key: cord-0839954-2ykft44q
authors: Kristoffersen, Espen Saxhaug; Jahr, Silje Holt; Faiz, Kashif Waqar; Storstein, Anette Margrethe; Winsvold, Bendik Slagsvold; Sandset, Else Charlotte
title: Acute stroke care during the first phase of COVID‐19 pandemic in Norway
date: 2021-01-09
journal: Acta Neurol Scand
DOI: 10.1111/ane.13392
sha: 49dd41229373adb727d30605c5edcdcbf6814254
doc_id: 839954
cord_uid: 2ykft44q

OBJECTIVES: The aim of the present study was to investigate how the initial phase of the COVID‐19 pandemic affected the hospital stroke management and research in Norway. MATERIALS AND METHODS: All neurological departments with a Stroke Unit in Norway (n = 17) were invited to participate in a questionnaire survey. The study focused on the first lockdown period, and all questions were thus answered in regard to the period between 12 March and 15 April 2020. RESULTS: The responder rate was 94% (16/17). Eighty‐one % (13/16) reported that the pandemic affected their department, and 63% (10/16) changed their stroke care pathways. The number of new acute admissions in terms of both strokes and stroke mimics decreased at all 16 departments. Fewer patients received thrombolysis and endovascular treatment, and multidisciplinary stroke rehabilitation services were less available. The mandatory 3 months of follow‐up of stroke patients was postponed at 73% of the hospitals. All departments conducting stroke research reported a stop in ongoing projects. CONCLUSION: In Norway, hospital‐based stroke care and research were impacted during the initial phase of the COVID‐19 pandemic, with likely repercussions for patient care and outcomes. In the future, stroke departments will require contingency plans in order to protect the entire stroke treatment chain.

systems simultaneously altered their procedures and structure in order to provide adequate care to critically ill patients with COVID-19. 1 Different changes, priorities, and strategies were chosen at each hospital, and to our knowledge, more detailed nationwide studies on this subject and how this differed from usual care have not yet been published. 10 We hypothesized that the first phase of the pandemic influenced the in-hospital management of stroke. Further, that stroke research was halted. The aim of this "Neurology during a pandemic (NeuroPan) study" was to examine how the COVID-19 pandemic affected the specialized hospital-based stroke care and stroke research in Norway.

Norway has a population of approximately 5.4 million inhabitants and is a country with large geographical differences, rural and remote areas and long distances. Forty-eight different hospitals take care of stroke patients, but more than 65% of all the patients are admitted to one of the 17 departments of neurology with a Stroke Unit in Norway. The neurological departments are located throughout Norway and are located at smaller district hospitals as well as larger university hospitals. Seven out of seventeen of the Stroke Units are comprehensive stroke centers.

In the Norwegian healthcare system, the general practitioners (GPs) act as gate keepers for referrals to secondary care specialists and hospitals except in emergencies such as acute stroke. The hospitals are almost exclusively publicly financed, and Norway has an all-covering national health insurance. Thus, all patients, irrespective of insurance, social, or financial status, enter the hospital on the same conditions and have the same access to diagnostics, treatment options, and further follow-ups.

The study was conducted as a web-based questionnaire survey during the primary stage of the COVID-19 pandemic in Norway in 2020. The link to the structured web-based questionnaire 

The design of the questionnaire was based on the authors' clinical experience from the first weeks of the pandemic lockdown, in addition to their general knowledge and experience within stroke medicine, neurology, and questionnaire studies. The questionnaire was distributed in the end of April 2020 and consisted of thirty-five questions of general character concerning their department's overall handling, impressions, and experiences regarding stroke patients during the initial phase of the pandemic between 12 March and 15

April 2020 (Figure 1 ). The Head of the Stroke Units were asked to answer the questionnaire by themselves and to answer the questions based on their impressions when accurate comparisons to the pre-pandemic period did not exist.

For descriptive data, proportions, means, and standard deviations (SD) or 95% confidence intervals (CI) are given. Groups were compared using the t-test (continuous data) or the chi-square test (categorical data).

Statistical significance was defined by p < 0.05, using a twosided test. Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 26.00 (SPSS Inc., Chicago, IL, USA).

The Data Protection Officer at Akershus University Hospital (Norway) approved the study. The NeurorPan study was registered in the COVID-19 trial registration at the Norwegian Clinical Research Infrastructure Network. According to the Norwegian Health Research Act, no ethical approval was deemed necessary as patient data were not used.

The responder rate was 94% (16 of 17 neurological departments).

The department that did not participate did not give any reason for this. Eighty-one % (13/16) reported that the pandemic affected their department, and 63% (10/16) reported that the pandemic changed their management of stroke. Work schedules of both residents and specialists were changed in 25% (4/16) of the hospitals due to reprioritization of demands and tasks.

