Reductions in Hospital Admissions and Delays in Acute Stroke Care During the Pandemic of COVID-19

Abstract

Background: Rapid and effective medical care for stroke is paramount to achieve maximal functional recovery. Because of the wide spreading of the coronavirus disease in 2019 (COVID-19), acute stroke care is negatively impacted. How much acute care for stroke has been affected during the pandemic remains to be assessed. Methods: The first-level response to major public health was launched from January 24th to April 29th, 2020 in Beijing to contain the spread of COVID-19. Based on a database connecting all 77 stroke centers, the quantity and quality in emergency care for stroke during the 97 lockdown days were compared with the equivalent period in 2019. During the pandemic, 15 of the 77 stroke centers were designated to receive patients sick with COVID-19. Subgroup analyses were carried out by different types of hospitals (designated and undesignated). Results: There were 1,281 and 2,354 stroke emergency hospital admissions in the lockdown period and the parallel period in 2019, respectively. A reduction of 45.6% in admission was shown in the lockdown period, with more reductions for hemorrhagic stroke (69.0%) compared with ischemic stroke (42.9%). More reductions happened in COVID-19 designated hospitals (52.6%) compared with undesignated hospitals (41.8%). The mean NIHSS score at hospital arrival was significantly higher in the lockdown period (9.4 ± 7.7 in 2020 vs. 8.4 ± 7.8 in 2019, P < 0.001). For the metrics measuring the quality of acute stroke care, the onset to door (OTD), onset to needle (ONT), and onset to recanalization (OTR) times didn't change significantly, while significant delays are shown for the door to CT scan (DTC, 1 min delay), door to needle (DTN, 4 min delays), and door to puncture (DTP, 29 min delays) times, which mainly happened in COVID-19 undesignated hospitals. Conclusions: Profound reductions in stroke hospital admissions and significant delays in emergency care for acute ischemic stroke occurred during the pandemic of COVID-19. Engagement and effective communication with all stakeholders including patients, health care providers, governmental policymakers, and other implementation partners are required for future success in similar crises.

Stroke admission rates before, during and after the first phase of the COVID-19 pandemic

“…This is in accordance with published reports from across the world [ 1 – 3 , 6 – 8 , 11 – 13 ]. A decrease in stroke activation codes and stroke admissions has been reported, and since the reduction has been mainly described for mild or moderate strokes, patient-related factors and avoidance behaviour due to COVID-19 have been postulated [ 1 – 3 , 6 – 8 , 11 – 13 ]. This behaviour may have the unfortunate consequence that people with strokes not seeking help during the pandemic may be at increased risk of future recurrent strokes due to the lack of optimal secondary prevention [ 16 ].…”

“…Many stroke centres have reported that COVID-19 discourages patients from contacting the health care system with an increase in prehospital delay and decrease in stroke admissions as a result [1][2][3][4][5][6][7][8][9][10][11][12][13][14]. We have previously reported a decrease of almost 1/3 in stroke admissions in relation to the lockdown in Norway [6].…”

“…Contrary to previous published studies, the present one includes stroke admissions as long as 5 months after the national lockdown [ 1 – 3 , 6 – 8 , 11 – 13 ]. Thus, this study shows the trend in stroke admissions in a longer period after a national lockdown.…”

“…To compare the weekly admission rates, the period from January 3 to March 12 was defined as before lockdown (weeks 1-10), the period from March 13 to April 30 was defined as during lockdown (weeks [11][12][13][14][15][16][17] and the period from May 1 to September 24 was defined as after lockdown (weeks 18-38).…”

“…We have previously reported a decrease of almost 1/3 in stroke admissions in relation to the lockdown in Norway [ 6 ]. In our country as in other countries, the reduction in the total number of stroke admissions was assumed to be mainly due to a drop in admission of milder strokes [ 1 – 3 , 6 – 8 , 11 – 13 ]. It is feared that, given that the number of mild strokes in the population was unchanged during the pandemic, a large number of these patients did not seek medical attention.…”