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Stroke Care During the COVID-19 Outbreak in Spain: the Experience of Spanish Stroke Units

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Stroke Care During the COVID-19 Outbreak in Spain: the Experience of Spanish Stroke Units Open access Original research Stroke Vasc Neurol: first published as 10.1136/svn-2020-000678 on 4 December 2020. Downloaded from Stroke care during the COVID-19 outbreak in Spain: the experience of Spanish stroke units María Alonso de Leciñana ,1 Mar Castellanos,2 Óscar Ayo- Martín,3 Ana Morales,4 On behalf of the Stroke Group - Spanish Society of Neurology To cite: Alonso de Leciñana M, ABSTRACT Spain has been one of the countries most Castellanos M, Ayo- Martín Ó, Background and purpose Spain has been heavily heavily affected by COVID-19 in Europe.1 The et al. Stroke care during the affected by COVID-19. Reallocation of resources for first case in Spain was confirmed on the 31 COVID-19 outbreak in Spain: managing the outbreak might have caused a disruption in the experience of Spanish January 2020, with number rapidly increasing stroke care. This study analyses the impact on stroke care stroke units. Stroke & Vascular thereafter, prompting the declaration of a of reorganising the healthcare system in response to the Neurology 2020;0. doi:10.1136/ national state of emergency and a population svn-2020-000678 first COVID-19 outbreak peak in Spain and the strategies adopted by Spanish stroke units to deal with this impact. lockdown on the 14 March 2020 in an effort Received 12 October 2020 Materials and methods We obtained data from a to halt the spread of the disease and prevent Revised 11 November 2020 structured survey sent to the responsible of stroke units the collapse of hospital services. The pandem- Accepted 17 November 2020 across the country. We recorded the number of strokes, ic’s first peak was reached during the last week stroke code activations, intravenous thrombolysis of March, when the cumulative rate for the treatments and mechanical thrombectomies during entire country was 217 cases/100 000 inhab- February and March 2019 and 2020. We also collected itants, ranging from 56 to 612 cases per 100 information on the impact on workflow metrics and 000 inhabitants in the various autonomous on the availability of specialised neurological care and 2 communities (figure 1). rehabilitation treatments, the characteristics of stroke care The burden of patients with SARS-CoV -2 for patients with SARS- CoV-2 infection and the impact on © Author(s) (or their human resources. We compared the activity data between infection forced the Spanish healthcare employer(s)) 2020. Re- use 2019 and 2020 and the information on activity and impact system to reorganise medical care and reallo- permitted under CC BY- NC. No on stroke care between regions classified according to the cate resources for managing COVID-19, which commercial re- use. See rights disease incidence rate. might have caused a disruption in stroke care and permissions. Published by BMJ. Results Fifty- seven (75%) of all stroke units in Spain and could have resulted in a negative impact responded to the survey. There was an overall reduction 3–5 http://svn.bmj.com/ 1Department of Neurology and on outcomes. Stroke is one of the leading 6 Stroke Center, Hospital La Paz in admissions for all stroke types during the outbreak’s causes of death and disability worldwide. Due Institute for Health Research- peak and in the number of stroke code activations and to the highly time- sensitive nature of stroke intravenous thrombolysis treatments, results that were IdiPAZ. La Paz University treatment, major efforts have been employed Hospital. Universidad Autónoma independent of the COVID-19 incidence rate. Participants de Madrid, Madrid, Spain reported a delay in workflow metrics and a reduction to construct well-organised healthcare systems 2Department of Neurology, of admissions to stroke units, outpatient clinics and to ensure rapid access to acute treatment, Complexo Hospitalario rehabilitation therapies. Specific pathways and protocols which might have been jeopardised by the on September 24, 2021 by guest. Protected copyright. Universitario A Coruña. for managing stroke patients with SARS- CoV-2 infection pandemic. Different strategies to fight this Biomedical Research Institute of have been established. threat according to particular situations and A Coruña, A Coruña, Spain 7–9 3Department of Neurology, Conclusion The COVID-19 outbreak has jeopardised all available resources have been published. Complejo Hospitalario phases of stroke care. As a consequence, some patients Collecting information on the impact of first Universitario de Albacete, with stroke did not receive adequate treatment. pandemic peak and the approaches imple- Albacete, Spain mented to cope with it could help us meet the 4Department of Neurology, University Clinic Hospital Virgen