key: cord-0844833-6wr6vex9 authors: Yavagal, Dileep R; Saini, Vasu; Inoa, Violiza; Gardener, Hannah E; Martins, Sheila O; Fakey, Manav; Ortega, Santiago; Mansour, Ossama; Leung, Thomas; Jadhav, Ashutosh P; Potter-Vig, Jennifer; Mairal, Anurag; Zhongrong, Miao; Sylaja, P.N.; Demchuk, Andrew M title: International survey of Mechanical Thrombectomy Stroke systems of care during COVID-19 pandemic date: 2021-04-06 journal: J Stroke Cerebrovasc Dis DOI: 10.1016/j.jstrokecerebrovasdis.2021.105806 sha: 1fc44b4f79e642d9476501b5973d3ef0da97cbdf doc_id: 844833 cord_uid: 6wr6vex9 BACKGROUND: The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on various aspects of thrombectomy systems. AIMS: We conducted a convenience electronic survey with a 21-item questionnaire aimed to identify the changes in stroke admission volumes and thrombectomy treatment practices seen during a specified time period of the COVID-19 pandemic. METHODS: The survey was designed using Qualtrics software and sent to stroke and neuro-interventional physicians around the world who are part of the Global Executive Committee (GEC) of Mission Thrombectomy 2020, a global coalition under the aegis of Society of Vascular and Interventional Neurology, between April 5th to May 15th, 2020. RESULTS: There were 113 responses to the survey across 25 countries with a response rate of 31% among the GEC members. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during the COVID-19 pandemic period until May 15(th), 2020 compared to pre-pandemic months. The intubation policy for MT procedures during the pandemic was highly variable across participating centers: 44% preferred intubating all patients, including 25% of centers that changed their policy to preferred-intubation (PI) from preferred non-intubation (PNI). On the other hand, 56% centers preferred not intubating patients undergoing MT, which included 27% centers that changed their policy from PI to PNI. There was no significant difference in rate of COVID-19 infection between PI versus PNI centers (p=0.60) or if intubation policy was changed in either direction (p=1.00). Low-volume (<10 stroke/month) compared with high-volume stroke centers (>20 strokes/month) were less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers were more likely to report them to be inadequate (58% vs 92%). CONCLUSION: Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic. Overall, respondents reported decreased stroke admissions as well as decreased cases of MT with no clear preponderance in intubation policy during MT. DATA ACCESS STATEMENT: The corresponding author will consider requests for sharing survey data. The study was exempt from institutional review board approval as it did not involve patient level data. Background: The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on various aspects of thrombectomy systems. Aims: We conducted a convenience electronic survey with a 21-item questionnaire aimed to identify the changes in stroke admission volumes and thrombectomy treatment practices seen during a specified time period of the COVID-19 pandemic. Methods: The survey was designed using Qualtrics software and sent to stroke and neurointerventional physicians around the world who are part of the Global Executive Committee (GEC) of Mission Thrombectomy 2020, a global coalition under the aegis of Society of Vascular and Interventional Neurology, between April 5th to May 15th, 2020. Results: There were 113 responses to the survey across 25 countries with a response rate of 31% among the GEC members. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during the COVID-19 pandemic period until May 15 th , 2020 compared to pre-pandemic months. The intubation policy for MT procedures during the pandemic was highly variable across participating centers: 44% preferred intubating all patients, including 25% of centers that changed their policy to preferred-intubation (PI) from preferred non-intubation (PNI). On the other hand, 56% centers preferred not intubating patients undergoing MT, which included 27% centers that changed their policy from PI to PNI. There was no significant difference in rate of COVID-19 infection between PI versus PNI centers (p=0.60) or if intubation policy was changed in either direction (p=1.00). Low-volume (<10 stroke/month) compared with high-volume stroke centers (>20 strokes/month) were less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers were more likely to report them to be inadequate (58% vs 92%). Conclusion: Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic. Overall, respondents reported decreased stroke admissions as well as decreased cases of MT with no clear preponderance in intubation policy during MT. Data access statement: The corresponding author will consider requests for sharing survey data. The study was exempt from institutional review board approval as it did not involve patient level data. On March 11 th 3 Invasive Neurological Therapy (ESMINT) 4 provided guidance statements for the care of patients requiring emergent neurointerventional procedures during COVID-19 pandemic. Availability and adequacy of personal protective equipment (PPE) is uniformly stressed to be of utmost importance to protect the frontline healthcare workers as evident by a large case series from Wuhan, China showing hospital-associated transmission as the presumed mechanism of infection in 29% of affected healthcare workers. 