key: cord-0828942-x5ba4kua
authors: Baracchini, Claudio; Pieroni, Alessio
title: Letter by Baracchini and Pieroni Regarding Article, “Protected Code Stroke: Hyperacute Stroke Management During the Coronavirus Disease 2019 (COVID-19) Pandemic”
date: 2020-06-22
journal: Stroke
DOI: 10.1161/strokeaha.120.030161
sha: 52ee7ccc0d9b25dce845befea2afbfc26616e9e5
doc_id: 828942
cord_uid: x5ba4kua

nan

Letter by Baracchini We read with interest the article recently published by Khosravani et al 1 who introduced the concept of a protected code stroke during the coronavirus disease 2019 (COVID-19) pandemic, both for patients and healthcare professionals. As they report, the former are at an increased risk of suboptimal outcomes due to time delays and limitations of resources impacting negatively on diagnostics, acute treatment, and poststroke care. The latter is engaged in triage, rapid assessment, and treatment during the hyperacute stage of ischemic stroke and, therefore, they need to be protected from viral transmission.

Our University Hospital, with a catchment area of about one million people and located in the Veneto region in North-Eastern Italy, has been faced with this problem since February. We had the first cluster of COVID-positive patients, the first dead due to COVID infection and the first locked down area (Vo' Euganeo) together with Codogno in Lombardy. This is truly a time of unprecedented challenge to our health systems, which requires responsiveness, flexibility, and adaptability. Considering the regional authorities' imposition to stay at home and the mounting fear of going to the hospital, especially among elderly with comorbidities, we expected to see a reduction of transient ischemic attacks and minor strokes and a delay of major strokes arriving either from the field or from spokes. Necessarily, we had to create a protected pathway both for patients and stroke team members as stroke remains a medical emergency despite COVID-19 outbreak, and eligible patients should receive reperfusion therapies that strongly affect functional outcome and mortality.

At first, we selected which stroke patients to screen for COVID before admitting them to our stroke unit, based on concurrent or recent symptoms (fever, cough, dyspnea, anosmia, ageusia, gastrointestinal symptoms) and recent infectious exposure. In case of a COVID-19 suspected patient, a fast track nasopharyngeal test and, if indicated, a chest computed tomography were performed just outside of the Emergency Area. COVIDpositive patients with stroke were admitted to dedicated COVID units after reperfusion therapies and followed by the stroke team with the objective of maintaining highquality care and promoting the best chance for recovery. With this strategy, we prevented viral transmission to our stroke team members and to other patients by isolating COVID-19 positive and suspected cases. 2 As the number of COVID-19 suspected patients arriving at the Emergency increased, there was a significant delay in processing the nasopharyngeal tests. We solved this problem by creating a limbo room where patients received best stroke care by our stroke team while waiting for the results of the test. With this pathway, we have been able to keep our stroke unit COVID-free, continue to be a referral for the spokes in our region, and reassure patients and caregivers.

Up till now, in Italy there have been about 140 000 infected people and >17 000 dead; the actual number of infected cases is probably much higher than the official count, and contagions continue to climb. Health professionals have paid a heavy toll, as ≈50% of them are infected, also owing to a shortage of effective personal protective equipment. We agree with Khosravani et al 1 that a protected code stroke is a prerequisite for any hospital especially for those delivering highly specific treatments 24/7, but it might not be quite enough. When one deals with a large percentage of the population being either COVID-positive or suspected to have a COVID infection, protected code stroke is definitely a useful tool. However, it must be combined with a structural change of the hospitals, a reorganization of the healthcare, and a specific intramural pathway that should offer a coordinated and diversified response according to the different needs of patients and health professionals. This pandemic could represent an opportunity to improve frontline clinical care if everyone plays their part including national leaders and government officials. When phase 2 of this global crisis will set in, and the lights will fade away, we should be prepared to coexist with this virus while continuing to guarantee a safe approach and a high-quality care to stroke patients.

Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy.

None.

Protected code stroke: hyperacute stroke management during the coronavirus disease 2019 (COVID-19) pandemic

Acute stroke management pathway during coronavirus-19 pandemic