International Survey of Mechanical Thrombectomy Stroke Systems of Care During COVID-19 Pandemic
The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only onstroke volumesbut also on various aspects ofthrombectomysystems.
We conducted a convenience electronic survey with a 21-item questionnaire aimed to identify the changes in stroke admission volumes and thrombectomy treatment practices seen during a specified time period of the COVID-19 pandemic.
The survey was designed using Qualtrics software and sent to stroke and neuro-interventional physicians around the world who are part of the Global Executive Committee (GEC) of Mission Thrombectomy 2020, a global coalition under the aegis of Society of Vascular and Interventional Neurology, between April 5th and May 15th, 2020.
There were 113 responses to the survey across 25 countries with a response rate of 31% among the GEC members. Globally there was a median 33% decrease in stroke admissions and a 25% decrease inmechanical thrombectomy(MT) procedures during the COVID-19 pandemic period until May 15th, 2020 compared to pre-pandemic months. The intubation policy for MT procedures during the pandemic was highly variable across participating centers: 44% preferred intubating all patients, including 25% of centers that changed their policy to preferred-intubation (PI) from preferred non-intubation (PNI). On the other hand, 56% centers preferred not intubating patients undergoing MT, which included 27% centers that changed their policy from PI to PNI. There was no significant difference in rate of COVID-19 infection between PI versus PNI centers (p=0.60) or if intubation policy was changed in either direction (p=1.00). Low-volume (<10 stroke/month) compared with high-volume stroke centers (>20 strokes/month) were less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers were more likely to report them to be inadequate (58% vs 92%).
Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic. Overall, respondents reported decreased stroke admissions as well as decreased cases of MT with no clear preponderance in intubation policy during MT.
Data access statement
The corresponding author will consider requests for sharing survey data. The study was exempt from institutional review board approval as it did not involve patient level data.
On March 11th 2020, the World Health Organization declared Coronavirus disease-2019 (COVID-19) a global pandemic which has burdened the healthcare systems worldwide. Globally, as of 28 November 2020, there have been 61,036,793 confirmed cases of COVID-19, including 1,433,316 deaths, reported to WHO.1Pre-hospital and in-hospital protocols during COVID-19 have been highly variable within and between different countries, ranging from changes in pre-hospital triage policy by designating certain hospitals as COVID-19 centers, protocols for testing patients based onsymptomatologyor exposure, to cancellation of elective procedures and postponement of semi-elective procedures. By mid-April 2020, various neurointerventional societies such as Society of Vascular and InterventionalNeurologists(SVIN),2Society ofNeurointerventional Surgery(SNIS)3and European Society of Minimally Invasive Neurological Therapy (ESMINT)4provided guidance statements for the care of patients requiring emergent neurointerventional procedures during COVID-19 pandemic. Availability and adequacy of personal protective equipment (PPE) is uniformly stressed to be of utmost importance to protect the frontline healthcare workers as evident by a large case series from Wuhan, China showing hospital-associated transmission as the presumed mechanism of infection in 29% of affected healthcare workers.5There is a consensus amongst the international medical community that presence of COVID-19 as a public health emergency should not alter the inclusion or exclusion criteria forMechanical Thrombectomy(MT),6though the recommendations on criteria and timing of intubation for patients undergoing MT is unclear and more heavily contingent on institutional resources available. Also, while expert recommendations have been published there is no consensus on appropriate changes in practice in the management of non-COVID-19 emergencies during the pandemic. Different countries or even different healthcare systems within a country responded with a varied spectrum of policy changes trying to balance the safety of its healthcare workers and uphold the continued quality of care for the patients presenting with emergencies including stroke. This cross-sectional convenience survey by the MT2020+ global alliance reports an international snapshot of the significant changes in acute stroke care with an emphasis on mechanical thrombectomy.
A survey comprising of 21-questions (supplemental item 1) was distributed to the members of Global Executive Committee of the MissionThrombectomy2020+ alliance7supported by the Society of Vascular and InterventionalNeurologists(SVIN). The survey was sent by electronic mail and answered online. The GEC members were encouraged to further disseminate the survey to practicing stroke physicians and or neuro-interventionalists in their region. The questionnaire was designed to collect responses on four main categories: (I) Stroke and (II)MTvolume pre and during-COVID-19; (III) Intubation policy changes due to COVID-19 for patients undergoing MT; (IV) Availability and adequacy of PPE and COVID-19 infections amongst neuroendovascular and stroke physicians, and ancillary staff. The survey responses were recorded between April 5th and May 15th, 2020. Participation was voluntary and responses were anonymized. Respondents from each country were allowed to choose the start of the COVID-19 timeline based on first COVID-19 cases documented in their respective countries.
