Protected Code Stroke: Hyperacute Stroke Management During the Coronavirus Disease 2019 (COVID-19) Pandemic

Abstract

Background and Purpose- Hyperacute assessment and management of patients with stroke, termed code stroke, is a time-sensitive and high-stakes clinical scenario. In the context of the current coronavirus disease 2019 (COVID-19) pandemic caused by the SARS-CoV-2 virus, the ability to deliver timely and efficacious care must be balanced with the risk of infectious exposure to the clinical team. Furthermore, rapid and effective stroke care remains paramount to achieve maximal functional recovery for those needing admission and to triage care appropriately for those who may be presenting with neurological symptoms but have an alternative diagnosis. Methods- Available resources, COVID-19-specific infection prevention and control recommendations, and expert consensus were used to identify clinical screening criteria for patients and provide the required nuanced considerations for the healthcare team, thereby modifying the conventional code stroke processes to achieve a protected designation. Results- A protected code stroke algorithm was developed. Features specific to prenotification and clinical status of the patient were used to define precode screening. These include primary infectious symptoms, clinical, and examination features. A focused framework was then developed with regard to a protected code stroke. We outline the specifics of personal protective equipment use and considerations thereof including aspects of crisis resource management impacting team role designation and human performance factors during a protected code stroke. Conclusions- We introduce the concept of a protected code stroke during a pandemic, as in the case of COVID-19, and provide a framework for key considerations including screening, personal protective equipment, and crisis resource management. These considerations and suggested algorithms can be utilized and adapted for local practice.

Keywords: COVID-19; algorithms; consensus; pandemics; stroke.

Figure 1.

Protected code stroke (PCS) framework. Two key sections are outlined: screening and PCS operational parameters. These parameters are use of personal protective equipment (1) with and without aerosol-generating medical procedures, placing a surgical mask on the nonintubated patient (2), and utilization of crisis resource management principles (3).

Figure 2.

Suggested approach to team designation in a protected code stroke (PCS). Minimize team members in the resuscitation room—use a lean team approach. MD1 should be either an attending, fellow, or experienced trainee able to effectively obtain an National Institutes of Health Stroke Scale. In some cases, 2 RNs may be required for patient care. Any team member can be the designated Safety Lead (including RN, RT, additional MD, or other staff with knowledge of donning and doffing). The safety lead ensures proper technique and inspection of the equipment. When present, MD2 or alternate can gain collateral history through existing health records and family members. Required personal protective equipment (PPE) is as described, fit-tested N95 masks should be used for members inside the room if aerosol-generating medical procedures are occurring. The PCS team can proceed with the patient to imaging before doffing with the safety lead facilitating transit (to and from imaging) and PPE procedures BiPAP indicates bi-level positive airway pressure; BVM, bag-valve-mask; and CPAP, continuous positive airway pressure.