Houman Khosravani
Houman Khosravani

A conversation with Houman Khosravani, MD, PhD, Assistant Professor, Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada. Twitter: @neuroccm

Interviewed by Victor J. Del Brutto, MD, Assistant Professor, Stroke Division, Department of Neurology, University of Miami Miller School of Medicine, Florida. Twitter: @vdelbrutto

They will be discussing the paper “Protected Code Stroke: Hyperacute Stroke Management During the Coronavirus Disease 2019 (COVID-19) Pandemic,” published in Stroke.

Dr. Del Brutto: First of all, I would like to thank you and your team for putting together these thoughtful recommendations on how to evaluate patients with suspected stroke during the Coronavirus Disease 2019 (COVID-19) pandemic. As a stroke neurologist, I share the global feeling of uncertainty that this pandemic has caused and look forward to modifying my institution practices in order to maximize patients’ outcomes, their safety, and the safety of the professionals involved in their care. In your article, you mention that stroke patients are at an increased risk of suboptimal outcomes during the COVID-19 pandemic. Could you please comment on the factors that may influence patient outcomes?

Dr. Khosravani: During the COVID-19 pandemic, patients are affected at several junctions in stroke care, including during the hyperacute phase. For example, paramedics responding to a stroke call, in some jurisdictions, will begin the screening process prior to arrival and then again on scene. When screening is positive, pre-notification to the hospital should occur, and this triggers a protected code stroke (PCS). Patients being brought directly to the ED will require additional screening. The necessary use of PPE, with a Safety Lead observing, will add some delays to the front-end processes, but these are essential to keeping providers safe. It is very plausible that, for example, door-to-needle/door-to-groin puncture times will be impacted. Similarly, at the point-of-care, a COVID-19–suspected patient going to imaging will result in having special precautions used in the scanner or neuroangiography suite, which will add additional time (for cleaning as well); this impacts scenarios with back-to-back code strokes as well.

As inpatients, need for isolation may delay access to isolation beds when coming from the ED, and this may delay bringing patients to the stroke unit or result in a backlog in the ED. The pressure put on hospitals to make COVID-19 specific units can also tax stroke bed and provider availability. Patients triaged as stroke, when having a stroke mimic, may not easily be transferable to their home hospital — therefore, repatriation processes can be affected as well. There is a strong human-factors toll as well — for example, visitation restrictions and less frequent encounters with healthcare professionals, already strained with new clinical pressures, can together make the inpatient experience for those requiring hospitalization more challenging. If indeed COVID-19 positive and with concomitant stroke, access and transfer to rehabilitation sites may be delayed or not possible, due to inter-facility transfer restrictions.

Taken together, there are a whole host of issues that can emerge, and these are just some examples that can contribute to added pressures to existing stroke pathways. Significant changes may have to occur to stroke systems (dedicated centers), as it occurred in Italy, to accommodate a large number of COVID-19 admissions to the hospital.

Dr. Del Brutto: What recommendations do you have to maximize the accuracy of the pre-code screening?

Dr. Khosravani: Firstly, if screening is not done, or cannot be performed (due to patient or extrinsic factors), then that code should be treated as a PCS. At some centers, there is a designated individual, usually the charge nurse or acute stroke coordinator, that receives pre-notifications from paramedics. We recommend that these individuals routinely ask the appropriate infection control screen questions so that the stroke team has adequate time to prepare for a PCS.

Pre-notification is not only important for screening, but it also allows for preparation of the room, for example, if the patient requires more advanced resuscitation. As we outlined in the article, the clinical history is important as well — because even during non-pandemic times, there are features of stroke mimics — including sepsis, and during the COVID-19 pandemic, the exposure risk to the team and other hospital patients can have major consequences. Thus, pre-arrival screening is essential.

If a patient cannot be screened, proceed as a PCS. Furthermore, all efforts should be made to screen and/or test the patient as fast as possible (i.e., same-day) to reduce risk of cross-contamination.

Dr. Del Brutto: Considering the rapid spread of COVID-19 in certain geographical regions, would you consider that the Protected Stroke Code be activated in all stroke codes regardless of the pre-hospital screening? Could you please comment on the pros and cons?

Dr. Khosravani: The threshold to designate a code as protected should be low and always at the discretion of the code leader. The reason is that patients may present with neurologic symptoms as a manifestation of this illness – given that the disease can be mild or asymptomatic, the disease state may even exacerbate underlying comorbidities (e.g., atrial fibrillation) resulting in stroke without clear infectious symptoms. Similarly, a patient in theory can be shedding virus, post-incubation, but not yet be fully symptomatic and present with either stroke or stroke-like symptoms.

