. While the national incidence of stroke had been reported to be decreasing in the years leading up to the COVID-19 pandemic, the sharp decrease seen between the pre-pandemic and pandemic periods seen in this study makes it unlikely to be an organic decrease in the incidence of stroke. It is more J o u r n a l P r e -p r o o f likely a reflection of public hesitancy to present to the ED settings due to concerns of contracting covid which has been previously reported. 5, 45 A statistically significant increase in onset-to-door time was found among stroke patients with a mean of 160 minutes in the pre-pandemic period to 231 minutes during the pandemic. This further supports previous literature that had found patients took longer to present to the ED after developing symptoms during the pandemic period. This change suggests public fear of potential nosocomial infection and hesitancy to increase contact with healthcare faculties during the COVID-19 pandemic has had a negative impact on the care of stroke patients since the start of the COVID-19 pandemic. 46, 47, 48, 49 Other factors contributing to increased onset-to-door time may be delays in emergency medical services (EMS). These transport and first responder services are a important part in management of time sensitive medical emergencies such as stroke and STEMI.

During the pandemic increased EMS call volumes were reported compared to prepandemic periods placing additional strain on these services. 52, 53 Also, delays in EMS response time including time form EMS call to scene arrival and scene arrival to door time have been reported. 52 However, the majority of studies found increased time form symptom onset to EMS call between pre-pandemic and pandemic periods. 55, 56, 57 While EMS may play a role in the increased onset-to-door time found in this study, the increased time to EMS call found in articles suggest that it may be due increased patient hesitancy to seek medical care due to fear of COVID-19 exposure.

The decrease in total number of stroke cases and increase in onset-to-door time for stroke both reflect a deleterious effect of the pandemic on the management of stroke.

However, we found that there was no significant change in door-to-CT, door-to-needle, door-to-puncture times, or mortality among stroke cases. These metrics reflect the speed with which stroke patients are directed to appropriate therapy upon presentation to the ED. The fact that there was not a significant increase in these markers suggests that EDs were able to accommodate the COVID-19 cases and protocols while also maintaining appropriate care for stroke patients. Similarly, door-to-balloon time and mortality among STEMI patients, was not found to be significantly different between the pre-pandemic and pandemic periods. This further demonstrates that managing COVID-19 cases and changes in isolation protocols did not preclude EDs from continuing to provide timely care for patients with STEMI.

One significant limitation of this analysis was that the included studies had a higher volume of pre-pandemic data compared to the pandemic period. The limited case volume during the pandemic period was largely due to the novelty of the COVID-19 pandemic and limited amount of published data during the search period compared to the literature regarding stroke and STEMI before the pandemic. Contributing to this was the search performed in this narrative review was limited to the National Library of Medicine. Furthermore, the pandemic has not been a singular change in terms of stress placed on the healthcare system. There have been peaks and troughs in terms of case load as well as multiple virus variants that have affected EDs differently. Another limitation of this study was that it did not stratify results by different phases of the J o u r n a l P r e -p r o o f pandemic. ED utilization has been shown to vary in time throughout the pandemic due to a number of factors. 58 These variations were not accounted for in our analysis which instead investigated the pre-and pandemic periods as a whole. As a result variations in stroke and STEMI care in EDs that may differ through pandemic phases may be masked in our analysis.

In summary, our analysis indicates that there was not a significant change in time required for key interventions for stroke and STEMI, including imaging (door-to-CT), tPA administration (door-to-needle), angiographic reperfusion (door-to-puncture), and percutaneous coronary intervention (door-to-balloon). In order to expand on these findings and more fully elucidate the effects of the pandemic on emergency medicine, further studies are needed. Potential future areas of investigation include how ED stroke and STEMI care has adapted in response to different COVID-19 variants or stages of the pandemic, and identifying strategies used by EDs that were successful in providing effective emergency care in the face of the pandemic. . STEMI mean quality measures for the pandemic and pre-pandemic periods. All times are measured in minutes and are: a) onset-to-door time, b) door-to-balloon time. Table 1 : Studies included after screening based on inclusion and exclusion criteria with demographic information. NR indicated that a value was not reported or was not reported as raw data that could be used for further analysis.

J o u r n a l P r e -p r o o f 

Fair Allocation of Scarce Medical Resources in the Time of Covid-19

Supporting the health care workforce during the COVID-19 global epidemic

Sourcing personal protective equipment during the COVID-19 pandemic

Emergency medicine physician burnout and wellness in Canada before COVID19: a national survey

Supporting the Health Care Workforce During the COVID-19 Global Epidemic

The challenge of emergency medicine facing the COVID-19 outbreak

Physician wellness during a pandemic

Suicide: Physician Loss in Emergency Medicine, Part I

Impact of the COVID-19 pandemic on the epidemiology of out-of-hospital cardiac arrest: a systematic review and metaanalysis

Out-of-hospital cardiac arrest volumes and characteristics during the COVID-19 pandemic

Public Perspectives on Decisions About Emergency Care Seeking for Care Unrelated to COVID-19 During the COVID-19

The impact of the COVID-19 pandemic on the care and management of patients with acute cardiovascular disease: a systematic review

