The stroke mothership model survived during COVID-19 era: an observational single-center study in Emilia-Romagna, Italy

Abstract

Introduction A reduction of the hospitalization and reperfusion treatments was reported during COVID-19 pandemic. However, high variability in results emerged, potentially due to logistic paradigms adopted. Here, we analyze stroke code admissions, hospitalizations, and stroke belt performance for ischemic stroke patients in the metropolitan Bologna region, comparing temporal trends between 2019 and 2020 to define the impact of COVID-19 on the stroke network. Methods This retrospective observational study included all people admitted at the Bologna Metropolitan Stroke Center in timeframes 1 March 2019–30 April 2019 (cohort-2019) and 1 March 2020–30 April 2020 (cohort-2020). Diagnosis, treatment strategy, and timing were compared between the two cohorts to define temporal trends. Results Overall, 283 patients were admitted to the Stroke Center, with no differences in demographic factors between cohort-2019 and cohort-2020. In cohort-2020, transient ischemic attack (TIA) was significantly less prevalent than 2019 (6.9% vs 14.4%, p = .04). Among 216 ischemic stroke patients, moderate-to-severe stroke was more represented in cohort-2020 (17.8% vs 6.2%, p = .027). Similar proportions of patients underwent reperfusion (45.9% in 2019 vs 53.4% in 2020), although a slight increase in combined treatment was detected (14.4% vs 25.4%, p = .05). Door-to-scan timing was significantly prolonged in 2020 compared with 2019 (28.4 ± 12.6 vs 36.7 ± 14.6, p = .03), although overall timing from stroke to treatment was preserved. Conclusion During COVID-19 pandemic, TIA and minor stroke consistently reduced compared to the same timeframe in 2019. Longer stroke-to-call and door-to-scan times, attributable to change in citizen behavior and screening at hospital arrival, did not impact on stroke-to-treatment time. Mothership model might have minimized the effects of the pandemic on the stroke care organization.

A meta‐analysis of the global impact of the COVID‐19 pandemic on stroke care & the Houston Experience

“…There was a transient increase in admissions before the 'second wave' of the pandemic in April-May 2020 (Figure 3). Moreover, similar to prior studies, we noticed a significant drop in patients with mild strokes (NIHSS 1-5), 9,30,35 but there was no difference in last known well to hospital arrival or the number of cases treated with thrombolysis and thrombectomy in our cohort. 8,19 A number of reasons have been postulated to explain the reduced stroke admissions witnessed during the ongoing pandemic.…”

“…A total of 52 studies reporting the impact of the COVID‐19 pandemic on stroke admissions were identified for qualitative synthesis. A total of 32,640 stroke admissions from 29 studies 6‐34 were included in the meta‐analysis (Figure 1) (Supplementary Table S1) based on a similar time frame of the study period and comparison period, of which ratios were derived, depending on each criterion data availability. Compared to the prepandemic period, the mean ratio of stroke admissions during the pandemic was 70.78% [95% CI: (65.02%, 76.54%)] (Figure 2) and the mean ratio of ICH cases was 83.10% [95% CI: (71.01%, 95.17%)] (Supplementary Figure S1).…”

Stroke and digital technology: a wake-up call from COVID-19 pandemic

“…Similar admission trends were observed in the UK where there was also an increase in the average severity of cases arriving in hospital [ 9 ]. An analysis of data in a secondary phase of the pandemic in tertiary care unit in Italy showed that the most serious strokes had hospital access rates comparable to previous years and the contraction was mainly in the milder forms [ 10 ]. Policies minimizing provider-patient interactions as well as personal reticence to come to the ED during the pandemic might have participated in such contraction, which has prompted international societies to speak up to maintain efficient stroke pathways.…”

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

“…Keeping a pre-hospital organization around a tertiary referral center capable of thrombectomy is essential for holding the quality of care in stroke to the highest standards [ 15 , 16 ] . Recent meta-analysis have favoured the “Directly to mothership” model over the “Drip and ship” one [ 17 , 18 ] , and a study done in another Italian hospital (Ospedale Maggiore, Bologna) during the SARS-CoV-2 pandemic also shared this view [ 19 ] . However, in the specific setting of NCGH, the sudden shut down of SC and redirection of stroke patients directly to the ER-NCGH, already overwhelmed with the surge of the SARS-CoV-2 infection, may not have worked in its favour.…”

“…One could argue that NCGH would not benefit as much with a change in the pre-hospital organization, or that the results would've been different if a “Mothership” model was already in place. In the case of our fellow colleagues from Ospedale Maggiore, Bologna, the Mothership model had been established 2 years prior to the pandemic [ 19 ] . Lastly, a small percentage of data was missing, namely CT scans performed in other hospitals, which could not be reviewed for the purpose of this study.…”