key: cord-267713-i75e5vtw
authors: Lim, Andy; Singhal, Shaloo; Lavallee, Philippa; Amarenco, Pierre; Rothwell, Peter M.; Albers, Gregory; Sharma, Mukul; Brown, Robert; Ranta, Annemarei; Maddula, Mohana; Kleinig, Timothy; Dawson, Jesse; Elkind, Mitchell S.V.; Guarino, Maria; Coutts, Shelagh B.; Clissold, Benjamin; Ma, Henry; Phan, Thanh
title: An International Report on the Adaptations of Rapid Transient Ischaemic Attack Pathways During the COVID-19 Pandemic
date: 2020-08-18
journal: J Stroke Cerebrovasc Dis
DOI: 10.1016/j.jstrokecerebrovasdis.2020.105228
sha: 
doc_id: 267713
cord_uid: i75e5vtw

BACKGROUND: This report aims to describe changes that centres providing transient ischaemic attack (TIA) pathway services have made to stay operational in response to the SARS-CoV-2 pandemic. METHODS: An international cross-sectional description of the adaptions of TIA pathways between 30(th) March and 6(th) May 2020. Experience was reported from 18 centres with rapid TIA pathways in seven countries (Australia, France, UK, Canada, USA, New Zealand, Italy, Canada) from three continents. RESULTS: All pathways remained active (n = 18). Sixteen (89%) had TIA clinics. Six of these clinics (38%) continued to provide in-person assessment while the majority (63%) used telehealth exclusively. Of these, three reported PPE use and three did not. Five centres with clinics (31%) had adopted a different vascular imaging strategy. CONCLUSION: The COVID pandemic has led TIA clinics around the world to adapt and move to the use of telemedicine for outpatient clinic review and modified investigation pathways. Despite the pandemic, all have remained operational.

The novel corona virus 2019 outbreak is now classified as a pandemic. 1 Unlike the recent viral H1N1 pandemic (also known as swine flu) in 2009, this pandemic has led to widespread disruption of society and has overwhelmed health care systems in some countries with a high level of infection. As part of ongoing preparatory measures, many health services have been reducing or ceasing 'non-urgent care', with impacts on secondary stroke prevention and urgent outpatient follow-up being one of the many potential adverse outcomes. 2 In addition, due to concerns about use of needed supplies and hospital beds, even the evaluation of patients with acute neurological problems, like stroke and TIA, has been affected.

Urgent evaluation of TIA in the outpatient or ED setting has been successful in providing urgent care and preventing stroke occurrence. 3, 4 These rapid care pathways have grown based on earlier 'natural history' work showing a high risk of stroke at 90 days post TIA. With urgent evaluation and medical treatment, the risk of recurrent stroke has been reduced from 10.3% to 2.1% in some settings. 3 A narrative survey of these innovative models of care illustrated their value in providing better health outcomes and reduction in healthcare costs. 5 Furthermore, these rapid TIA clinics can potentially assist the healthcare system during this crisis. Management of patients in the outpatient setting can facilitate patient flow and allows inpatient resource and beds to be utilised for other purposes. The aim of this report is to provide a description of existing rapid TIA pathways around the world and understand the necessary adjustments in practice required to optimally evaluate and manage TIAs during the pandemic.

An international, multicentre, cross-sectional study to describe the adaptions of TIA pathways in response to the COVID-19 pandemic. The study was approved as a Quality Assurance activity (reference number: QA/63676/MonH-2020-209422) by the Monash Health Human Research Ethics Committee. Informed consent was not required.

To identify our collaborators, we performed a literature review of rapid TIA pathways in PubMed. Choice of publication was based on the description of a structured pathway from primary care and/or the emergency department to a dedicated TIA clinic that was aimed at expediting the evaluation and initial management of TIA. Review papers, surveys of practice, and tests of diagnostic accuracy were excluded. Audits of existing services against national targets, and models that introduced more aggressive secondary prevention strategies but did not include a rapid pathway were excluded. Two independent researchers (A.L and T.P) reviewed all articles meeting inclusion criteria. Final choice of included centres was by consensus.