Six out of sixteen (38%) Stroke Units reduced the number of hospital beds ( Table 1 ). All 16 departments reported a drop in new acute admissions in terms of both stroke (ischemic stroke, hemorrhagic stroke, and transient ischemic attacks) and stroke mimics (Table 1) .

Further, fewer patients received thrombolysis (69%) and endovascular treatment (43%).

Seventy-five % of the hospitals made practical changes to the thrombolysis procedures with 19% switching from alteplase to tenecteplase, and half of the hospitals reported longer time than usual on thrombolysis assessments. In addition, the respondents reported that fewer patients were given the opportunity for proper follow-up (73%) and stroke rehabilitation (50%) ( Table 1 ). The mandatory 3 months of follow-up consultations were postponed at 73% (11/15) of the hospitals. The in-hospital diagnostic evaluation of stroke did not change in the vast majority of hospitals (Table 1) .

Twenty-seven% (n = 4) decreased the proportion who received carotid ultrasound to reduce the possibility of SARS-CoV-2 exposure. Overall, 43% (6/14) reported that the standard of care for stroke patients was worse during the pandemic compared to pre-COVID-19.

The main findings were that 81% of the neurological departments changed their practice during the initial phase of the COVID-19 pandemic and that a worse standard of stroke care was reported by 43% of the hospitals.

During the lockdown, primary care physicians, emergency medical communication centers, and hospitals expressed concern regarding the impression that fewer people sought medical help for TA B L E 1 Data on hospital-based stroke care during the COVID-19 pandemic in Norway All % (n)

In-hospital management

The work situation changed 81 (13) 19 (3) Our work schedule was changed 25 (4) 75 (12) We reduced the number of beds for stroke patients 38 (6) 63 (10) The pandemic affected our course of treatment for stroke 63 (10) 38 (6) We made changes to the thrombolysis procedures (practical implementation) 75 (12) 25 (4) We used tenecteplase rather than alteplase 19 (3)

We spent more time than usual on thrombolysis assessments 50 (6) 50 (6) Fewer patients received thrombolytic therapy 69 (9) 31 (4) We increased the proportion of patients who received MRI in the acute phase 0 (0) 100 (16) We increased the proportion of patients who received CT angiography to avoid carotid ultrasound 20 (3) 80 (12) We reduced the proportion of patients who received carotid ultrasound to avoid SARS-CoV-2 exposure 27 (4) 73 (11) We changed the TIA protocols to reduce the number of admissions 21 (3) 79 (11) Fewer patients received extended etiologic assessment 6 (1) 94 (15) We discharged patients faster than usual 6 (1) 94 (15) Stroke patients had reduced access to rehabilitation services 50 (7) 50 (7) The overall standard of care for stroke patients decreased during the pandemic 43 (6) 57 (8)

Fewer stroke patients came to the hospital than usual 100 (16) 0 (0)

Stroke patients arrived at the hospital later than usual 100 (16) 0 (0)

The stroke patients who came to the hospital were more severely affected than those we usually see 55 (6) 45 (5) Fewer stroke mimics came to the hospital than usual 100 (12) 0 (0)

Outpatient follow-ups after stroke were postponed 73 (11) 27 (4) | 353 a number of serious conditions, including cerebrovascular diseases.

All hospitals reported fewer admissions of suspected strokes and most of the hospitals had fewer interventions. Even though this nationwide study is based on a questionnaire and not absolute numbers, these impressions are confirmed by findings from Norway and other countries. [2] [3] [4] [5] 7 The decrease in Norway has also mainly been in transient ischemic attacks and minor strokes and those admitted have been more severe than pre-COVID-19 as also reported in the present questionnaire study. 5 All ongoing research projects were halted. This may be justified

given the circumstances but pausing intervention trials may yield problems for the patients not receiving the intervention or follow-ups as intended. It is also imperative that grants and fellowships are extended for the affected time period to ensure that projects are completed according to protocol. The potential long-term repercussion is the lack of implementation of possible beneficial treatments for patients.

As far as we know, this is the first nationwide study to report on how the COVID-19 pandemic affected the stroke care pathways and management on a national level. 

During the initial phase of the COVID-19-pandemic in Norway, hospital-based stroke care and research were impacted. Contingency plans to ensure adequate stroke care in national emergencies should be in place, and collaboration within the Norwegian stroke community can be improved. More research on institutional and governmental strategies and priorities for stroke patients and prognosis during the pandemic is warranted.

The authors want to express their sincere gratitude to the participants and hospitals, without them the study would not have been possible.

BWS has received speaking fees from Novartis, unrelated to the present work. ECS has received speaking fees from Bayer and Novartis, unrelated to the present work. AMS, ESK, KWF, and SHJ report no conflicts of interest.

The authors declare that the data supporting the findings of this study are available within the article.

Espen Saxhaug Kristoffersen https://orcid. 

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