5 There is a consensus amongst the international medical community that presence of COVID-19 as a public health emergency should not alter the inclusion or exclusion criteria for Mechanical Thrombectomy (MT) 6 , though the recommendations on criteria and timing of intubation for patients undergoing MT is unclear and more heavily contingent on institutional resources available. Also, while expert recommendations have been published there is no consensus on appropriate changes in practice in the management of non-COVID-19 emergencies during the pandemic. Different countries or even different healthcare systems within a country responded with a varied spectrum of policy changes trying to balance the safety of its healthcare workers and uphold the continued quality of care for the patients presenting with emergencies including stroke. This cross-sectional convenience survey by the MT2020+ global alliance reports an international snapshot of the significant changes in acute stroke care with an emphasis on mechanical thrombectomy. A survey comprising of 21-questions (supplemental item 1) was distributed to the members of Global Executive Committee of the Mission Thrombectomy Statistical analysis was performed using SPSS statistics software, version 25 (IBM Corp., Armonk, N.Y., USA). Fisher's exact test or Chi-square test, as appropriate, was used for categorical variables and p-value < 0.05 was considered significant. During the survey period from April 5 th , 2020 to May 15 th , 2020, we received 113 responses across 25 countries (figure 1), with a response rate of 31% among the GEC members. The response rate of the non-GEC members is not known. 12/25 (48%) countries had three or more respondents (n=99). The overall group of respondents, with 3 or more responses from a country, reported a median 33% (IQR -60 -50) decrease in stroke admissions during COVID-19 pandemic. Among this group, respondent in countries without STP change, reported a median percentage decrease in stroke admissions by 43% ranging from a decrease of 62% in India to 20% in Columbia. Intubation policy for during the performance MT was variable across countries and centers pre and during COVID-19 pandemic. Also, any change of policy due to the pandemic did not have preponderance in one direction (figure 6). During COVID-19, 44% centers preferred intubation (PI) during MT, including 25% centers that changed their policy to PI during-COVID-19 from preferred non-intubation (PNI) pre-COVID-19. On the other hand, 56% centers PNI which included 27% centers that changed their policy from PI to PNI (figure 6). Based on volume, 48% high, 32% medium and 40% low volume centers preferred intubation during MT, which included 24%, 25% and 35% centers respectively that reported a change in policy to PI from PCS during COVID-19 (figure 7). There is wide variation in preference for intubation policy within countries, none of the centers in Italy versus 67% centers in Germany preferred intubation during COVID-19. None of the centers in Germany changed their intubation policy during COVID-19, whereas all centers in Japan reported a change in intubation policy including 75% to PI and 25% to PNI (figure 6). Amongst centers with PI, 20.9% (9/43) reported at least 1 or more stroke or Globally, 88% participating stroke centers reported neuroendovascular-specific written PPE protocols and 80% considered them to be adequate. Figure 8A shows responses from individual countries. Amongst centers based on volume, reportedly low-volume centers are less likely to have neuroendovascular specific written PPE protocols (74% versus 88% or 89% high or medium-volume respectively) and when present, less likely to report them to be adequate (58% vs. 92% or 81% high or medium-volume respectively) (p=0.25) (figure 8B). Amongst centers with written neuroendovascular-specific PPE protocols, 19.1% (16/84) reported at least one or more stroke or neuroendovascular team personnel COVID-19 infection versus 14.3% (2/14) centers without these protocols (p=1.00). In centers where the respondents felt the neuroendovascular-specific PPE protocols were adequate, notably 20.5% (16/78) reported at least one or more COVID-19 infection amongst stroke or neuroendovascular team personnel versus 12.5% (2/16) respondents in centers that reported the PPE protocols to be inadequate (p=0.73). Similarly, there was no statistically significant difference noted in availability of respective PPE equipment such as N95 masks (p=0.51), Surgical masks (p=1.00), Bunny suit (p=0.34) and Face shield (p=0.51), and COVID-19 infection amongst stroke or neuroendovascular team personnel (supplemental item 3). The COVID-19 pandemic has a significantly impacted the emergency response mechanisms of the healthcare systems worldwide. This cross-sectional convenience survey by the MT2020+ global alliance reports an international snapshot of the significant changes in acute stroke care with an emphasis on mechanical thrombectomy systems of care. Our study shows that worldwide, stroke specialists report an overall median percentage decrease of 33% in stroke admissions and 25% in MT procedures performed during COVID-19 pandemic. A similar trend of reduced stroke admissions and about 25% decrease in acute stroke interventions such as intravenous thrombolysis (IVT) and MT was reported in a survey completed by members of World Stroke Organization. 8 A prospective international study during COVID-19 surge reported longer door-toreperfusion times (138 vs. 100 min) and higher in-patient mortality (RR 1.87) in patients undergoing preferred intubation for MT 18 , though details about direction of institutional intubation policy change in respective centers due to COVID-19 was not detailed. While there is no consensus regarding the optimal intubation policy for MT, our survey was able to capture the magnitude of any change in the intubation policy at centers in response to the pandemic. Our study shows that 52% stroke centers instituted intubation policy change for patients undergoing MT with an almost equal change in either direction: 25% changed their policy to PI from PNI and 27% centers changed their policy to PNI from PI. Interventional cardiology expert consensus guidelines recommended a low threshold for intubating patients prior to transfer to catheterization suite to avoid emergent intubation and reduce potential transmission risk to catheterization staff. 