Delays in Stroke Onset to Hospital Arrival Time During COVID-19

Abstract

Background and Purpose: The current coronavirus disease 2019 (COVID-19) pandemic represents a global public health crisis, disrupting emergency healthcare services. We determined whether COVID-19 has resulted in delays in stroke presentation and affected the delivery of acute stroke services in a comprehensive stroke center in Hong Kong. Methods: We retrospectively reviewed all patients with transient ischemic attack and stroke admitted via the acute stroke pathway of Queen Mary Hospital, Hong Kong, during the first 60 days since the first diagnosed COVID-19 case in Hong Kong (COVID-19: January 23, 2020–March 24, 2020). We compared the stroke onset to hospital arrival (onset-to-door) time and timings of inpatient stroke pathways with patients admitted during the same period in 2019 (pre–COVID-19: January 23, 2019–March 24, 2019). Results: Seventy-three patients in COVID-19 were compared with 89 patients in pre–COVID-19. There were no significant differences in age, sex, vascular risk factors, nor stroke severity between the 2 groups ( P >0.05). The median stroke onset-to-door time was ≈1-hour longer in COVID-19 compared with pre–COVID-19 (154 versus 95 minutes, P =0.12), and the proportion of individuals with onset-to-door time within 4.5 hours was significantly lower (55% versus 72%, P =0.024). Significantly fewer cases of transient ischemic attack presented to the hospital during COVID-19 (4% versus 16%, P =0.016), despite no increase in referrals to the transient ischemic attack clinic. Inpatient stroke pathways and treatment time metrics nevertheless did not differ between the 2 groups ( P >0.05 for all comparisons). Conclusions: During the early containment phase of COVID-19, we noted a prolongation in stroke onset to hospital arrival time and a significant reduction in individuals arriving at the hospital within 4.5 hours and presenting with transient ischemic attack. Public education about stroke should continue to be reinforced during the COVID-19 pandemic.

Effects of the COVID-19 Pandemic on Stroke Patients

“…Another study showed similar results with a significant increase in LKWT to door time during the COVID-19 period, and more importantly a significant reduction in patients who arrived within the 4.5 hour tPA window [ 2 ]. Similarly, Kerleroux et al also found that patients who were treated during the same time period were less likely to receive tPA [ 3 ].…”

“…In addition to its effect on the economy, SARS2-CoV-2 also caused major disruptions in healthcare as many hospitals were forced to cancel elective surgeries and postpone outpatient and specialty appointments to conserve personal protective equipment (PPE) and reduce exposure risk. Teo et al has suggested that the recent change in healthcare has had a significant impact on care of stroke patients [ 2 ].…”

“…Similarly, Kerleroux et al also found that patients who were treated during the same time period were less likely to receive tPA [ 3 ]. While the cause of delay in presentation is unclear, it may be related to reluctance to go to the hospital due to fear of infection [ 2 ]. Another possibility is that there is a delay in ambulance response times, but further studies will be necessary to identify the cause of the delays.…”

“…At the same time, hospitals across the nation started to prepare for a surge in hospitalizations and began focusing efforts on providing COVID-directed care. Since the pandemic began, delays in presentation and decreases in patients receiving tissue plasminogen activator (tPA) have been reported [ 2 ]. We performed a retrospective study using our institutional stroke registry to investigate pre- and intra-hospital delays during the COVID period.…”

COVID-19 lock-down significantly reduced the number of surgical presentations in an emergency department

“…A possible explanation for this fact might be that not the incidence of certain diseases decreased during that time, but patients were afraid of infection and avoided attending hospitals for further diagnosis and treatment [10]. Furthermore, reports from Spain and Hong Kong showed that in the case of a cerebral stroke, not only was the number of treated cases reduced but also the arrival time and start of treatment was delayed [12,13].…”