AHA Advice on Prehospital Acute Stroke Triage Amid COVID-19

Megan Brooks

May 19, 2020

The American Heart Association (AHA)/American Stroke Association (ASA) has developed a "conceptual framework" to assist emergency medical service (EMS) providers and in-hospital triage teams handle suspected cases of acute stroke during the ongoing COVID-19 crisis and future pandemics.

A key goal is to ensure timely transfer of patients while minimizing the risk of infectious exposure for EMS personnel, coworkers, and other patients, the writing group says.

"Acute ischemic stroke is still a highly devastating disease and the 'time is brain' paradigm remains true during the COVID-19 pandemic as well," writing group chair Mayank Goyal, MD, University of Calgary, Alberta, Canada, told Medscape Medical News.

"We have highly effective and proven treatments available. As such, treatment delays due to additional screening requirements and personal protection equipment (PPE) should be kept at a minimum," Goyal said.

"Practicing COVID-19 stroke workflows, through simulation training, can help to reduce treatment delays, minimize the risk of infectious exposure for patients and staff, and help alleviate stress," he added.

A New Layer of Complexity

The guidance statement, Prehospital Triage of Acute Stroke Patients During the COVID-19 Pandemic, was published online May 13 in the journal Stroke.

"The need to limit infectious spread during the COVID-19 pandemic has added a new layer of complexity to prehospital stroke triage and transfer," the writing group notes.

They say "timely and enhanced" communication between EMS, hospitals, and local coordinating authorities are critical, especially ambulance-based and facility-based telestroke networks.

The main factors to guide the triage decision are the likelihood of a large vessel occlusion; the magnitude of additional delays due to inter-hospital transfer and workflow efficiency at the primary stroke center or acute stroke ready hospital; the need for advanced critical care resources; and the available bed, staff, and PPE resources at the hospitals.

The group says it "seems reasonable" to lower the threshold to bypass hospitals that can't provide acute stroke treatment in favor of transporting to a hospital that is "stroke ready," particularly in patients likely to require advanced care. They caution, however, that taking all acute stroke patients to a comprehensive stroke center could overwhelm these centers and lead to clustering of COVID-19 patients.

They say it's equally important to ensure "necessary transfers" of stroke patients who would benefit from endovascular therapy or neurocritical care and avoid unnecessary patient transfers. "Doing so will likely require local hospital boards and health care authorities to collaborate and establish local guidelines and protocols," the writing group says.

"During the COVID-19 pandemic, it is more important than ever to ensure that stroke patients are taken to the right hospital that can meet their urgent needs at the outset," Goyal comments in an AHA news release.

The writing group emphasizes that the principles put forth in the document are intended as suggestions rather than strict rules and will be adapted and updated to meet the evolving needs during the COVID-19 crisis and future pandemics.

"The process of improving stroke workflow and getting the correct patient to the correct hospital fast is dependent on training, protocols, simulation, technology, and — probably most importantly — teamwork. These principles are extremely important during the current pandemic but will be useful in improving stroke care afterwards as well," Goyal told Medscape Medical News.

This research had no commercial funding. Members of the writing committee are on several AHA/ASA Council Science Subcommittees, including the Emergency Neurovascular Care, the Telestroke, and the Neurovascular Intervention committees. Goyal is a consultant for Medtronic, Stryker, Microvention, GE Healthcare, and Mentice. A complete list of author disclosures is available with the original article.

Stroke. Published online May 13, 2020. Full text

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