Given that this virus is new, we need further studies and information to establish the boundaries of its various clinical presentations. We at our site have definitely seen an increase in stroke mimics, of an infectious nature, triaged initially as a stroke. This is why clinical features such as decreased level of alertness or presyncope/syncope should be considered with a heightened sense of alertness.

With community spread, which has evolved even further since we submitted the manuscript, the travel history screen on its own is not value-added (from an infectious screen perspective). But with isolated neurologic symptoms and travel, that should be a protected code stroke as well.

Therefore, we need to balance the risk of COVID-19 exposure during a code stroke with the available supply of PPE, and rational decision-making. If there are features of an alternate diagnosis, no screening performed/possible, or positive infectious screen, then a PCS is certainly the right path forward in our opinion. In our proposed algorithm, there is room for clinical decision-making, but also a framework is recommended that each site can adapt to local protocols.

Furthermore, the information is rapidly evolving, and it’s essential to remain nimble and responsive. As said in a recent World Health Organization briefing (https://youtu.be/Gi69S1UNAVA; see 30:45 onwards in the recording), “If you need to be right before you move, you will never win; perfection is the enemy of the good.”

This is a good time to state that the usual pathways and timelines for in-house protocol development should be rapidly expedited to keep staff and trainees safe. There are a lot of good resources out there; it’s time to use them and adapt quickly for a cohesive response to COVID-19, including for stroke patients.

Dr. Del Brutto: Could you summarize the role of the Safety Leader during the Protected Code Stroke?

Dr. Khosravani: The Safety Lead is akin to a “safety net.” This individual (not part of the in-room stroke resuscitation team) observes the protected code stroke and provides real-time feedback, from the start, to ensure that all aspects are being followed correctly. Specifically, the donning and doffing of PPE, ensuring an open and clear route to the scanner (and beyond) without contamination of the environment, and overseeing the code. This role can also feel open to communicate with the Team Lead (MD1 in Figure 2 of the article) with regards to all aspects of crisis resource management. Appropriate use of PPE is a matter of utmost importance.

Figure 2. Suggested approach to team designation in a protected code stroke (PCS).  

Figure 2. Suggested approach to team designation in a protected code stroke (PCS).

Dr. Del Brutto: What recommendations do you have to decrease the risk of aerosolization during the evaluation of patients with suspected acute stroke?

Dr. Khosravani: Let’s start with some scientific considerations — aerosolization has within it both droplets (particles greater than 5 micrometers) and airborne particles (less than 5 micrometers). Aerosolization occurs, for example, during coughing or sneezing (i.e., what I refer to as intrinsic aerosolization). The droplet particles are larger and heavier, and thus spread within the 1-2-meter radius of the individual. Intriguingly, a single virus is itself approximately 0.13 micrometers (just slightly larger than 100 nanometers). A coughing or sneezing patient generates aerosolization, which is a mixture of both particle sizes.  It turns out that the risk of infectious spread is greater with droplet-type particles — hence, placement of a surgical mask on the non-intubated patient can significantly reduce droplet spread. However, during medical procedures, we as providers generate a great deal of aerosol spread with a similar mixture of droplet and airborne-size particles. These Aerosol Generating Medical Procedures (AGMPs) necessitate proper PPE (N95, goggles and/or face shield, in addition to other elements) in order to provide the needed additional protection.

Therefore, two key principles emerge:

1) Mask on the non-intubated patient: Upon entering the room with PPE, place a surgical facemask on the patient. This will reduce droplets and larger particular aerosolization right at the source — these pertain to the highest risk of infection based on current understanding.

  • With regards to the facemask on the non-intubated patient, we recommend it be placed over any nasal prongs. Therefore, oxygen can be delivered, underneath the mask. Generally, less than 6 L/min of flow is what is discussed due to risk of aerosolization.
  • For patients who need oxygen via face masks (e.g., venturi devices), it is ideal to use masks such as the HiOx mask with a respiratory filter or a Tavish mask — in each of these cases, exhalations ports are filtered. These masks may not be readily available, but if you can get them, it’s a great option to have. If this is not possible, then the facemask is to be placed on the patient and then the mask. There is not a perfect answer here because both the surgical facemasks with O2 mask impairs O2 seal, and vice-versa, the surgical mask over the O2 mask is very suboptimal for catching particulates in devices such as venturi. The precise infection risk with this new virus and this setup is not known. The surgical mask fits better on the patient, and thus a simple venturi-type device can go on top of that (by shaping the mask), accepting that the FiO2 will be lower due to entrainment of room air.

