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. 2020 Sep;51(9):2664-2673.
doi: 10.1161/STR.0000000000000347. Epub 2020 Jul 31.

Stroke Code Presentations, Interventions, and Outcomes Before and During the COVID-19 Pandemic

Adam S Jasne  1 , Pola Chojecka  1 , Ilavarasy Maran  1 , Razaz Mageid  1 , Mohamed Eldokmak  1 , Qiang Zhang  1 , Karin Nystrom  1 , Kelsey Vlieks  1 , Michael Askenase  1 , Nils Petersen  1 , Guido J Falcone  1 , Charles R Wira 3rd  2 , Paul Lleva  1 , Neer Zeevi  1 , Reshma Narula  1 , Hardik Amin  1 , Dhasakumar Navaratnam  1 , Caitlin Loomis  1 , David Y Hwang  1 , Joseph Schindler  1 , Ryan Hebert  3 , Charles Matouk  3 , Harlan M Krumholz  4 , Serena Spudich  1 , Kevin N Sheth  1 , Lauren H Sansing  1 , Richa Sharma  1
Affiliations

Stroke Code Presentations, Interventions, and Outcomes Before and During the COVID-19 Pandemic

Adam S Jasne et al. Stroke. 2020 Sep.

Abstract

Background: Anecdotal reports suggest fewer patients with stroke symptoms are presenting to hospitals during the coronavirus disease 2019 (COVID-19) pandemic. We quantify trends in stroke code calls and treatments at 3 Connecticut hospitals during the local emergence of COVID-19 and examine patient characteristics and stroke process measures at a Comprehensive Stroke Center (CSC) before and during the pandemic.

Methods: Stroke code activity was analyzed from January 1 to April 28, 2020, and corresponding dates in 2019. Piecewise linear regression and spline models identified when stroke codes in 2020 began to decline and when they fell below 2019 levels. Patient-level data were analyzed in February versus March and April 2020 at the CSC to identify differences in patient characteristics during the pandemic.

Results: A total of 822 stroke codes were activated at 3 hospitals from January 1 to April 28, 2020. The number of stroke codes/wk decreased by 12.8/wk from February 18 to March 16 (P=0.0360) with nadir of 39.6% of expected stroke codes called from March 10 to 16 (30% decrease in total stroke codes during the pandemic weeks in 2020 versus 2019). There was no commensurate increase in within-network telestroke utilization. Compared with before the pandemic (n=167), pandemic-epoch stroke code patients at the CSC (n=211) were more likely to have histories of hypertension, dyslipidemia, coronary artery disease, and substance abuse; no or public health insurance; lower median household income; and to live in the CSC city (P<0.05). There was no difference in age, sex, race/ethnicity, stroke severity, time to presentation, door-to-needle/door-to-reperfusion times, or discharge modified Rankin Scale.

Conclusions: Hospital presentation for stroke-like symptoms decreased during the COVID-19 pandemic, without differences in stroke severity or early outcomes. Individuals living outside of the CSC city were less likely to present for stroke codes at the CSC during the pandemic. Public health initiatives to increase awareness of presenting for non-COVID-19 medical emergencies such as stroke during the pandemic are critical.

Keywords: coronavirus disease; pandemics; stroke.

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Conflict of interest statement

Dr Krumholz works under contract with the Centers for Medicare & Medicaid Services to support quality measurement programs; was a recipient of a research grant, through Yale, from Medtronic and the US Food and Drug Administration to develop methods for post-market surveillance of medical devices; was a recipient of a research grant with Medtronic and is the recipient of a research grant from Johnson & Johnson, through Yale University, to support clinical trial data sharing; was a recipient of a research agreement, through Yale University, from the Shenzhen Center for Health Information for work to advance intelligent disease prevention and health promotion; collaborates with the National Center for Cardiovascular Diseases in Beijing; receives payment from the Arnold & Porter Law Firm for work related to the Sanofi clopidogrel litigation, from the Martin/Baughman Law Firm for work related to the Cook Celect IVC filter litigation, and from the Siegfried and Jensen Law Firm for work related to Vioxx litigation; chairs a Cardiac Scientific Advisory Board for UnitedHealth; was a member of the IBM Watson Health Life Sciences Board; is a member of the Advisory Board for Element Science, the Advisory Board for Facebook, and the Physician Advisory Board for Aetna; and is the co-founder of HugoHealth, a personal health information platform, and co-founder of Refactor Health, an enterprise healthcare AI-augmented data management company. Dr Spudich directs a study within the AIDS Clinical Trials Group that receives study medications donated by ViiV Healthcare, Inc. Dr Sheth reports research grant funding from Biogen, Novartis, Bard, Hyperfine, is on the data and safety monitoring board for a study from Zoll, and reports equity in Alva Health. The other authors report no conflicts.

Figures

Figure 1.
Figure 1.
Map showing telestroke hub (Yale-New Haven Hospital, star), Greenwich and Lawrence + Memorial Hospitals (triangles), telestroke spoke hospitals (squares), and telephone consultation hospitals (circles).
Figure 2.
Figure 2.
Temporal trends in stroke code calls. A, Piecewise linear regression models from weeks 1–7 (black triangles), weeks 8–11 (unfilled circles), and weeks 12–17 (gray squares). B, Linear spline of weekly stroke codes activated at Yale-New Haven Hospital (YNHH), Greenwich Hospital (GH), and Lawrence and Memorial Hospital (LMH) in 2020.
Figure 3.
Figure 3.
Cubic spline model of weekly stroke codes activated at Yale-New Haven Hospital (YNHH) and Greenwich Hospital (GH) in 2019 (dashed/o) and 2020 (solid/+).
Figure 4.
Figure 4.
Seven-day moving average of stroke codes activated at Yale-New Haven Hospital (YNHH) in March and April, 2019 (dashed) and 2020 (solid) by calendar day with state, regional, and federal events overlaid. CDC indicates Centers for Disease Control and Prevention; CT, Connecticut; NJ, New Jersey; NY, New York; and RI, Rhode Island.
See this image and copyright information in PMC

Comment in

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MeSH terms