ABSTRACT
Introduction: The evaluation and risk stratification of patients with TIA/non-disabling ischemic stroke (TIA/NDS) arriving to the Emergency Department (ED) incurs high-cost imaging and increases ED length of stay (EDLOS). We evaluated the safety and feasibility of an ED-toOutpatient Pathway for TIA/NDS. Methods: In April 2020, we developed a risk stratification algorithm for TIA/NDS in the ED using features of the clincal presentation, limited blood tests, telemetry, and head-neck CT/CTA. Patients deemed low risk based on a 'safety checklist' were discharged with plans for expedited outpatient testing as warranted (e.g., brain MRI, echocardiogram) followed by rapid outpatient follow-up. To assess safety/feasibility of this pathway, we analyzed data of the first 101 patients prospectively enrolled through October 2020. Results: Mean age 68 years (range, 33-99);53% men;median NIHSS score 0 (range 0-3). Symptom duration was classified as <10 min (24%), 10-59 min (23%), >60 min (49%), unclear (4%). Deficits included isolated weakness (16%), isolated aphasia (15%), amaurosis fugax (6%), numbness/combined deficits/other (63%). Median ABCD2 score 3 (range 1-7). Outpatient follow-up included stroke clinic (82%), primary care (4%), not required or patient declined (6%), other hospital (1%);7% were lost to follow-up;43% had follow-up within 7 days. Imaging performed in the ED included CT/CTA only (39%), MRI/MRA only (27%), both (33%), or no imaging (1%). EDLOS was significantly less for patients when CT/CTA only was performed, as per pathway (12.8 versus 16.8 hours, p<0.05). The safety checklist was followed in 69% of patients. When the checklist was used properly, there were 0 recurrent strokes or TIAs within 90-days (versus 2 when not used correctly, p<0.05). Return rates to the ED were 8% with use of checklist and 6% without use (p=0.76). Conclusion: Our TIA/NDS pathway, implemented shortly after the outbreak of Covid-19 in the USA, significantly decreased EDLOS, and still allowed for TIA/NDS patients to be safely discharged from the ED. Acceptable risk stratification and safety is suggested by the low rates of recurrent events when the pathway was followed properly. More education is needed to ensure consistent and proper use of the pathway.
ABSTRACT
Introduction: Patterns of hospital presentation have changed during the COVID-19 pandemic. In stroke, delayed or avoided care may translate to substantial morbidity. We sought to determine the effect of the pandemic on patterns of stroke patient presentation and quality of care. Methods: We analyzed data from 25 New England hospitals: one urban, academic comprehensive stroke center (CSC) and telestroke hub, and 24 spoke hospitals in the telestroke network. We included all telestroke consultations from the 24 spokes and stroke admissions to the CSC from 11/1/2019 through 4/30/2020. We examined trends in stroke presentation including large vessel occlusion (LVO), alteplase use, and endovascular thrombectomy among eligible subjects. We compared proportions and bivariate comparisons to examine for changes pre- vs. post-3/1/2020, and used linear regression to examine trends over time. Results: Among 1248 patient presentations, telestroke consultations (0.4 fewer consults per week, p=0.005) and ischemic stroke patient admissions (decrease of 0.2 patients per week, p=0.04) decreased among the spokes and hub. Age and stroke severity were unchanged over the study period. We found no change in alteplase administration at telestroke spoke hospitals, but did note a decrease in both alteplase use (1.5 per week prior to March 1 and 1 per week after, p=0.05) and thrombectomy at our CSC (0.1 fewer cases per week, p=0.02). Time metrics for patient presentation and care delivery were unchanged, however, rates of adherence for several quality measures were reduced during the pandemic (Table 1). Conclusions: In this regional analysis, we found decreasing telestroke consultations and ischemic stroke admissions, and reduced performance on stroke quality of care measures during the COVID 19 pandemic. Contrary to prior reports, we did not find an increase in thrombectomy nor decrease in clinical severity that might be expected if patients with milder symptoms avoided hospitalization.(Figure Presented).