Aneurysmal subarachnoid hemorrhage (SAH) patients require frequent neurological examinations, neuroradiographic diagnostic testing and lengthy intensive care unit stay. Previously established SAH treatment protocols are impractical to impossible to adhere to in the current COVID-19 crisis due to the need for infection containment and shortage of critical care resources, including personal protective equipment (PPE). Centers need to adopt modified protocols to optimize SAH care and outcomes during this crisis. In this opinion piece, we assembled a multidisciplinary, multicenter team to develop and propose a modified guidance algorithm that optimizes SAH care and workflow in the era of the COVID-19 pandemic. This guidance is to be adapted to the available resources of a local institution and does not replace clinical judgment when faced with an individual patient.

Subarachnoid hemorrhage guidance in the era of the COVID-19 pandemic - An opinion to mitigate exposure and conserve personal protective equipment.

Background The COVID-19 pandemic has presented unprecedented challenges to healthcare organizations worldwide. A steadily rising number of patients requiring intensive care, a large proportion from racial and ethnic minorities, demands creative solutions to provide high-quality care while ensuring healthcare worker safety in the face of limited resources. Boston Medical Center has been particularly affected due to the underserved patient population we care for and the increased risk of ischemic stroke in patients with COVID-19 infection. Methods We present protocol modifications developed to manage patients with acute ischemic stroke in a safe and effective manner while prioritizing judicious use of personal protective equipment and intensive care unit resources. Conclusion We feel this information will benefit other organizations facing similar obstacles in caring for the most vulnerable patient populations during this ongoing public health crisis.

Optimization of resources and modifications in acute ischemic stroke care in response to the global COVID-19 pandemic.

In the unprecedented current era of the COVID-19 pandemic, challenges have arisen in the management and interventional care of patients with acute stroke and large vessel occlusion, aneurysmal subarachnoid hemorrhage, and ruptured vascular malformations. There are several challenges facing endovascular therapy for stroke, including shortages of medical staff who may be deployed for COVID-19 coverage or who may have contracted the infection and are thus quarantined, patients avoiding early medical care, a lack of personal protective equipment, delays in door-to-puncture time, anesthesia challenges, and a lack of high-intensity intensive care unit and stroke ward beds. As a leading regional neurovascular organization, the Middle East North Africa Stroke and Interventional Neurotherapies Organization (MENA-SINO) has established a task force composed of medical staff and physicians from different disciplines to establish guiding recommendations for the implementation of acute care pathways for various neurovascular emergencies during the current COVID-19 pandemic. This consensus recommendation was achieved through a series of meetings to finalize the recommendation.

/pdf/mena-sino-consensus-statement-on-implementing-care-pathways-3w4qwrbayf.pdf

MENA-SINO Consensus Statement on Implementing Care Pathways for Acute Neurovascular Emergencies During the COVID-19 Pandemic

To support safe provision of mechanical thrombectomy services for patients with acute ischaemic stroke: 2021 consensus guidance from BASP, BSNR, ICSWP, NACCS, and UKNG.

OBJECTIVE
This scoping review explores the structure and process-level strategies that are associated with medical retrieval outcomes. A secondary aim is to identify the range of medical retrieval outcomes used to assess the performance of remote retrieval services.


DESIGN
A scoping review of peer-reviewed literature from PubMed, CINAHL and the Web of Science was undertaken following guidelines set by the Johanna Briggs Institute manual for scoping reviews. All articles were assessed by two reviewers. Themes were derived inductively from the data extracted.


SETTING
Medical retrievals in sparsely populated remote locations in high-income countries.


PARTICIPANTS
Staff and clients of remote medical retrieval services.


INTERVENTIONS
Structures and processes (e.g. resource availability, retrieval staff structures and governance protocols) that aimed to improve medical retrieval outcomes.


OUTCOMES
Patient health outcomes and service efficiency.


RESULTS
Twenty-four articles were included. Three broad themes, related to the nature of the interventions, were included: optimising prehospital management of retrievals, staffing and resourcing of retrieval services and retrieval model evaluation. Mortality was the most frequently used outcome indicator in these studies, but was not measured consistently across studies.


CONCLUSIONS
This review highlights significant gaps in the literature that describes the structure and processes of retrieval models operating in remote areas and a dearth of literature evaluating specific operational strategies implemented within medical retrieval models. The available literature does not meaningfully assist with identifying key outcome indicators for developing a consistent monitoring and evaluation framework for retrieval services in geographically, culturally and demographically diverse remote contexts.

Optimising medical retrieval processes and outcomes in remote areas in high-income countries: A scoping review.

Background and purpose Healthcare systems are challenged to provide access to thrombectomy in acute stroke patients. Either the “drip and ship” or “mothership” models result in increased numbers of patients in the endovascular stroke centre (ESC). We describe our approach for a “drip, ship, retrieve and leave” model repatriating patients immediately or within 24 hours of thrombectomy. Methods We included consecutive patients who underwent thrombectomy from January 2016 to June 2018. Patients from local region primary stroke centres (PSC) are immediately repatriated and those from remote region PSCs are admitted for 24 hours before repatriation. Key parameters recorded included clinical, radiological and timeline data as well as 90-day modified Rankin Scale (mRS). Patients who stayed beyond the intended time period in the ESC were analysed. Results From January 2016 to June 2018, 435 patients were transferred, with 352 patients in the local region group and 83 in the remote region group. The median NIHSS was 16 with a median ASPECTS of 9. Good functional outcome was seen in 47% of patients with a mortality rate of 19%. The local region group that were repatriated at the intended time period had a 90-day mRS 0–2 of 47% compared with 20% of those admitted to the ESC (P=0.006). Mortality rates were 20% and 27% respectively (P=0.377). The remote region group, repatriated at 24 hours9 post-emergency endovascular thrombectomy had 90-day mRS 0–2 of 65% compared with 41% in the group admitted (P=0.042). Mortality rates were 4% and 22% respectively (P=0.007). Conclusion This model enables the treatment of large numbers of patients with large vessel occlusion acute ischaemic stroke with thrombectomy within a national stroke service and system of care which would not otherwise be facilitated.

https://jnis.bmj.com/content/neurintsurg/12/12/1166.full.pdf

Early repatriation post-thrombectomy: a model of care which maximises the capacity of a stroke network to treat patients with large vessel ischaemic stroke.

Sebastian McWilliams

Papers

Early repatriation post-thrombectomy: a model of care which maximises the capacity of a stroke network to treat patients with large vessel ischaemic stroke.