Streamlined Poststroke Treatment Order Sets During the SARS-CoV-2 Pandemic

Abstract

Background and Purpose: Standard poststroke treatment monitoring protocols are made problematic during the coronavirus disease 2019 (COVID-19) pandemic by the frequency of patient assessments, requiring repeated donning and doffing procedures in a short interval of time. Methods: A streamlined poststroke treatment protocol was developed to limit frequency of patient encounters while maximizing the yield of each encounter by grouping together different components of poststroke care into single bedside visits. Results: Streamlined order sets were developed late March 2020. During the first 6 weeks following implementation, 70 patients were admitted to a geographically defined designated warm COVID-19 unit with modified poststroke care order sets. Of these, 33 (47.1%) patients received acute reperfusion therapy. All but 3 patients evolved favorably with either stable or improving National Institutes of Health Stroke Scale at 24 hours. In the 3 patients who experienced early neurological deterioration, none were found to be attributable to insufficient patient monitoring. Conclusions: Adapting preexisting poststroke care protocols may be necessary while the risk of COVID-19 infection remains high. We propose a streamlined approach to facilitate poststroke monitoring in patients with stroke with unknown COVID status.

Three-month functional outcomes following endovascular thrombectomy during the first wave of the COVID-19 pandemic: a Canadian single-center cohort study

“…Comparable outcomes between groups also suggest that reduced intensity of clinical monitoring did not negatively affect outcomes, as we previously anticipated. 6 Furthermore, in-house acute stroke metrics normalized during the tail of the first wave—that is, the summer months following the first wave—except door-to-needle delays which improved without reaching reference cohort levels. This improvement in most acute stroke metrics is reassuring and likely reflects a learning curve as stroke teams adjusted to new pandemic protocols.…”

“…To minimize contact between healthcare professionals and potentially infected patients, we modified our post-reperfusion monitoring protocol by decreaseasing the intensity of neurological and vital sign surveillance. 6 …”

“…To minimize contact between healthcare professionals and potentially infected patients, we modified our post-reperfusion monitoring protocol by decreaseasing the intensity of neurological and vital sign surveillance. 6 In this study we used data from the Montreal Neurovascular and Stroke Data Repository (MONSTER), a routine electronic medical record tool allowing systematic guideline-based quality assurance, to compare a prospective cohort of consecutive adult patients evaluated for acute stroke between March 30 (date of formal implementation of our modified code stroke protocol) and September 30, 2020 with a retrospective reference cohort of patients evaluated for stroke during the corresponding time period of 2019. We excluded in-hospital strokes.…”

“…3 4 In response to COVID-19, most CSCs adjusted their hyperacute stroke management procedures and their post-reperfusion monitoring protocols to minimize contact between healthcare professionals and potentially infected patients, as suggested by professional society recommendations and various experts. [5][6][7] It is currently unknown whether increased delays to presentation and treatment, as well as decreased neurological monitoring in the hours after reperfusion treatment, translate into worse long-term functional outcomes for patients suffering an acute stroke during the COVID-19 pandemic. Our primary objective was to assess the impact of the early pandemic on 90-day functional outcomes for patients with stroke treated with endovascular therapy (EVT) at our CSC.…”

Neurohospitalist

“…For example, reduced frequency of patient assessments after admission was shown to be safe in a small study. 9 Some hospitals started using tenecteplase, instead of alteplase, for IV thrombolysis because of a simplified workflow that may minimize staff exposure. 10 Most vascular neurologists are familiar with telestroke evaluations for patients at remote sites; however, the pandemic led to the initiation of emergency department and inpatient telestroke evaluations at home institutions.…”