INTRODUCTION challenge of maintaining the adequate care of de la Arrixaca, Murcia, Spain SARS- CoV-2 infection, which causes COVID- patients with stroke, given that the pandemic 19, has spread rapidly throughout the world is still far from being controlled. Correspondence to since December 2019 when the first outbreak In this study, we analysed the impact of Dr María Alonso de Leciñana, Department of Neurology and was detected in Wuhan, China. The outbreak the COVID-19 pandemic on stroke care and Stroke Center, Hospital La Paz was declared an international public health the activity of stroke units (SUs) in Spain, Institute for Health Research- emergency by the International Health Regu- according to the burden this pandemic has IdiPAZ. La Paz University lations (2005) Emergency Committee on the placed on the various regions and we describe Hospital. Universidad Autónoma the organisational strategies implemented de Madrid, Madrid, Spain; 30 January 2020 and was recognised by the malecinanacases@ salud. WHO as a global pandemic on the 11 March by Spanish neurologists during the first madrid. org 2020. pandemic peak. Alonso de Leciñana M, et al. Stroke & Vascular Neurology 2020;0. doi:10.1136/svn-2020-000678 1 Open access Stroke Vasc Neurol: first published as 10.1136/svn-2020-000678 on 4 December 2020. Downloaded from survey that was sent to all neurologists working at SUs in hospitals throughout Spain, along with a letter of invita- tion to voluntarily participate that explained the study objectives and provided access to the web- based question- naire. To avoid data duplication, respondents were asked to provide only one survey per hospital. The need to provide only verified data and not estimates was empha- sised. The survey was launched on the 13 April 2020 and closed on the 13 August 2020. Throughout the study period, reminders were sent to encourage participation. The survey recorded five different blocks of questions: (1) the participants’ names and contact details and the number of staff neurologists and residents per neurology department, (2) data on SU activity during February and March 2019 and 2020 (number of transient ischaemic Figure 1 Map of the autonomous communities of Spain. attacks (TIAs), ischaemic strokes (ISs) and intracerebral Population density and COVID-19 incidence rate. The circles haemorrhages (ICH) treated, number of stroke code represent the incidence rate at the peak of the pandemic (per activations and number of intravenous thrombolysis 100 000 inhabitants). Population density is shown beside (IVT) treatments and mechanical thrombectomies (MT) the name of the community (inhabitants/km2). 1: Andalucía performed), (3) information on the impact on acute (96). 2: Aragón (28). 3: Principality of Asturias (96). 4: Balearic stroke care during the pandemic (whether the respon- Islands (230). 5: Canary Islands (289). 6: Cantabria (109). 7: dents considered that there was an impact or not and Castilla y León (25). 8: Castilla- La Mancha (26). 9: Cataluña whether the impact consisted of longer delays in hospital (239). 10: Community of Valencia (215). 11: Extremadura (26). 12: Galicia (91). 13: La Rioja (63). 14: Community of Madrid admission, in attention by a neurologist, in the perfor- (830). 15: Murcia region (132). 16: Chartered Community of mance of diagnostic tests or in initiation of IVT or MT Navarra (63). 17: Basque Country (305). 18: Autonomous City or whether the availability of SUs facilities, specialised of Ceuta (7207). 19: Autonomous City of Melilla (4239). neurological care, Doppler ultrasound studies, outpa- tient clinics, or rehabilitation treatments was reduced, METHODS and if telemedicine was reinforced), (4) information Setting regarding the characteristics of care for stroke patients Spain is divided into 17 autonomous communities and with a suspected or confirmed diagnosis of SARS- CoV-2 2 autonomous cities (figure 1). Each community has its infection (whether the protocols and care pathways were own regional government with legislative and executive modified and whether the modifications affected the stroke code pathways, in-hospital pathways, diagnostic autonomy that includes health policies. Healthcare is http://svn.bmj.com/ essentially provided by Spain’s public health system and protocols, treatment protocols, creation of specific and hospitals that provide stroke care are managed by the separated SUs and/or neurology wards) and (5) data regional government of the autonomous communities. on the impact on human resources (number of medical All communities have developed organisational models leaves due to contagion or quarantine and the number of for stroke care according to their particular characteris- neurologists reallocated to reinforce other hospital areas tics and needs, aiming to provide optimal treatment to for the care of patients with COVID-19, whether there was on
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