19 Similarly, the neuroendovascular expert consensus statements encouraged adequate PPE precautions, and lower threshold for intubation when adequate negative pressure rooms are available to reduce the possible risk of infection. This is supported by the evidence that about 6 -14% patients undergoing MT require emergent intubation during procedure 20 , therefore reducing the threshold for intubating all patients undergoing MT with unknown COVID-19 status preemptively in a more controlled environment such as negative pressure room prior to the procedure has the potential in reducing the risk of transmission of COVID-19 infection to neuroendovascular staff. Our data did not show a significant difference in infection rates amongst stroke or neuroendovascular staff with PI versus PNI or change in intubation policy in either direction, though it's important to note that the study was not powered to make these associations. An international study across 35 centers with neuroendovascular units showed a strong positive correlation between number of quarantined providers (38%) and those testing positive for COVID-19 (12%), suggesting appropriate and effective implementation of quarantine measures though the details of these measures were not discussed. 21 In addition, the elective interventions in these centers were reportedly canceled within median 14 days from first reported case of COVID-19 in their respective regions, which could explain the lower rates of infection amongst the providers compared to infection rates in their respective communities, thus allowing continued availability of emergency thrombectomy services. 21 In our survey, majority of the centers reported establishing written neuroendovascular-specific PPE protocols (88%) and amongst the centers with these protocols, majority respondents considered them to be adequate (80%). Interestingly, we did not find any significant difference between the presence of established neuroendovascular-specific PPE protocols or reported adequacy of the same with rate of COVID-19 infections amongst stroke or neuroendovascular staff, but again our study was not powered to conclusively analyze these differences. Low-volume stroke centers in comparison to high or medium-volume centers are less likely to have established neuroendovascular-specific PPE protocols (74% versus 88% or 89% respectively); and if established, only 58% respondents from these centers considered them to be adequate compared with large or medium-volume centers (92 or 81% respectively). This study is based on a convenience cross-sectional survey and does not represent a random sample of global medical institutions, and therefore the results should be viewed considering this important limitation. Though separate analyses were conducted restricted to countries with three or more responses to provide a better representation of practices within a particular country, there is a potential for reporting bias which can skew the data for a given country. The actual time frame defining pre and during COVID-19 infection was left to the respondents and was therefore variable due to differences in first reported COVID-19 infection in their respective cities or countries. In addition, we analyzed and reported the countries with pandemic related change in pre-hospital STP separately. This is important as change in prehospital triage of stroke patients during the pandemic to designated tertiary care stroke centers lead to an increase in stroke admissions in these centers. Nevertheless, pertinent reason to include these countries with pre-hospital STP is to present a complete picture of the effects of the pandemic on stroke systems care including effects of the STP change. A convenience survey is a useful tool to study physician practices and changes implemented due to unprecedented healthcare crisis during COVID-19 pandemic. Average survey response rates amongst healthcare professionals is about 53% 22 , therefore the lower response rates in our survey can potentially lead to non-response bias and the survey results should be viewed keeping this limitation in mind. 23 To conclude, our data provides a valuable snapshot of the impact of the first surge of the COVID-19 pandemic on global stroke systems of care and provides lessons for the future. It highlights the need to increase public awareness about seeking urgent medical care for focal neurological deficits. More studies are needed to shed light on whether PI versus PNI or avoiding adopting intubation policy changes in workflow helps curtail COVID-19 infection despite adequate PPE precautions or not. However, it's unclear at this juncture that changes in local healthcare policy varying from pre-hospital triage or preferred-intubation affected the long-term patient outcomes. These results can be useful to policymakers to anticipate and counter adverse stroke care changes during future public healthcare emergencies. The survey was supported by funds from the Society of Vascular and Interventional Neurologists. Dr. Yavagal is on the steering committee of TIGER clinical trial sponsored by Rapid Medical and steering committee of CALM-2 sponsored by Vascular Dynamics. He is a consultant to Medtronic, Cerenovus, Poseydon, Neurosave, and other Neuralanalytics. All of these relationships are outside of the current work. All other co-authors declare that there are no conflicts of interest. Figure 8A -B: A global representation of presence of established written personal-protectiveequipment protocols specific for neuro-interventional suite and if these protocols were considered adequate to prevent SARS-CoV-2 infection amongst countries with at least 3 or more responses (8A), and amongst high, medium or low volume stroke centers (8B). Organization WH. 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The study was exempt from institutional review board approval as it did not involve patient level data.