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      Acute Stroke Presentation, Care, and Outcomes in Community Hospitals in Northern California During the COVID-19 Pandemic

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          Abstract

          Supplemental Digital Content is available in the text.

          Background and Purpose:

          Shelter-in-place (SIP) orders implemented to mitigate severe acute respiratory syndrome coronavirus 2 spread may inadvertently discourage patient care-seeking behavior for critical conditions like acute ischemic stroke. We aimed to compare temporal trends in volume of acute stroke alerts, patient characteristics, telestroke care, and short-term outcomes pre- and post-SIP orders.

          Methods:

          We conducted a cohort study in 21 stroke centers of an integrated healthcare system serving 4.4+ million members across Northern California. We included adult patients who presented with suspected acute stroke and were evaluated by telestroke between January 1, 2019, and May 9, 2020. SIP orders announced the week of March 15, 2020, created pre (January 1, 2019, to March 14, 2020) and post (March 15, 2020, to May 9, 2020) cohort for comparison. Main outcomes were stroke alert volumes and inpatient mortality for stroke.

          Results:

          Stroke alert weekly volume post-SIP (mean, 98 [95% CI, 92–104]) decreased significantly compared with pre-SIP (mean, 132 [95% CI, 130–136]; P<0.001). Stroke discharges also dropped, in concordance with acute stroke alerts decrease. In total, 9120 patients were included: 8337 in pre- and 783 in post-SIP cohorts. There were no differences in patient demographics. Compared with pre-SIP, post-SIP patients had higher National Institutes of Health Stroke Scale scores ( P=0.003), lower comorbidity score ( P<0.001), and arrived more often by ambulance ( P<0.001). Post-SIP, more patients had large vessel occlusions ( P=0.03), and there were fewer stroke mimics ( P=0.001). Discharge outcomes were similar for post-SIP and pre-SIP cohorts.

          Conclusions:

          In this cohort study, regional stroke alert and ischemic stroke discharge volumes decreased significantly in the early COVID-19 pandemic. Compared with pre-SIP, the post-SIP population showed no significant demographic differences but had lower comorbidity scores, more severe strokes, and more large vessel occlusions. The inpatient mortality was similar in both cohorts. Further studies are needed to understand the causes and implications of care avoidance to patients and healthcare systems.

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          Most cited references28

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          Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China

          Ling Mao, Huijuan Jin, Mengdie Wang … (2020)
          The outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, China, is serious and has the potential to become an epidemic worldwide. Several studies have described typical clinical manifestations including fever, cough, diarrhea, and fatigue. However, to our knowledge, it has not been reported that patients with COVID-19 had any neurologic manifestations.
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            Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young

