As COVID-19 limits how patients are cared for, healthcare workers will need to modify their approach to stroke care, such as introducing ‘telestroke’ – caring for stroke patients using telemedicine.
Using telestroke – or telemedicine – will help to limit the spread of infection within hospitals, preserve health resources, and ensure optimal care for patients.
Jose Biller, chairperson of neurology at Loyola University Medical Center, and professor at Loyola University Chicago Stritch School of Medicine, as well as co-author of the editorial, said: “Doctors are seeing a rise in COVID-19 patients of all ages suffering from stroke and other vascular complications, as the COVID-19 virus overwhelms the healthcare system.
“COVID-19 may increase the risk of stroke as a result of several mechanisms, including enhanced inflammatory response, increased blood clotting tendencies, and damage of the inner layers of the blood vessels (endothelial damage).”
The article ‘Acute Stroke Care in the Coronavirus 2019 Pandemic’ was published in the Journal of Stroke and Cerebrovascular Diseases.
Caring for stroke patients
Many stroke patients are older and have underlying medical conditions associated with poor outcomes related with COVID-19.
Dr Biller says new guidelines are needed to safely manage stroke patients, both with and without COVID-19, within the limitations of strained health systems during this “ferocious novel pandemic.”
Co-author Rima Dafer, and Nicholas Osteraas, both of Rush University Medical Center, said: ‘We believe that it is crucial for the stroke community to relax guidelines and stroke pathways while continuously providing high quality of care, including treatment algorithms, post intravenous thrombolysis monitoring, diagnostic work up, disposition planning, prevention measures, in order to optimally care for stroke patients while minimising the chances of contributing to the rapid spread of COVID-19.’
Recommendations
The editorial lays out recommendations relating to all aspects of stroke care including the use of telestroke medicine, separated hospital units, and suggestions for transfers and discharges.
The first recommendation included in the paper is for stroke patients to continue to contact emergency services, and that they should be screened over the phone for COVID-19 symptoms. Telemedicine should also be considered for patients with mild symptoms or a low suspicion of stroke. All patients should also be treated as possible COVID-19 cases and assessed in the emergency room before stroke evaluation.
Secondly, that all hospitals should designate isolated units for stroke care and that all patients receiving intravenous chemical thrombolysis (a common stroke treatment involving an intravenous injection of drugs directly to the blood clot) may be monitored virtually with two-way video conferencing to minimise staff infection.
As part of a patient’s rehabilitation planning, the paper recommends that all therapists should wear Personal Protective Equipment (PPE) and any exercises or rehabilitation that could be done at home should be.
Currently, due to COVID-19, many hospitals are restricting visitors. For stroke patients an extra effort will need to be made to reach families by phone to discuss a patient’s condition, treatment options and discharge planning. Exceptions to the visitor policy, such as discussions regarding end-of-life care, should be made when appropriate.
The paper also makes recommendations for transfers and discharges as stroke care often involves networks of hospitals. Telestroke should be encouraged to evaluate patients and to prevent unnecessary transfers. For arterial ischemic stroke (AIS) patients, neuroimaging and COVID-19 screening should be obtained at the smaller, spoke site hospital before a patient is transferred to a larger medical centre.
Hospitals may need to designate rehabilitation beds for patients who do not qualify for transfer to acute inpatient facilities, as well as discussing possible discharge to home when medically stable and appropriate until the pandemic is under control.
Finally, the article recommends establishing stroke networks within cities: “Collaborations among stroke networks to establish a rotating weekly coverage for acute stroke care in a specified geographic area; thus, both freeing hospital resources and releasing stroke call responsibilities, and allowing these physicians to help in caring for patients on the COVID-19 units.”