The other side of novel coronavirus outbreak: Fear of performing cardiopulmonary resuscitation

Door-to-balloon time and mortality among patients undergoing primary PCI

Prognostic Implications of Door-to-Balloon Time and Onset-to-Door Time on Mortality in Patients With ST-Segment-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

Reducing Door-to-Puncture Times for Intra-Arterial Stroke Therapy: A Pilot Quality Improvement Project

Schwamm LHGWTG-Stroke Steering Committee and Investigators. The "golden hour" and acute brain ischemia: presenting features and lytic therapy in >30,000 patients arriving within 60 minutes of stroke onset

Impact of Covid-19 on Stroke Code Activations

Acute Stroke Care during the COVID-19 Pandemic: Reduction in the Number of Admissions of Elderly Patients and Increase in Prehospital Delays

The effect of the COVID-19 pandemic on ED referrals and care for stroke patients: A four-year comparative study

Decline in Stroke Presentations During

Impact of the COVID-19 outbreak on acute stroke care

Impact of the COVID-19 pandemic on hyperacute stroke treatment: experience from a comprehensive stroke centre in Singapore

Delays in Stroke Onset to Hospital Arrival Time During COVID-19

Impact of the SARS-COV-2 Pandemic on the Endovascular Treatment of Acute Stroke -an Italian Single-Center Experience

Impact of COVID-19 pandemic on acute stroke care: facing an epidemiological paradox with a paradigm shift

Impact of the COVID-19 Pandemic on Acute Stroke Care, Time Metrics, Outcomes, and Racial Disparities in a Southeast Michigan Health System

Impact of the SARS-CoV-2 Pandemic on Emergency Department Presentations in an Integrated Health System

The Pandemic's impacts on patients without Covid-19 on multidisciplinary aspects in emergency medicine care

Providing essential clinical care for non-COVID-19 patients in a Seoul metropolitan acute care hospital amidst ongoing treatment of COVID-19 patients

Presentations of stroke and acute myocardial infarction in the first 28 days following the introduction of State of Emergency restrictions for COVID-19

Influence of the Coronavirus Disease 2019 Pandemic on Patients with ST-Segment Elevation Myocardial Infarction in Taiwan

Impact of COVID-19 outbreak on regional STEMI care in Germany

Management of cardiovascular emergencies during the COVID-19 pandemic

Incidence, delays, and outcomes of STEMI during COVID-19 outbreak: Analysis from the France PCI registry

Impact of the SARS-CoV-2 Pandemic on Primary Percutaneous Coronary Intervention for Patients with ST-Elevation Myocardial Infarction

Decrease in emergency medical services utilization during early stages of the COVID-19 pandemic in British Columbia

Reduced hospital admissions for ACS -more collateral damage from COVID-19

Impact of COVID-19 Pandemic on Mechanical Reperfusion for Patients With STEMI

Treatment delays and in-hospital outcomes in acute myocardial infarction during the COVID-19 pandemic: A nationwide study

Stroke care during the COVID-19 pandemic: experience from three large European countries

Changes in Emergency Department Arrival Times for Acute Myocardial Infarction During the COVID-19 Pandemic Suggest Delays in Care Seeking

Emergency Department Utilization and Patient Outcomes During the COVID-19 Pandemic in America

Academic Emergency Medicine Physicians' Anxiety Levels, Stressors, and Potential Stress Mitigation Measures During the Acceleration Phase of the COVID-19 Pandemic

The other side of novel coronavirus outbreak: Fear of performing cardiopulmonary resuscitation

Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns -United States

Reports of Forgone Medical Care Among US Adults During the Initial Phase of the COVID-19

Fear and avoidance of healthcare workers: An important, under-recognized form of stigmatization during the COVID-19 pandemic

Where Are All the Patients? Addressing Covid-19 Fear to Encourage Sick Patients to Seek Emergency Care. Nejm Catalyst Innovations in Care Delivery

Changes in Emergency Medical Services Before and During the COVID-19 Pandemic in the United States

EMS) Calls During COVID-19: Early Lessons Learned for Systems Planning (A Narrative Review)

Delays in the Management of Patients with Acute Ischemic Stroke during the COVID-19 Outbreak Period: A Multicenter Study in Daegu, Korea

EMS) Calls During COVID-19: Early Lessons Learned for Systems Planning (A Narrative Review)

Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

Patient voluntarily delays call to emergency medical system for ST-elevation myocardial infarction during COVID-19 pandemic

Reduced Emergency Department Utilization During the Early Phase of the COVID-19 Pandemic: Viral Fear or Lockdown Effect?

The authors thank John S. Wang for his help in preparing this manuscript for publication.

 Table 1 : Studies included after screening based on inclusion and exclusion criteria with demographic information. NR indicated that a value was not reported or was not reported as raw data that could be used for further analysis. 

To whom it may concern-On behalf of all authors, I am submitting the following manuscript ("Cardiopulmonary Resuscitation Training: A Narrative Review Comparing Traditional Educational Programs with Alternative, Reduced-resource Methods of CPR Instruction for Lay Providers") for consideration of publication in The American Journal of Emergency Medicine. None of the authors have any conflicts to declare.