            Thomas Oxley, J Mocco, Shahram Majidi … (2020)
            To rapidly communicate information on the global clinical effort against Covid-19, the Journal has initiated a series of case reports that offer important teaching points or novel findings. The case reports should be viewed as observations rather than as recommendations for evaluation or treatment. In the interest of timeliness, these reports are evaluated by in-house editors, with peer review reserved for key points as needed. We report five cases of large-vessel stroke in patients younger than 50 years of age who presented to our health system in New York City. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was diagnosed in all five patients. Cough, headache, and chills lasting 1 week developed in a previously healthy 33-year-old woman (Patient 1) (Table 1). She then had progressive dysarthria with both numbness and weakness in the left arm and left leg over a period of 28 hours. She delayed seeking emergency care because of fear of Covid-19. When she presented to the hospital, the score on the National Institutes of Health Stroke Scale (NIHSS) was 19 (scores range from 0 to 42, with higher numbers indicating greater stroke severity), and computed tomography (CT) and CT angiography showed a partial infarction of the right middle cerebral artery with a partially occlusive thrombus in the right carotid artery at the cervical bifurcation. Patchy ground-glass opacities in bilateral lung apices were seen on CT angiography, and testing to detect SARS-CoV-2 was positive. Antiplatelet therapy was initiated; it was subsequently switched to anticoagulation therapy. Stroke workup with echocardiography and magnetic resonance imaging of the head and neck did not reveal the source of the thrombus. Repeat CT angiography on hospital day 10 showed complete resolution of the thrombus, and the patient was discharged to a rehabilitation facility. Over a 2-week period from March 23 to April 7, 2020, a total of five patients (including the aforementioned patient) who were younger than 50 years of age presented with new-onset symptoms of large-vessel ischemic stroke. All five patients tested positive for Covid-19. By comparison, every 2 weeks over the previous 12 months, our service has treated, on average, 0.73 patients younger than 50 years of age with large-vessel stroke. On admission of the five patients, the mean NIHSS score was 17, consistent with severe large-vessel stroke. One patient had a history of stroke. Other pertinent clinical characteristics are summarized in Table 1. A retrospective study of data from the Covid-19 outbreak in Wuhan, China, showed that the incidence of stroke among hospitalized patients with Covid-19 was approximately 5%; the youngest patient in that series was 55 years of age. 1 Moreover, large-vessel stroke was reported in association with the 2004 SARS-CoV-1 outbreak in Singapore. 2 Coagulopathy and vascular endothelial dysfunction have been proposed as complications of Covid-19. 3 The association between large-vessel stroke and Covid-19 in young patients requires further investigation. Social distancing, isolation, and reluctance to present to the hospital may contribute to poor outcomes. Two patients in our series delayed calling an ambulance because they were concerned about going to a hospital during the pandemic.
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              The Untold Toll — The Pandemic’s Effects on Patients without Covid-19

              Debra Malina, Lisa Rosenbaum (2020)
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                Author and article information

                Journal
                Journal ID (nlm-ta): Stroke
                Journal ID (iso-abbrev): Stroke
                Journal ID (publisher-id): STR
                Title: Stroke
                Publisher: Lippincott Williams & Wilkins (Hagerstown, MD )
                ISSN (Print): 0039-2499
                ISSN (Electronic): 1524-4628
                Publication date (Print): 17 August 2020
                Publication date (Electronic): 07 August 2020
                Electronic Location Identifier: 10.1161/STROKEAHA.120.031099
                Affiliations
                [1 ]Division of Research (M.N.N.-H., D.R.V., A.C.F., J.G.A., S.S.), Kaiser Permanente Northern California, Oakland.
                [2 ]Department of Neurology (M.B.), Kaiser Permanente Northern California, Oakland.
                [3 ]Department of Neurology, Kaiser Permanente Northern California, Walnut Creek (M.N.N.-H., J.G.K.).
                [4 ]Department of Neurology (X.N.T.), Kaiser Permanente Northern California, Sacramento.
                [5 ]Department of Emergency Medicine (D.R.V.), Kaiser Permanente Northern California, Sacramento.
                [6 ]Department of Neurology, Kaiser Permanente Northern California, Roseville (X.N.T.).
                [7 ]Department of Neurology, Kaiser Permanente Northern California, Redwood City (A.C.F.).
                [8 ]Kaiser Permanente Foundation Hospitals, Northern California, Oakland (M.M.).
                Author notes
                Correspondence to: Mai N. Nguyen-Huynh, MD, MAS, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612. Email mai.n.nguyen-huynh@ 123456kp.org
                Article
                Accession ID: 00006
                DOI: 10.1161/STROKEAHA.120.031099
                PMC ID: 7434008
                PubMed ID: 32762619
                SO-VID: d9991506-dcdd-4170-8110-1ed1ad85eec9
                Copyright © © 2020 American Heart Association, Inc.
                License:

                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.

                History
                Date received : 29 May 2020
                Date revision received : 29 June 2020
                Date accepted : 16 July 2020
                Categories
                Subject: 10173
                Subject: 10178
                Subject: Original Contribution
                Custom metadata
                SDC T

                Keywords: cohort studies,coronavirus,inpatients,patient care,stroke
                Data availability:
                Keywords: cohort studies, coronavirus, inpatients, patient care, stroke

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