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

BACKGROUND: COVID-19 has impacted acute stroke care with several reports showing worldwide drops in stroke caseload during the pandemic. We studied the impact of COVID-19 on acute stroke care in our health system serving Southeast Michigan as we rolled out a policy to limit admissions and transfers. METHODS: in this retrospective study conducted at two stroke centers, we included consecutive patients presenting to the ED for whom a stroke alert was activated during the period extending from 3/20/20 to 5/20/20 and a similar period in 2019. We compared demographics, time metrics, and discharge outcomes between the two groups. RESULTS: of 385 patients presented to the ED during the two time periods, 58% were African American. There was a significant decrease in the number of stroke patients presenting to the ED and admitted to the hospital between the two periods (p \u3c0.001). In 2020, patients had higher presenting NIHSS (median: 2 vs 5, p = 0.012), discharge NIHSS (median: 2 vs 3, p = 0.004), and longer times from LKW to ED arrival (4.8 vs 9.4 h, p = 0.031) and stroke team activation (median: 10 vs 15 min, p = 0.006). In 2020, stroke mimics rates were lower among African Americans. There were fewer hospitalizations (p \u3c0.001), and transfers from outside facilities (p = 0.015). CONCLUSION: a trend toward faster stroke care in the ED was observed during the pandemic along with dramatically reduced numbers of ED visits, hospitalizations and stroke mimics. Delayed ED presentations and higher stroke severity characterized the African American population, highlighting deepening of racial disparities during the pandemic

MINDtime: Keeping an Eye on the Clock

Background: During an ischemic stroke, time is brain. Patients arriving within 4.5 hours of Last Known Well (LKW) are eligible for treatment with intravenous tissue plasminogen activator (t-PA) based on their respective inclusion/exclusion criteria. It is well established that the benefits of IV t-PA are time-dependent, thus published guidelines recommend a door-to-needle treatment time of 60 minutes. More recently, there has been a nationwide push to treat 50% of t-PA patients within 45 minutes. Numerous steps have been implemented to facilitate rapid decision making and treatment; however, challenges remain. At our Comprehensive Stroke Center, we proposed a simple and non-invasive tool to help expedite the door-to-needle times by attaching a stopwatch to the t-PA eligible patient\u27s bed in an effort to remind all members of the care team that “the clock was ticking.” Methods: Data was collected on all patients who received IV t-PA from 5/29/17 - 11/27/17. Dates ending in an odd number were designated the intervention group, where eligible patients would have a large digital clock attached to their bed that counted upwards from their arrival time. The even number days were the control group, where patients would be assessed and treated based on established hospital protocol. The outcome was measured in minutes. Results: A total of 68 patients were treated with IV t-PA during the pre-specified time period. All patients that met either the 3 hour or 4.5 hour IV t-PA criteria were included in the study. There were 39 patients (50%) treated during the “odd” days with the stopwatch present. The median door-to-needle time was 52 minutes [IQR 43 - 72] for this cohort, while the median door-to-needle time was 49 minutes [IQR 42 - 70] for the other group (p = 0.79). Conclusion: Our study did not demonstrate a significant difference in door-to-needle time between the two groups. We believe there are some possible reasons for these findings. During our study period, there were several simultaneous improvement processes occurring, which could have diluted our study results. We believe that the concept of displaying time to the members of the care team can assist in expediting door-to-needle times. This resource-limited and relatively simple intervention may be attractive to Acute Stroke Ready Hospitals (ASRHs) and some Primary Stroke Centers (PSCs)

A widely accepted metric (telephone assessment of the modified Rankin scale score at 90 days) may not accurately reflect the real-life outcome of endovascular stroke treatment

Introduction: The modified Rankin Score (mRS) collected at approximately 90 days after stroke onset is a reliable and reproducible measure of stroke outcome. It was utilized in the randomized controlled trials that established the safety and efficacy of endovascular stroke treatment. It has been incorporated as a core metric for measuring quality of care in comprehensive stroke centers. We aimed to evaluate the value of the 90-day mRS considering that a certain percentage of patients may fail to respond to coordinator phone calls. Methods: We retrospectively analyzed patients who received endovascular stroke treatment in a comprehensive stroke center from January 2015 to March 2017, and who were prospectively enrolled in the Get With The Guidelines-Stroke Registry. We calculated the response rates to coordinator phone calls at approximately 90 days from stroke onset. Several calls were placed according to the established institutional policy. We compared the response rates of patients who had successful or unsuccessful recanalization, as reported by the endovascular specialist at the time of the procedure. Results: We identified 79 patients who received endovascular treatment, and who were contacted by the coordinators at approximately 90 days after stroke onset. 58 patients had successful recanalization (as defined by reported TICI grades IIb and III), whereas 21 patients had unsuccessful recanalization (as defined by reported TICI grades O, I, and IIa). 44/58 patients with successful recanalization responded to coordinator calls, compared to 11/21 patients with unsuccessful recanalization. The difference in proportions was statistically significant (p=0.045). Conclusions: Patients who have unsuccessful recanalization after endovascular stroke treatment are significantly less likely to respond to coordinator calls. Therefore, their mRS cannot be estimated, and the long-term outcome of the endovascular procedure cannot be assessed. Since these patients are more likely to have died, or be in a supervised facility (and therefore not accessible at their previous phone number), the telephone assessment of the mRS is likely not an accurate measure for the long-term therapeutic effect of endovascular stroke treatment

CTA for All : Emergency CT Angiography for All Stroke Patients Presenting Within 24 Hours of Onset Improves Outcome After Large Vessel Occlusion

Introduction: Computed tomographic angiography (CTA) is an important initial assessment for detecting large vessel occlusion (LVO) in acute ischemic stroke (AIS) and for selecting patients for mechanical thrombectomy (MT). This study is designed to evaluate the impact of an emergency CTA protocol on outcome of AIS patients with LVO. Methods: On July 1, 2017 we implemented the policy of performing CTA at the same time as non-contrast CT (NCCT) in all AIS patients presenting within 24 hours of symptom onset regardless of baseline NIHSS. Previously emergency CTA was reserved for patients presenting within 6 hours with an NIHSS ≥6. We compared treatment processes and outcomes between AIS patients admitted 1-year before (N=396) and 1-year after (N=494) protocol implementation. Results: After protocol implementation, more patients underwent CTA (90% VS 60%, P \u3c 0.001) and had CTA performed at the time of the initial NCCT (77% VS 34%,