2) Avoidance of AGMPs: Try to avoid Aerosol Generating Medical Procedures in stroke patients. Common AGMPs that apply to stroke patients are open suctioning of the patient, and NG placement (discouraged in the hyperacute phase). Thus, we recommend that if suctioning is being performed, that PPE should include an N95 in addition to the other items. This ideally includes neck protection, where available, for AGMPs.

  • This article (https://www.ncbi.nlm.nih.gov/pubmed/22563403) is a great resource for AGMPs. Site-specific protocols and resource constraints may impact what each site called AGMPs. Certainly, high risk AGMPs are: intubation, BVM with manual ventilation, non-invasive ventilation (BiPAP), and tracheostomy.
  • Be sure to know the full list of AGMPs as recognized by your local IPAC (infection prevention and control).

On the topic of aerosolization, with increasing patient numbers, we may be forced to have to use high-flow nasal oxygen (such as OptiFlow, and possibly even CPAP) to stave intubation in the context of bed and/or ventilator shortages. With regards to this, the medical community needs to gather more evidence. We tried to strike a balance in the article about do’s and don’ts recognizing that things can change.

It’s also a good time to bring up the topic of airway management and when to do it. It should be considered early for those that are looking like they will deteriorate in the scanner or neuroangiography suite —so that it’s done in a controlled setting with proper PPE and with the most expert provider performing intubation. There is no hard target of when to intubate; as with COVID-19, we are seeing some patients that are compensated but have low oxygen saturations — therefore, we have to treat the patient rather than a specific FiO2 requirement or oxygen saturation — this appears to be emerging and needs closer monitoring as time goes on. We need more data and evidence on this topic.

We need more evidence and study of extubation as well, as this is a high-risk procedure as well. For now, same protocol/PPE as with intubation.

Dr. Del Brutto: What recommendations do you have to balance an appropriate clinical examination and minimizing contact between provider and patient?

Dr. Khosravani: Clinicians will know best what constitutes an adequate exam for the specific patient before them — on-the-ground clinical judgement is prime. Some modifications can be made to routine practice, however, including minimizing exam maneuvers that are not a value-add, and certainly this is a time to minimize repeated examinations (e.g., pre- and post-CT exam; serial language assessments).

Dr. Del Brutto: In your opinion, do you think patients with a clinical presentation suggestive of a large vessel occlusion and positive Infection Control Screen should proceed to early intubation in anticipation of endovascular thrombectomy?

Dr. Khosravani: As mentioned earlier, perhaps with COVID-19 more than other scenarios given that we are dealing with a new virus affecting a diversity of patients, the act of prophylactic intubation must not be taken lightly. There are significant pre- and post-intubation harms (need for sedation) that can occur, and reports emerging suggest that some patients can be managed with high-flow nasal oxygen or CPAP. This is a tricky item to recommend one way or another — but any procedure causing AGMPs in the neuroangiography suite has consequences for the staff as well and for cleaning of the suite — so there has to be some deep consideration of whom to intubate and whom we may be able to get away with supplemental O2 modalities, underneath the mask (on the patient), ideally in a neuroangiography suite with negative pressure, and with a team donned with N95 (or higher) PPE (for the un-intubated patient with AGMP risk).

Dr. Del Brutto: What do you think is the role of telemedicine for acute stroke evaluation during the COVID-19 pandemic?

Dr. Khosravani: Both during but especially post-pandemic, I believe that clinicians will think differently about the use of technology and optimizations moving forward. We are very fortunate to be in an era with advanced remote telehealth/virtual technologies. We are learning just how much is possible using these modalities. In stroke care, telestroke is well established — this pandemic highlights the role (in small and large centers alike) for telemedicine/virtual care in the hyperacute assessment of stroke patients. What is very intriguing is that this will only get better in the coming years with ever more advanced technologies!

Dr. Del Brutto: Finally, what advice do you have for the physicians treating stroke patients during the COVID-19 pandemic?

Dr. Khosravani: Remember, there is no emergency in a pandemic. In other words, always take the necessary time to don and doff PPE safely, have a designated Safety Lead for each code, to ensure that you as a provider stay healthy so you can continue to provide care for your acute stroke patients now and in the future to come. Wishing all members of the stroke community safety and wellness.

Thank you Dr. Del Brutto and Blogging Stroke for this opportunity to provide some additional comments. I am happy to answer any questions for folks at other centers who want to implement and adapt this protocol for their site. I can be reached at houman@stroke.dev or @neuroccm.