Stroke Care Services in Singapore During COVID-19 Pandemic—A National Perspective

Abstract

Stroke is a significant cause of admission to Singapore's acute care hospitals. Because of the current COVID-19 pandemic, there have been major changes in the stroke care system. On calling for the public ambulance, those suspected to have COVID-19 infection are taken to the National Center for Infectious Diseases. Otherwise, on arrival at the emergency room, all cases with fever or respiratory symptoms [COVID-19 suspect patients (CSPs)] are evaluated separately by staff wearing full personal protective equipment (PPE). Triage is not delayed. CSPs needing hyperacute therapies are sent to a specially prepared scanner; if not, imaging is deferred to the latter part of the day. CSPs are managed in isolation rooms, and sent to the acute stroke unit (ASU) if two consecutive COVID-19 swabs are negative. Investigation and rehabilitation are done within the room. ASU rounds are attended by essential members, communication by electronic means. Multidisciplinary team rounds have largely ceased, and discussions are via electronic platforms. Patient transfer and staff movement are minimized. All hospital staff wear face-masks, infection control is strictly enforced. Visitors are not allowed; staff make daily calls to update families. Mild stroke patients may be sent home with rehabilitation advice. Outpatient rehabilitation centers are closed. Patients return for outpatient visits only if needed; medications are sent to their home, and nurses make essential home visits. Stroke support and rehabilitation activities have started on-line. Continuing medical education activities are mainly by webinars. Stroke research has been severely hampered. Overall, evidence-based stroke care is delivered in a reorganized manner, with a clear eye on infection control.

COVID-19 Pandemic Impact on Care for Stroke in Australia: Emerging Evidence From the Australian Stroke Clinical Registry

“…While delivery of care in some hospitals and systems has not been significantly restructured, others have experienced redeployment of specialist staff and repurposing of dedicated stroke beds to meet the demands of increased patients requiring treatment for COVID-19 (4,26,27). Changes have included the necessity of establishing different triaging protocols for presentations with respiratory symptoms or other signs of COVID-19, altered transportation protocols, changes to stroke pathways and fewer multidisciplinary team rounds (15,16).…”

“…The impacts on patient arrival times to hospital (3,6,7,(12)(13)(14) and the delivery of stroke care that have been reported has differed between studies (4). Reported changes have included altered transportation protocols, changes to triage processes and stroke pathways, and fewer multidisciplinary team rounds (15,16). Provision of reperfusion treatments and the timeliness of these have decreased or remained stable (3,5,6,8,12,17,18).…”

Reductions in Hospital Admissions and Delays in Acute Stroke Care During the Pandemic of COVID-19

“…Similar academic societies in various regions and neurological physicians from different hospitals continue to make recommendations/guidelines and share treatment experiences (1,(7)(8)(9)(10). Despite these efforts, acute stroke care is still negatively impacted (11)(12)(13)(14)(15). Reductions of 10-70% in stroke hospital admission are reported in several countries (13,(16)(17)(18)(19), though COVID-19 may probably increase the risk of ischemic stroke as a result of endothelial injury and hypercoagulable status and other impacts on the central nervous system (20)(21)(22).…”

Association of air pollution with acute ischemic stroke risk in Singapore: a time-stratified case-crossover study

“…Seven public state-owned hospitals manage more than 95% of acute stroke patients in Singapore. 16 The majority of stroke patients presenting within the time window for hyperacute stroke care (4.5–6 h from stroke onset) are transferred to one of three comprehensive stroke centers. 17…”