Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

Abstract

Introduction: The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system's bottlenecks from a territorial point of view.

Methods: Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15-May 2, 2020) and an immediate prepandemic period (January 26-March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days.

Results: Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = -0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05-2.4], p 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4-0.9], p 0.015) during the pandemic period.

Conclusion: During the COVID-19 pandemic, Catalonia's stroke system's weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system's analysis is crucial to allocate resources appropriately.

Keywords: Coronavirus disease 2019; Emergency medical services; Organization; Stroke.

Fig. 1

Temporal trends in EMS calls, COVID-19 cases, and stroke-related activity. a Course of COVID-19 cases, EMS alerts, and the number of stroke code activations and reperfusion treatments. Note the sharp increase of EMS alerts and COVID-19 cases around the lockdown implementation date and the subsequent decrease in the number of stroke code activations and reperfusion treatments. b Course of COVID-19 cases, EMS alerts, and stroke care delays. The time from stroke onset to hospital door increased during the pandemic, whereas the time to rtPA initiation did not. EMS, Emergency Medical System; rtPA, recombinant tissue plasminogen activator.

Fig. 2

Relationship between the frequency of COVID-19 cases and several aspects of stroke care compared to the prepandemic period. Joint plots showing the univariate distributions and the relationships, with Spearman's rho correlations, between weekly cases of COVID-19 and several aspects of stroke care at the main sanitary regions in Catalonia. The figures show points representing weekly ratios in each region relative to median values during the prepandemic period, with the linear regression fit line and bootstrap confidence intervals for the regression estimate. Note the strong correlation of COVID-19 cases with EMS alerts, the moderate negative correlation with the stroke code activations, and the slight correlation with times from onset to hospital door. In contrast, the number of COVID-19 cases and intrahospital delays to reperfusion treatments was uncorrelated. EMS, emergency medical services.