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

      a , * , b , a , c , d , e , f , g , h , i , j , k , l , m , n , o , p , q , r , s , t , u , v , w , x , y , z , A , B , C , C , D , E , F , d
      Cerebrovascular Diseases (Basel, Switzerland)
      S. Karger AG
      Stroke, Emergency medical services, Organization, Coronavirus disease 2019

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          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.


          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.


          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.


          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.

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          Most cited references25

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          A Novel Coronavirus from Patients with Pneumonia in China, 2019

          Summary In December 2019, a cluster of patients with pneumonia of unknown cause was linked to a seafood wholesale market in Wuhan, China. A previously unknown betacoronavirus was discovered through the use of unbiased sequencing in samples from patients with pneumonia. Human airway epithelial cells were used to isolate a novel coronavirus, named 2019-nCoV, which formed a clade within the subgenus sarbecovirus, Orthocoronavirinae subfamily. Different from both MERS-CoV and SARS-CoV, 2019-nCoV is the seventh member of the family of coronaviruses that infect humans. Enhanced surveillance and further investigation are ongoing. (Funded by the National Key Research and Development Program of China and the National Major Project for Control and Prevention of Infectious Disease in China.)
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            Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.

            In 2015, five randomised trials showed efficacy of endovascular thrombectomy over standard medical care in patients with acute ischaemic stroke caused by occlusion of arteries of the proximal anterior circulation. In this meta-analysis we, the trial investigators, aimed to pool individual patient data from these trials to address remaining questions about whether the therapy is efficacious across the diverse populations included.
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              Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis.

              Endovascular thrombectomy with second-generation devices is beneficial for patients with ischemic stroke due to intracranial large-vessel occlusions. Delineation of the association of treatment time with outcomes would help to guide implementation.

                Author and article information

                Cerebrovasc Dis
                Cerebrovasc Dis
                Cerebrovascular Diseases (Basel, Switzerland)
                S. Karger AG (Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, karger@karger.com )
                21 May 2021
                : 1-9
                [1] aStroke Unit, Hospital Germans Trias i Pujol, Badalona, Spain
                [1A] AEmergency Department, Fundació Hospital d'Olot, Olot, Spain
                [2] bStroke Unit, Hospital Universitari Vall D'Hebron-VHIR, Barcelona, Spain
                [2B] BEmergency Department, Hospital Campdevànol, Campdevànol, Spain
                [3] cHospital Universitari Vall D'Hebron-VHIR, Barcelona, Spain
                [3C] CSistema d'Emergències Mèdiques, Barcelona, Spain
                [4] dStroke Unit, Hospital Clínic, Barcelona, Spain
                [4D] DHospital del Mar, Barcelona, Spain
                [5] eStroke Unit, Hospital Universitari Bellvitge, Hospitalet de Llobregat, Spain
                [5E] EDepartament de Salut de Catalunya, Catsalut, Barcelona, Spain
                [6] fStroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
                [6F] FCatalan Stroke Program, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
                [7] gStroke Unit, Department of Neurology, Mar Hospital, Barcelona, Spain
                [8] hStroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
                [9] iDepartment of Neurology, Hospital Universitari Joan XXIII, Tarragona, Spain
                [10] jDepartment of Neurology, Stroke Unit, Hospital Arnau de Vilanova, Lleida, Spain
                [11] kDepartment of Neurology, Hospital Moisés Broggi, Sant Joan Despí, Spain
                [12] lDepartment of Neurology, Hospital Verge de la Cinta, Tortosa, Spain
                [13] mDepartment of Neurology, Hospital Parc Taulí, Sabadell, Spain
                [14] nDepartment of Neurology, Hospital Mútua Terrassa, Terrassa, Spain
                [15] oDepartment of Neurology, Hospital Sant Joan de Déu − Fundació Althaia, Manresa, Spain
                [16] pDepartment of Neurology, Hospital Mataró, Mataró, Spain
                [17] qDepartment of Neurology, Hospital General Granollers, Granollers, Spain
                [18] rEmergency Department, Hospital Universitari Vic, Vic, Spain
                [19] sEmergency Department, Fundació Hospital Seu Urgell, La Seu d'Urgell, Spain
                [20] tEmergency Department, Hospital del Pallars, Tremp, Spain
                [21] uEmergency Department, Hospital Mora Ebre, Mora Ebre, Spain
                [22] vEmergency Department, Hospital Figueres, Figueres, Spain
                [23] wEmergency Department, Hospital Palamós, Palamós, Spain
                [24] xEmergency Department, Hospital Cerdanya, Puigcerdà, Spain
                [25] yMedical Director, Hospital Igualada, Igualada, Spain
                [26] zDepartment of Neurology, Consorci Sanitari Alt Penedès-Garraf, Vilafranca del Penedés, Spain
                Author notes
                *Natàlia Pérez de la Ossa, natperezossa@gmail.com, Xabier Urra, xabierurra@ 123456gmail.com

                Anna Ramos-Pachón and Álvaro García-Tornel contributed equally as first authors.

                Natàlia Pérez de la Ossa and Xabier Urra contributed equally as corresponding authors.

                Copyright © 2021 by S. Karger AG, Basel

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

                : 26 January 2021
                : 2 April 2021
                Page count
                Figures: 2, Tables: 2, References: 25, Pages: 9
                Clinical Research in Stroke

                stroke,emergency medical services,organization,coronavirus disease 2019
                stroke, emergency medical services, organization, coronavirus disease 2019


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