The Drastic Effects of COVID-19 on Stroke Services

November 11, 2020

The COVID-19 pandemic has caused large reductions in the number of patients with acute stroke presenting to hospital, increased in-hospital stroke mortality, and many post-stroke patients reportedly feeling abandoned at home, with caregivers left overwhelmed.

This was the picture painted by presentations during a special session on COVID-19 and stroke services at the recent European Stroke Organisation-World Stroke Organization (ESO-WSO) Conference 2020.

But there were also descriptions of how some stroke services quickly reorganized with the speedy development of telemedicine and tele-rehabilitation strategies, many of which will probably remain in practice after the pandemic is over.   

"COVID-19 has not only affected quantity of stroke care but also quality of care," commented Raul Nogueira, MD, professor of neurology at Emory University School of Medicine in Atlanta, Georgia.

"COVID-19 is having a major effect on patients with stroke," Nogueira said. Most of the problem is not actually a direct effect of the virus causing a stroke — which is probably quite rare — but rather, there is a large collateral damage on stroke care, with a significant reduction in the numbers of patients coming to the hospital, he said.

"Our data show that COVID-19 collateral damage on stroke care is an indisputable fact, with global distribution. This affects a wide spectrum of cerebrovascular disorders and other emergencies," including myocardial infarction (MI), he added.

Nogueira reported a study comparing the March-May 2020 period with a similar period before the pandemic across 97 hospitals in 20 US states. It included data on more than 23,000 patients, showed a 23% reduction in neuroimaging, and a 17% in detection of large vessel occlusions.

Our data show that COVID-19 collateral damage on stroke care is an indisputable fact … Dr Raul Nogueira

Comparing March and April 2020 with the same period in 2019 found a 39% decline in stroke hospitalizations, a 30% decline in patients receiving thrombolysis, and a 23% decline in thrombectomy procedures. 

Outcomes in hospitalized patients with acute ischemic stroke showed a 41% increase in in-patient mortality in the 2020 study period as compared with 2019.

The MI figures showed a 39% drop in acute MI hospitalizations and a 35% drop in PCI volumes. "That is pretty remarkable," Nogueira said.  

In terms of the global situation, Nogueira presented data from 187 stroke centers in 40 countries across six continents showing that in the 3-month period of March to May 2020, compared with the immediately preceding 3 months, there was a 19% decline in stroke admissions. This affected all continents, with higher-volume COVID-19 hospitals showing a higher rate of decline in stroke admissions, and higher-stroke-volume centers also suffering more.

Both thrombectomy and thrombolysis rates declined by 13% globally in this period in 2020. Rates of subarachnoid hemorrhage fell by 22% and there was an 11.5% drop in the number of aneurysms embolized. 

"We are seeing some signs of recovery, though, if we compare data early in the pandemic with a bit later on — by May/June there is a 10% recovery," Nogueira reported.   

The global data showed that 1.5% of patients with COVID-19 also had a diagnosis of stroke during hospitalization, and 3.3% of hospitalized stroke patients also had a diagnosis of COVID-19. This varied across continents, rising to 9% in South America.

"I would say there is a relationship between COVID-19 and stroke but this is relatively rare. In most of these patients who have stroke and COVID-19 at the same time, this is probably due to an overlap of two common conditions," Nogueira said.

Patients Feel Abandoned

David Hargroves, MD, the national lead for stroke at NHS England, reported the results of a UK survey of more than 2000 stroke survivors and their families conducted by the UK Stroke Association.

"Our findings show that patients feel abandoned and have significant mental health challenges, but we can optimize virtual working, which can be as good as face-to-face contact to support patients during this very challenging time," he said.  

Results of the survey showed that 29% of patients who had stroke during the pandemic admitted that they delayed calling healthcare services because of fear of COVID if admitted to the hospital.

While 70% of stroke survivors felt satisfied with care received in the hospital, half had therapy appointments or home care visits cancelled or postponed, and 55% did not feel safe to go to scheduled appointments, which Hargroves said demonstrated "the significant disruption to rehabilitation and support caused by COVID-19."

"About one third of patients felt they did not receive enough services after they left the hospital. These findings were not uncommon before the pandemic, but they seem to have been exacerbated during the pandemic," Hargroves said.  

Of those who had a stroke in 2019 (before the pandemic), 34% said support they received had worsened during the pandemic, and 70% reported feeling more anxious during this pandemic.

In addition, 77% of caregivers had to provide more care during the pandemic, and over 60% of caregivers felt overwhelmed.

Hargroves highlighted some of the recommendations that came out of the report, many of which he said were transferable to other countries.

These included an absolute need for government to ensure that emergency response and the FAST educational campaign are continued during the pandemic; attempts should be made to reach out to "the forgotten cohort" of patients discharged during the epidemic to ensure they are receiving some support services; and a requirement not to overlook the psychological impacts of stroke, which are often underdiagnosed and poorly treated.

Hargroves also described a project in which patients were offered a phone call by a non-healthcare professional up to 48 hours after discharge inquiring about well-being and asking specific questions — potential red flags — designed to direct them back to secondary care if necessary, or to other relevant services.

"We have had overwhelmingly positive feedback on this, with a quarter of patients wanting to be signposted to secondary Stroke Association services. Many patients reported that the phone call alleviated their anxiety," he noted.  

However, 20% of patients had cause for re-referral to secondary care, mostly related to medication concerns, lack of understanding of diagnosis, or changes in symptoms, a finding that Hargroves referred to as "anxiety provoking."

