Elizabeth M. Aradine, DO
The COVID-19 pandemic has changed the process of pre-hospital acute stroke triage. Actions such as EMS providers assessing a patient, walking into a patient’s room, transferring a patient to a comprehensive stroke center: These are things we once did without considering if we will contract or spread a virulent airborne virus. Now, special precautions are needed to provide acute stroke care, and they pose various challenges to the process of pre-hospital acute stroke triage. The authors of “Pre-hospital Triage of Acute Stroke Patients During the COVID-19 Pandemic” have established a guide to address these issues, and below is each challenge and possible solution.
EMS providers need to obtain additional history regarding COVID-19 symptoms or exposures which may not be readily available. The authors propose that EMS providers use the COVID-19 Screening Tool, 5 questions on signs, symptoms, COVID-19 contacts, and patient age plus non-respiratory symptoms, as a quick way to assess for COVID-19. EMS providers can then communicate a positive screen to the receiving hospital so they can efficiently prepare for a protected stroke code. Proper donning of PPE can be time consuming, thus the authors propose donning PPE prior to the patient’s arrival to minimize delay in the acute stroke evaluation. Symptomatic COVID-19 patients may need supplemental oxygen or intubation before arrival to the hospital. The authors propose continuous monitoring of vitals and to provide necessary emergent respiratory treatments by EMS after donning appropriate PPE. Staff shortages can occur due to quarantine or illness, leaving these duties to be covered by other providers who may be unfamiliar with acute stroke care. Simulation training can provide training for these new roles. COVID-19 positive stroke patients may need treatment at comprehensive stroke centers, but initially may not be transported directly to one due to location or other factors. Additionally, inter-facility transfers may be delayed due to unavailable transport staff for a COVID-19 positive stroke patient. The authors propose coordination between EMS and hospitals to facilitate re-routing patients to the appropriate hospital, for example, routing suspected LVO patients directly to a comprehensive stroke center. Not only could this prevent delay in acute stroke treatment, but it could also minimize PPE use and unnecessary staff exposure to COVID-19.
Revisiting the process of pre-hospital stroke triage is integral to providing high-quality care to our stroke patients during the COVID-19 pandemic. The authors provide a framework to restructuring this process; however, this may be difficult to implement in some communities. For example, coordinating the re-routing of suspected LVO patients to a comprehensive stroke center may be more seamless in communities with only one EMS servicer. This change requires education and coordination with EMS servicers and coordinating centers, easier to do with one servicer than multiple. Also, simulation training is a great way to train staff unfamiliar with acute stroke triage, but it may not be available in all communities. Lastly, as COVID-19 testing becomes more accessible, some hospitals may test all patients as community spread increases. A pending COVID-19 test can lead to delay in transfer to a tertiary care facility as the receiving hospital may have limited COVID-19 bed availability, thus COVID-19 status would be imperative. As the COVID-19 pandemic evolves, the pre-hospital process of stroke care will also evolve. In the meantime, the framework provided by these authors can be a resource to establish pre-hospital stroke protocols best suited for a community.