The impact of COVID-19 on measures of stroke care

A recent study published in PLOS ONE assessed the effects of the coronavirus disease 2019 (COVID-19) pandemic on stroke code (CS) measures.

Study: The effect of the COVID-19 pandemic on Madrid Prehospital Stroke Code measures and diagnostic accuracy. Image Credit: SewCream/Shutterstock


Spain is one of the countries most affected by the COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). More than 70,000 cases of COVID-19 have been registered in the Community of Madrid (CM) as of June 15, 2020. This disaster has obscured other pathologies causing substantial interference in health systems.

Acute stroke is the leading cause of disability in adults and the second leading cause of death worldwide. Therapies developed over the past three decades have reduced mortality in patients with acute ischemic stroke. However, clinical outcomes are dependent on time since symptom onset and reperfusion therapy.

Reports suggest that every minute saved at the start increases the life without sequelae by a week. Detection of calls with suspicion of acute stroke, dispatch of an ambulance, in situ assessment of the patient, selection of the appropriate (nearest) hospital, alert of on-call neurologists and transfer patients make up the SC protocol.

Implementation of the SC protocol has significantly reduced treatment time, with implications for patient outcomes. Disruptions to SC protocol functionality could impact stroke care and worsen patient outcomes. Several research groups have warned of a drastic drop in AS cases, delays to ambulance services, and saturation of call centers and hospital emergency departments during the first wave of the coronavirus pandemic. COVID-19. However, there is little information on which wards are most affected in the prehospital and hospital phases of AS urgent care.

About the study

In the present study, researchers assessed the impact of the COVID-19 pandemic on SC protocol in CM. The main objective was to compare the time spent in each phase of the SC protocol in the pre-COVID-19 period (27 February – 15 June 2019) and during the first wave of COVID-19 (same period in 2020) in the CM. The secondary objective was the comparison of other fundamental aspects of SC (diagnostic accuracy and in-hospital death, among others) between the two periods.

The study included the Madrid Emergency Medical Service SC cohort (SUMMA 112) and summary discharge data from 10 hospitals with a stroke unit. Patients meeting the SC criteria were eligible for inclusion. Patients were excluded if they did not have a health identification number (HIN) or minimum basic data set (MBDS) record.

The time elapsed at each stage of the pre-hospital CS process was analyzed. Data on sex, age, vital signs, suspicion of large vessel occlusion (LVO), place of patient admission, and Glasgow Coma Scale were collected in the prehospital phase. Patient severity status was assessed using 1) Charlson Comorbidity Index (CCI), 2) severity level and mortality risk, and 3) in-hospital death.


The SC protocol has been activated for 966 patients – 514 in the pre-COVID-19 period and 452 during the pandemic. During the COVID-19 period, SC protocol activation decreased by 6.4% compared to the corresponding pre-pandemic period.

During the COVID-19 period, patients were younger and predominantly male. Vital signs, CCI, degree of severity and mortality risk were not statistically different between the two periods. The proportion of patients undergoing a prehospital electrogram has decreased by 10% during the pandemic.

Hospital mortality fell from 14% to 9% during the pandemic, although statistically insignificant. During the pandemic, call handling time by the coordination center and time spent on site increased by 9% and 12%, respectively, compared to the pre-pandemic period. The median length of stay (LOS) in hospital has also increased by more than 3% during the pandemic.

The differences in the proportion of patients treated with intravenous thrombolysis (IVT) or mechanical thrombectomy (MT) between the two periods were not significant. Similarly, in-hospital mortality was not significantly different between the two periods, although it was lower during the COVID-19 period.


In summary, the researchers observed that 112 call center response times and in situ time increased by more than 10% during the first wave of COVID-19, although ambulance transit time did not increase. was not significantly affected. Median hospital SD has increased slightly during the pandemic.

Nevertheless, the diagnostic accuracy of emergency medical services (EMS) professionals has not been affected by the pandemic. The proportion of patients treated with MT or IVT during the pandemic was not significantly different from the pre-pandemic period, highlighting the resilience of the stroke network.

About Antoine L. Cassell

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