He added that one of the main barriers has been "perceived chaos in communication" that ensued during the pandemic.

Reorganizing Stroke Services

Reporting on the European situation, Blanca Fuentes, MD, PhD, La Paz University Hospital, Madrid, Spain, noted that "hospitals overloaded with COVID redirected resources to these patients."

In a European survey of stroke professionals early in the pandemic, 77% of those who responded felt that stroke patients were not receiving usual care, with this number in Italy and Spain rising to 82%. Many stroke professionals reported working longer hours because of lack of personnel and 15% had been assigned to tasks outside the stroke area.

Fuentes reported that the Madrid region reorganized stroke services to include protective equipment for staff, patients checked for COVID symptoms and given a PCR test, transport of severe patients directly to comprehensive centers to minimize contact with too many different people, limiting additional neuroimaging, and outpatient management of patients with transient ischemic attack (TIA) and minor stroke.

There were also different pathways for COVID-infected and uninfected patients, and early supported hospital discharge and telemedicine for follow-up and rehabilitation.  

Despite a reduction in stroke unit beds, the Madrid region still managed to provide reperfusion to 43% of patients with ischemic stroke and kept time metrics in the recommended ranges, Fuentes noted. But CT imaging in the emergency department was significantly delayed. "This reinforces the need to assess performance of different departments," she said.

The Rise of Telemedicine

Gary Ford, MD, professor of stroke medicine at Oxford University, described new recommendations for telemedicine introduced in his region of the UK.

His team produced rapid guidance recommending that stroke units that do not currently use telemedicine should strongly consider putting a system in place, and those currently using telemedicine after-hours should consider moving to 24/7, with all centers advised to maximize telemedicine throughout the whole stroke pathway.

"The key issue is to avoid unnecessary hospital presentation of patients who are not having a stroke or who are having a minor stroke/TIA and who can be managed as an outpatient," Ford noted.      

If formal videoconference was not available in the emergency department then personnel were advised to use informal methods such as WhatsApp or FaceTime.

Other recommendations included moving staff over the age of 55 years to low-risk areas, virtual stroke ward rounds involving contact with the specialist in the office or at home if self-isolating.  

"The use of videoconferencing for rehabilitation and communication with families has been a positive development, which we will continue with after the pandemic is over," Ford commented.   

"These telemedicine approaches will be increasingly adopted across the stroke pathway, but we need a stronger evidence base for remote assessment of suspected acute stroke for thrombolysis," he concluded. "Teamwork collaboration and shared learning is more important now than ever before for the stroke community."  

Increasing Role for Tele-rehabilitation

Finally, in a presentation on the speedy establishment of a tele-rehabilitation service, Mark Bayley, MD, Toronto Rehabilitation Institute, Canada, explained that the massive disruption to traditional in-person rehabilitation because of the COVID pandemic has affected many medical conditions. 

"This will limit recovery — particularly in stroke where we know that rehabilitation intervention leads to enhanced recovery, particularly in the first 18 weeks," he said.  

As well as the obvious issues of patients not wanting to travel to the hospital for appointments, or for therapists to enter their homes, he pointed out that vigorous exercise may generate more aerosols and may increase the risk for COVID transmission. In addition, some rehabilitation resources were redeployed to treating COVID patients.

To try and meet these challenges, his group set up a tele-rehabilitation service in just a few weeks, with rollout starting in mid-April. Feedback was collected by email from patients and staff.

The biggest challenge, not surprisingly, was technology with 26% of patients reporting issues with this at the start. "But maybe this is not as high as you might think, and 50% of patients reported no issues with technology," Bayley noted. By fall, technology had become less of a concern — only 8% reported still having problems.

"What surprised us the most was that there were greater challenges reported by the providers than the patients and [caregivers]," Bayley said. Less than one third of therapists said they were satisfied with the technology, and there was a need for greater access to laptops and hands-free Bluetooth headsets. In addition, unstable connections were also an issue.

Additional training was required by 35% regarding how to learn to use the technology and how to teach patients to log on. They also reported "virtual fatigue" when moving from session to session.

"We learned that patients with more severe impairments were harder to serve in this way with video rehab, and this approach is limited to specific patients and those who had access to technology, which involves socioeconomic factors," Bayley reported. A caregiver often needed to be with the patient to enhance the safety and value of a virtual visit. "This is critical in many cases," he emphasized.

"Virtual rehab is not for everyone, but it can meet the needs of many and is preferable to not receiving any therapy," he added. "We are now trying to figure out how we can develop more of a hybrid model."

Bayley noted that tele-rehabilitation was more suitable for the less physical activities such as subjective assessments; operational assessment of the patient and home environment; cognition/depression screening; education; limited exercise and activity progression; self-management coaching; problem solving of activities of daily living; risk assessments; caregiver support; and communication therapies.

He cited several Cochrane reviews showing evidence in favor of virtual rehabilitation for many of these purposes. He also highlighted some useful resources available online, including the GRASP program for upper arm and hand exercise and "a great NHS website – My Therapy – which rates available smartphone Apps."

His group has developed the Toronto Tele-Rehabilitation Toolkit — also available online — which provides information on how to get started, how to prepare patients and caregivers, how to implement virtual rehabilitation, and how to evaluate and monitor the sessions.  

European Stroke Organisation-World Stroke Organization (ESO-WSO) Conference 2020: Presented November 9, 2020.

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