How to Safely Preserve Stroke Care Quality in the COVID-19 Era

Delivering stroke care in the time of COVID-19 can be a uniquely daunting task. Acute stroke care carries high risk of provider exposure to the virus. Care delivery is fast-paced, requiring numerous patient interactions. And opportunities to screen for COVID-19 can be highly limited, as patients frequently suffer impaired language and/or cognition.

No formal guidelines yet exist for addressing these challenges, but a multicenter group of experts — stroke neurologists, neurocritical care physicians, and endovascular/interventional neurologists — has issued what may be the next best thing: a descriptive review that outlines key ways the pandemic is impacting stroke care and proposes recommendations for addressing these impacts.

The document, titled “Preserving Stroke Care During the COVID-19 Pandemic: Potential Issues and Solutions” and published in Neurology on May 8, is not a formal position statement but rather resulted from exchanges among a number of experts from the American Academy of Neurology’s Stroke Section and the Neurocritical Care Society. They enlisted colleagues from over two dozen major medical centers in the U.S. — plus two centers battered by the pandemic in Italy and Spain — and developed the review to meet a clear need.

“I’d describe us as a group of like-minded neurologists who wanted to put forth some guidance on how to best care for people with COVID-19 while simultaneously advocating for patients with stroke and advocating for healthcare providers caring for stroke patients,” says Andrew Russman, DO, one of the document’s principal authors and Medical Director of Cleveland Clinic’s Comprehensive Stroke Center. “This review centralizes the issues and potential solutions people need to be thinking about when managing stroke care throughout the continuum of the COVID-19 pandemic.”

Four realms of stroke care examined

It does so by laying out the pandemic’s potential impact across four broad realms of stroke care:

• Quality of care as influenced by changes in patient demand and provider supply
• Ethical considerations
• Safety and logistics issues for providers of stroke care
• Stroke research

Specific issues and potential threats in each realm are discussed, and recommendations are offered for addressing threats to optimal care. These are helpfully outlined in several tables for quick perusal. The document is fully referenced and draws on recent literature when possible, including evidence of widespread reductions in presentations of acute stroke since the pandemic’s start as well as emerging data on cerebrovascular manifestations of COVID-19.

Responses need to be scaled

Significant discussion is devoted to bed capacity for stroke patients and planning for the possibility of physician shortages and the need to restructure stroke call and inpatient services to maintain a viable workforce of providers.

“We’ve outlined a tiered response system based on scalability at different stages of response to the pandemic,” says Dr. Russman. He explains that these range from conventional preparation, focused on measures like conservation of personal protective equipment (PPE) and staffing adjustments to maximize flexibility, to the contingency stage, which prompts decisions about use of resources, to the crisis stage, when treatment triage is required along with decisions around patient transfers, overflow patients and use of stroke experts in consultative roles for additional facilities.

“We make clear that it’s critical to have a multilayered plan to deal with the potential of an impending crisis, to keep it from becoming unmanageable,” Dr. Russman observes. “The aim is to understand how you’re going to shift your workforce and your systems to provide essential care to the sickest patients and necessary care to everybody. As long as you can do that, you’re managing the disease instead of the disease managing you.”

More than just acute care

While acute stroke care is a major focus of the review, attention is also paid to post-stroke rehabilitation and follow-up care for secondary prevention in the context of the continuing pandemic.

The discussion of stroke research outlines a vision forward despite the reality that the pandemic has created a challenge for continuing trials in view of exposure risks and reduced resources. The authors contend that research not requiring in-person contact is logistically feasible, and they call for epidemiologic studies, including biobanking, to illuminate COVID-19’s impact on stroke and stroke care.

Drawing from Cleveland Clinic’s preparatory experience

Dr. Russman drew on Cleveland Clinic’s experience for his contributions to the review in several areas. The most notable example, he says, was in shaping the document’s call for expansion of telemedicine to minimize the bidirectional risk of virus transmission from patient/provider contact and to increase patient access to care.

“Before the pandemic, Cleveland Clinic had a robust telestroke system in place,” he says, which included placement of mobile telemedicine carts in the emergency departments (EDs) of Cleveland Clinic regional hospitals. These carts — complete with touchscreen interface, high-definition camera, speaker and microphone — allow stroke neurologists to remotely evaluate patients with suspected stroke.

In preparation for the pandemic, Cleveland Clinic deployed these telemedicine carts in additional EDs in its system. “This has allowed us to reduce PPE use and minimize the number of providers exposed to patients during evaluation for stroke,” Dr. Russman notes.

Deployment of additional telemedicine carts in inpatient settings, including the neurological ICU, has also allowed staff to round on hospitalized stroke patients via telemedicine, again reducing PPE use and bidirectional risk of virus transmission. “We’ve also dedicated a telemedicine cart to each of the temporary hospital facilities we created in preparation for a large surge in COVID-19 cases,” Dr. Russman says, noting that these facilities have fortunately not yet been needed.

Cleveland Clinic is also doing virtual rehabilitation evaluations. “We’ve implemented telemedicine technology so that every stroke patient discharged from the hospital has a telemedicine follow-up,” he adds. “That’s the type of follow-on care that our review document recommends for discharge planning.”