Three demographic variables were noted À continent, pathway setting (hospital, ED, GP), and lockdown status. Lockdown status was measured based on the New Zealand Government alert system definition, with four tiers of increasing restriction À 1 = prepare, 2 = reduce, 3 = restrict, 4 = lockdown. 6 Four adaptation variables were noted À whether a centre was active, whether a centre retained in-person assessment, if so, was PPE use reported, and whether brain and arterial imaging strategy was changed. Date of response and national COVID prevalence 7,8 on the 28 th of April 2020 was also recorded. Non-responder data were extracted from the published article and included pathway setting, assessment method (in-person or telemedicine), and imaging choice. For these, clinic status (active versus non-active) was inferred by visiting the institution's website, and the date of the internet search was recorded.

We used descriptive statistics to describe the findings.

The PRISMA statement and the reasons for excluding studies are provided in Fig. 1 . A total of 1258 potential papers were identified in the PubMed search strategy. An additional two pathways were added from searching article reference lists. 9,10 After searching 1260 titles and/or abstracts, 28 studies/pathways were selected. The final collaboration reported experience from eighteen centres in seven countries (Australia, France, UK, Canada, USA, New Zealand, Italy, Canada) from three continents (Oceania, Europe, North America). Table 1 displays key results. The responses range from 30 th March 2020 to 6 th May 2020. All eighteen pathways reported remaining active. Six of the sixteen centres with TIA clinics (38%) continued to provide in-person assessment 3,4,9,11À13 while the others (63%) have changed their patient assessment method to exclusively telephone or video-enabled visit. Of these, three (Paris, Oxford, Leicester) reported PPE use and three (Wellington, Adelaide, Sydney) did not. Five centres with clinics (31%) adopted a different vascular imaging strategy. 3 

In-person TIA clinic assessment Six centres in Paris, 4 Oxford, 3 Wellington, 9 Adelaide, 11 Sydney, 12 and Leicester 13 retained in-person assessments, but with modifications. A seventh centre in Rochester, 18 Minnesota reported a plan to reinstate the in-person evaluation in follow-up to the initial ED evaluation in late April with patient and staff masking, and extensive patient COVID-19 screening. The SOS-TIA France model 4 allowed patients with or without suspicion of COVID-19 to be evaluated in the TIA clinic, with the patient and the staff wearing a surgical mask and the medical staff 9 patients who were deemed likely to have TIA after telephone screen were sent to a raid access community testing centre for a swab. The result is available within hours, and the patient is seen in the TIA clinic on the same day if COVID-19 negative. In Adelaide patients were seen in clinic if there was symptomatic carotid artery stenosis or the diagnosis had been revised to stroke after a review of the MRI scans, provided that there was no suspicion of COVID-19. Those with suspicion were redirected from the hospital entrance to the COVID clinic. In Sydney, 12 if diagnostics were performed as an outpatient before TIA clinic appointment, video telehealth or phone consult was offered to discuss results and further management. Before being offered in-patient assessment, a series of COVID risk questions are asked. If the patient questionnaire is positive, they are redirected for testing instead. Leicester 13 was still seeing patients face-to-face, but were increasing their focus on triage and referral with occasional phone review. PPE use included goggles, surgical mask, apron, and gloves for seeing inpatients, and goggles and surgical mask for outpatients with no symptoms.

The centres in Melbourne, 14 Oxford, 3 Ottawa, 15 Glasgow 16 and New York 17 have largely replaced carotid ultrasonography with computed tomography angiogram (CTA). Mayo, 18 New York, 17 Paris, 4 and Stanford 19 also reported additional imaging variations. At Mayo, 18 for a short period in late March and April 2020, cardiac CT and transthoracic echocardiogram were used as short-term replacement for transoesophageal echocardiography (TEE) to lessen use of personal protective equipment (PPE) given that TEE is an aerosol generating procedure. The practice has now returned to use of TEE with appropriate PPE use. New York 17 additionally performs an MRI brain in the ED, as clinically indicated, if follow-up is considered unlikely. The SOS-TIA France model allowed patients to their TIA clinic. In case of suspected COVID infection the patients were screened with CT chest prior to MRI brain. Stanford TWO ACES model 19 admitted high risk TIA patients to facilitate MRI scanning; this change had occurred prior to the COVID-19 pandemic. Table 2 provides results from the ten centres that did not respond to the survey. The data were obtained from the published article and internet search. Six centres 20À25 appeared active based on their institutional website. None of the papers described telemedicine follow-up. Three of these pathways had CTA as an option for vascular imaging. 21, 22, 24 

