Decline in stroke alerts and hospitalisations during the COVID-19 pandemic

Abstract

IntroductionPatients with stroke-like symptoms may be underutilising emergency medical services and avoiding hospitalisation during the COVID-19 pandemic. We investigated a decline in admissions for stroke and transient ischaemic attack (TIA) and emergency department (ED) stroke alert activations.MethodsWe retrospectively compiled total weekly hospital admissions for stroke and TIA between 31 December 2018 and 21 April 2019 versus 30 December 2019 and 19 April 2020 at five US tertiary academic comprehensive stroke centres in cities with early COVID-19 outbreaks in Boston, New York City, Providence and Seattle. We collected available data on ED stroke alerts, stroke severity using the National Institutes of Health Stroke Scale (NIHSS) and time from symptom onset to hospital arrival.ResultsCompared with 31 December 2018 to 21 April 2019, a decline in stroke/TIA admissions and ED stroke alerts occurred during 30 December 2019 to 19 April 2020 (p trend <0.001 for each). The declines coincided with state stay-at-home recommendations in late March. The greatest decline in hospital admissions was observed between 23 March and 19 April 2020, with a 31% decline compared with the corresponding weeks in 2019. Three of the five centres with 2019 and 2020 stroke alert data had a 46% decline in ED stroke alerts in late March and April 2020, compared with 2019. Median baseline NIHSS during these 4 weeks was 10 in 2020 and 7 in 2019. There was no difference in time from symptom onset to hospital arrival.ConclusionAt these five large academic US hospitals, admissions for stroke and TIA declined during the COVID-19 pandemic. There was a trend for fewer ED stroke alerts at three of the five centres with available 2019 and 2020 data. Acute stroke therapies are time-sensitive, so decreased healthcare access or utilisation may lead to more disabling or fatal strokes, or more severe non-neurological complications related to stroke. Our findings underscore the indirect effects of this pandemic. Public health officials, hospital systems and healthcare providers must continue to encourage patients with stroke to seek acute care during this crisis.

Patient Characteristics and Outcomes Associated with Decline in Stroke Volumes During the Early COVID-19 Pandemic

“…8 Daily stroke volumes ultimately reached a nadir of 30.6 strokes/day on March 27, 2020, a decrease of 35.0% compared with the expected volume based on 2019 data. These findings are comparable to those from other parts of the country 1 , 2 and world. 9 , 10 , 11 , 12 This analysis also included more recent data, which demonstrated recovery of stroke volumes from March 27 – June 23, 2020, though at a more gradual rate of 0.15 strokes/day.…”

“… 15 However, another study of 691 patients presenting to five comprehensive stroke centers on the East and West coasts found a statistically significant increase in median NIHSS from 7 to 10 for patients presenting from March 23 – April 19 2020 compared with similar dates in 2019. 2 Higher presenting NIHSS has also been reported in other countries. 12 In our univariate analysis, patients in the pandemic group were less likely to present with mild stroke (NIHSS ≤ 5; 61.0 vs 65.1%, P=0.02) and more likely to present with severe stroke (NIHSS > 15; 16.2 vs 13.6%, P=0.06).…”

“…Recent studies have documented a decrease in evaluations of stroke patients during the early weeks of the coronavirus disease 2019 (COVID-19) outbreak in the United States (US). 1 , 2 , 3 , 4 This phenomenon raises concern that delays in emergent treatment and implementation of secondary stroke prevention measures may contribute to the morbidity and mortality of the pandemic. As a second wave of COVID-19 sweeps through the country, there is an urgent need for public health communication that targets populations most likely to delay evaluation for stroke-like symptoms.…”

The Many Faces of Covid-19 at a Glance: A University Hospital Multidisciplinary Account From Milan, Italy

“…Admissions for stroke also dramatically decreased compared with the same period in the previous year. In their study published this year, Sharma et al ( 21 ) report a decrease up to 46% in ED stroke alerts during the pandemic.…”

Consultations Decline for Stroke, Transient Ischemic Attack, and Myocardial Infarction during the COVID-19 Pandemic in Germany

“…Amid the current situation, maintaining the delivery chain for the provision of medical care is essential for stroke neurologists and cardiologists, as time is the most important factor when it comes to saving brain/heart tissue in case of acute ischemia [ 6 ]. In the algorithm for the treatment of an acute ischemic vascular event, the first step, the patient's awareness in recognizing the dysfunction and calling for medical assistance, may well be the most critical of all [ 7 , 8 , 9 ]. While acute care delivery could be optimized by streamlining infrastructures in order to recuperate resources for potential coronavirus disease 2019 (COVID-19) patients, the environment of a pandemic with “stay at home” appeals to the public may have deterred many from seeking help rapidly [ 7 , 8 , 9 ], and this might be one of the reasons for a reduction in presentations.…”