Impact of Covid-19 on Stroke Code Activations, Process Metrics, and Diagnostic Error

Abstract

Background and Purpose: In a comprehensive stroke center, we analyzed the stroke code activations (SCA), assessed the impact of Covid-19, and the measures taken by the local government to lessen the spread of the disease. Methods: We retrospectively reviewed SCA and classified them into 2 groups: pre-pandemic activations (February 15 to March 10) and Covid-19 pandemic activations (March 11 to April 30). The primary outcome was the ratio of true positive diagnoses of stroke relative to the total number of SCA in the 2 time periods. Results: Among the 212 SCA, 83 (39.2%) were from the pre-pandemic period, whereas 129 (60.8%) were from the pandemic period, 147 (69.3%) in the Emergency Department (ED) versus 65 (30.7%) in the inpatient service. In the ED cohort, a rapid decrease in the number of SCA at the beginning of the pandemic was followed by a gradual increase to pre-pandemic levels and a significant increase in the number of true positive strokes over time (44.2% vs 61.1%, p = 0.037). An increase in door-to-CT time (p = 0.001) and an increase in the rate of diagnostic error in patients admitted from the ED (p = 0.016) were also seen. The in-hospital cohort had a sustained decrease in the number of SCA following the pandemic declaration, with no difference in the rate of true positive stroke. Conclusions: We observed a rapid decline and slow recovery in ED SCA with a shift toward increased true positive cases following the Covid-19 pandemic. Also, delays in obtaining CT and diagnostic error was increased, however, no difference in early clinical outcomes were seen between groups.

Stroke Codes during the COVID-19 Pandemic: Clinical Characteristics

“…The fear of contracting the COVID-19 disease was suggested to explain the drop in stroke codes and interventional vascular radiology emergencies in a study from Spain (15). The research group from the University of Chicago Medical Center, similar to our study, observed a rapid decline and slow recovery in the process of stroke code activation in the month of March-April compared to two pre-pandemic months (16). A research group from New York noticed that during pandemic period (January-April 2020), there was a significantly decreased number of stroke codes but simultaneous increases in positivity rates, symptom severity, and inpatient codes (17).…”

Establishing a hyperacute stroke service during the COVID-19 pandemic: our institution’s one year experience

“…The COVID-19 pandemic has affected the delivery of hyperacute stroke services globally, with many countries seeing a decline in stroke code activation and the number of patients presenting with stroke in the emergency department [ 15 , 16 ]. Many centers reported that the decline in the patient presentation was due to movement restriction orders causing difficulty to reach health care facilities, while others reported reduced stroke code activation and delivery of health care systems due to restriction of beds and utilization of intensive care units for the care of COVID-19 patients [ 17 – 19 ].…”

“…This phenomenon is echoed worldwide, and some stroke centers also struggle to keep up with DTN and DTP [ 21 , 22 ]. Velez et al reported that the prolonged DTP in their center was due to COVID-19 SOPs that required negative pressure room for intubation and the need for PPE and powered air purifying respirator (PAPR) while securing the airway prior to MT [ 17 ]. In our center, this was mainly due to financial restrictions.…”

Long-term evaluation of the COVID-19 pandemic impact on acute stroke management: an analysis of the 21-month data from a medical facility in Tokyo

“…The findings in these studies are rather mixed, with some reporting detrimental impacts [ 28 , 29 ], whereas others report limited impacts [ 26 ]. One potential source of such disagreements is the duration of the observation periods.…”