Descriptive statistics were used to calculate the median stroke admissions and MT performed per month pre (A) and during (B) COVID-19, and then, the median of thestroke volumechange reported by each respondent was calculated (i.e. median of B1-A1, B2-A2, B3-A3…). Two separate analysis of the data were performed: in the first analysis, countries with three or more responses were included in order to have a better representation of a country. Of note, respondents from all 19 centers from Germany, Poland, Italy and France reported a change in their local pre-hospital stroke triage policy (STP) diverting stroke patients to pre-specified centers. This had a direct effect on the descriptive statistics. Hence, these results were dichotomized by countries with and without change in pre-hospital triage policies for stroke admission during COVID-19. In the second analysis, we included responses from all the countries which were grouped into low, medium and high-volume centers based on their pre-COVID-19 stroke admissions representing < 10, 10–20 and > 20 average strokes per month respectively. The reported rate of COVID-19 infection amongst the physicians and ancillary staff was standardized based on pre-COVID-19 stroke admission volume because we lacked information on the denominator for the number of physicians and staff at risk.
Statistical analysis was performed using SPSS statistics software, version 25 (IBM Corp., Armonk, N.Y., USA).Fisher's exact testor Chi-square test, as appropriate, was used for categorical variables and p-value < 0.05 was considered significant.
During the survey period from April 5th, 2020 to May 15th, 2020, we received 113 responses across 25 countries (Fig. 1), with a response rate of 31% among the GEC members. The response rate of the non-GEC members is not known. 12/25 (48%) countries had three or more respondents (n=99).
The overall group of respondents, with 3 or more responses from a country, reported a median 33% (IQR -60 – 50) decrease in stroke admissions during COVID-19 pandemic. Among this group, respondent in countries without STP change, reported a median percentage decrease in stroke admissions by 43% ranging from a decrease of 62% in India to 20% in Columbia. (Fig. 2). High, medium and low-volume stroke centers without a change in STP reported a median percentage decrease of 50% (IQR -71 – -10), 17% (IQR -51 – 13) and no change respectively during COVID-19 (Fig. 3).
For STP countries, Germany, France, Italy and Poland reported a median percentage increase of 85% (IQR 0-138), 113% (IQR -32 – 500), 125% (IQR 63-125) and 0% (IQR -3 – 93) stroke admissions during COVID-19 respectively (Fig. 2). Amongst STP countries, high and medium volume centers reported a median percentage increase of 85% (IQR -5 – 125) and 113% (IQR 100 – 225), respectively. Not enough data was reported from low volume centers in countries with STP change (Fig. 3).
Mechanical thrombectomy volume
Globally our survey reported a 25% (IQR -60 – 50) median percentage decrease in MT performed during COVID-19. This rose to 33% median percentage decrease after excluding countries with STP change ranging from -100% in Peru and Ecuador, to -10% in China (Fig. 4). Similarly, high volume centers in countries without change in their local triage policy showed a median decrease of 21% (IQR -63 – 0) in MTs performed during COVID-19. Medium and low volume centers without change in local triage policy showed no change in MTs performed during COVID-19 (Fig. 5).
Countries with STP, Germany, France, Italy and Poland reported a median increase of 35% (IQR -15 – 113), 120% (IQR -16 – 240), 185% (IQR 108 – 209) and 0% (IQR -53 – 125) respectively (Fig. 4). All the centers that responded from countries with STP change were high-volume MT centers, reporting a 22% median percentage increase in MT during COVID-19 (Fig. 5).
Intubation policy for during the performance MT was variable across countries and centers pre and during COVID-19 pandemic. Also, any change of policy due to the pandemic did not have preponderance in one direction (Fig. 6). During COVID-19, 44% centers preferred intubation (PI) during MT, including 25% centers that changed their policy to PI during-COVID-19 from preferred non-intubation (PNI) pre-COVID-19. On the other hand, 56% centers PNI which included 27% centers that changed their policy from PI to PNI (Fig. 6). Based on volume, 48% high, 32% medium and 40% low volume centers preferred intubation during MT, which included 24%, 25% and 35% centers respectively that reported a change in policy to PI from PCS during COVID-19 (Fig. 7).
There is wide variation in preference for intubation policy within countries, none of the centers in Italy versus 67% centers in Germany preferred intubation during COVID-19. None of the centers in Germany changed their intubation policy during COVID-19, whereas all centers in Japan reported a change in intubation policy including 75% to PI and 25% to PNI (Fig. 6).
Anesthesia policy and reported Covid-19 infections in personnel
Amongst centers with PI, 20.9% (9/43) reported at least 1 or more stroke or neuroendovascular team personnel testing positive for COVID-19 versus 16.1% (9/56) centers with PNI (p=0.6). Furthermore 18.9% (10/53) centers with change in intubation policy during COVID-19 pandemic in either direction reported at least one COVID-19 infection amongst stroke or neuroendovascular team personnel versus 17.4% (8/46) centers with no change in policy (p=1) (supplemental item 2).
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