Challenges and Changes in Stroke Care Systems
During the pandemic, extreme measures were taken to prevent the spread of COVID-19. Chinese government locked down cities and communities, shut down public transportation and most public services, declared temporary suspensions of production and schools, etc., aiming to reduce population movements and aggregation. In health system, body temperature was strictly monitored. Fever patients were compulsively arranged to an independent procedure called “fever clinic”. After excluding the possibility of COVID-19 infection, the fever patients would then be transferred to the regular medical system. In the meantime, more than 40 thousand doctors and nurses nationwide were sent to Hubei Province, China, to combat COVID-19 .
The admission of AIS patients were not decreased during the pandemic, which was quite different from the United States . This may be because: (a) as a regional comprehensive stroke center, the stroke unit remained open during the pandemic; (b) even during the pandemic, patients still tended to visit a comprehensive stroke center rather than a nearest primary stroke center; (c) stroke causes more concern and afraid even than COVID-19 due to the serious sequelae and consequence; (d) the popularity of stroke education to the public in recent years. In contrary to AIS, the admission rate of cerebral hemorrhage dropped by more than a half. A possible explanation of this phenomenon is that ordinary hospitals can be competent for the treatment of patients with cerebral hemorrhage, so during the pandemic patients with cerebral hemorrhage may just choose the nearest hospital as possible. In China, patients can decide by themselves to ignore the system of tiered diagnosis and treatment, and even emergency medical service personnel tend to send patients directly to comprehensive stroke centers for treatment. This also reflects the importance of the construction of stroke centers, the optimization of stroke care systems, and stroke education.
Obviously, COVID-19 pandemic had a negative impact on stroke patients and stroke care. The onset-to-door time was greatly extended during the pandemic for the possible reasons: (a) the will of patients to go to hospital reduced; (b) the emergency medical systems were overloaded; (c) the lockdowns of communities, and the cumbersome body temperature monitoring procedures objectively hindered the timeliness of patient visits. The average NIHSS scores on admission and on discharge were both higher than in 2019, while the decreased NIHSS score after treatment was lower than the same period last year, suggesting that the degree of neurological deficit on admission and on discharge, the effects after treatment, and the long-term prognosis were all worse during the pandemic. In addition, compulsory lung CT scan of stroke patients may cause potential negative effects. These changes eventually lead to an increase of the hospital stays and the total cost of hospitalization. In total, onset-to-door time is still the most important factor affecting the prognosis and the treatment cost of stroke patients. COVID-19 pandemic directly and indirectly affected the will, time, and capacity of the AIS patients to the stroke centers, which in turn caused negative effects and a higher medical burden.
Suggestions and Strategies for Government, Medical systems, and Patients
As the worst global public health event in recent decades, COVID-19 pandemic keeps continuing and it seems difficult to obtain effective control in the short term. Therefore, it is of great significance to understand how the COVID-19 affect stroke care systems in the real-world and then take effective measures. We recommend the following strategies to be implemented as soon as possible:
For government: (a) make a decision very carefully on the lockdown of cities and communities; (b) keep the public transportation and services as normal as possible, especially the emergency medical system; (c) optimize allocations of medical resources to prevent a collapse of medical system; (d) remind the public even during the pandemic it is highly recommended to visit a nearest stroke center as soon as possible; (e) continue improving the public stroke education, encouraging primary prevention, advancing acute therapy, appreciating secondary prevention and recovery, and reducing regional disparities in stroke care.
For medical systems: (a) ensure that stroke centers still provide high-quality stroke care during the pandemic; (b) review and optimize the stroke care quality according to the pandemic situation; (c) add body temperature monitoring, lung CT scan and COVID-19 nucleic acid detection to the standard stroke care system if possible, and ensure that the DTN time of more than 50% of AIS patients treated with IV alteplase is still within 60 minutes ; (d) Establish independent passages and isolation wards for stroke patients with fever, a history of epidemics, or suspected COVID-19 infection; (e) provide necessary and sufficient personal protective equipment against COVID-19 for healthcare professionals in stroke centers ; (f) prevent healthcare professionals from overwork; (g) use telemedicine in locked-down regions for timely review of brain imaging in stroke patients, decision making for rapid imaging interpretation in time for IV alteplase , etc.; (h) explore the feasibility of high-tech applications for stroke care during the pandemic, such as unmanned wards, artificial intelligence, big data analysis, virtual reality technology, etc.
For patients: (a) adhere to the primary prevention of stroke, such as hypertension, diabetes, etc.; (b) as soon as early stroke symptoms appear, seek help from the nearest stroke center; (c) provide doctors with detailed medical history, such as epidemiology, close contact history of patients with COVID-19 infection, etc.
This study was a real-world study and it was observational and retrospective. Although the present study has provided some evidence suggesting that COVID-19 posed a threat to stroke care systems, large-sample and long-term follow-up studies are still needed to determine the ultimate impact of COVID-19 on stroke patients and stroke care systems.