This report regarding the adaptations of urgent TIA evaluation in response to the COVID-19 pandemic provides a description of the current international experience. The results cover eighteen centres across seven countries and three continents. The key findings were: (1) all participating centres remained operational, (2) change in assessment to telephone and/or video-enabled visits; (3) change in type of vascular imaging investigations, First, the fact that all participating centres reported an active status suggests that the commitment that health services have made to redirecting TIA patients to rapid and/or outpatient pathways is significant. The ease of adoption did not seem to differ between jurisdictions, as all centres were able to adapt and remain active. This high operational status could be interpreted as a marker of the essential nature of this service, especially in a period of widespread elective surgical cancellations and shutdown of non-essential services worldwide. However, the seven countries represented (Australia, France, UK, Canada, USA, New Zealand, and Italy) all belong the upper quintile of the World Health Organization's universal health coverage index. 26 Therefore, this could simply reflect a high level of health service resourcing.

Second, telemedicine has been recommended for the assessment of a patient with TIA during the pandemicthe American Heart Association/American Stroke Association have issued temporary guidance for the use of telemedicine for stroke care during this time. 27 Similarly, the British National Health Service has also recommended this in order to reduce the need to use PPE for management of COVID-19 patients. 28 While other countries may not have explicit guidance for TIA clinics, regulatory changes have supported the adoption of telemedicine. 29, 30 This is reflected in the change in pattern of practice seen in most centres. However, evidence is lacking regarding the safety of a TIA pathway via telemedicine. The downside to delivering care via telephone or a telemedicine platform is that patients may miss out on other aspects of secondary prevention such as blood pressure measurement and lipid management, 31 in-person risk factor and lifestyle advice, driving issues, other diagnostic tests and timely prescription of medicine. 3 These pathways were designed such that the TIA clinic component has in-person assessments with detailed neurological examination by a neurologist or stroke physician. This step is important as some patients may not have been evaluated by neurology or stroke physician staff at the ED presentation. For example, investigators have reported TIA mimics in 38.3% after evaluation in TIA clinic. 14 The TIA clinics for non-admitted patients represent a significant step in confirming or refuting the diagnosis. Such evaluation can be difficult with telephone consultation especially for hearing impaired or patients with cognitive impairment. Given that these pathways have previously provided exclusively in-person assessments, this represents a significant shift in practice. This change does raise concerns regarding the quality of care that can be delivered and requires monitoring to evaluate the change in model of care on stroke recurrence. Last, the imaging strategies during the COVID-19 era reflect local adaptation. Five centres replaced carotid ultrasonography with CT angiography. 3,14À17 These changes are not without precedents as eleven centres had already been performing CTA as a vascular imaging option in the pre-COVID era. 11,12,15,16,21,22,24,32À35 The changes in strategies may reflect the impracticality of bringing patients back for carotid ultrasound as a separate investigation.

This study had several limitations. First, only published pathways were investigated. Therefore, our results may not reflect activity among other TIA clinics. Second, our reporting on the use of PPE as a binary variable is simplistic, as different health services have a range of PPE availability and utilization based on the procedure and setting. For instance, PPE use may imply a single surgical mask, or it may incorporate an N95 respirator, face shield, surgical gown, gloves, and hair net. Third, it remains uncertain how the COVID era has altered the patient demographics and number of patients referred for TIA clinic evaluation. Finally, we had described the 10 clinics in which we have tried to contact but have not received a written response. This data is described in separately in Table 2 to highlight that the data came from a different source and possibly less reliable as the websites may not have kept up to date with changes in the operational status of TIA clinics during the pandemic.

This study has provided an initial description of the global impact of COVID-19 on these pathways. These results reflect the recognition of TIA as a medical emergency, and treatment remains an essential health service, even if performed through telehealth. It will be important to perform a patient-level analysis of pre-and post-COVID clinical outcomes.

None

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The authors are very grateful to the physicians who spent time answering our survey.AL is supported by an Australian Government Research Training Program Scholarship.