In the paper, published today in Stroke: Journal of the American Heart Association, research teams from King’s, Guy’s and St Thomas’ NHS Foundation and the Sentinel Stroke National Audit Programme (SSNAP) analysed the data of 184,017 patients admitted to hospital with confirmed stroke during October-April periods across four consecutive years. This patient data were collected from 114 hospital trusts in England, Wales and Northern Ireland.
Starting from the third week of February 2020 there was an increase in seven-day in-patient case fatality (people who died within seven days of being admitted to hospital) from 6.9% to 9.4%, compared to the same period in the three previous years.
This was significantly higher in stroke patients with confirmed or suspected COVID-19, at 22.0% and 21.9% respectively, compared to 7.3% for patients with negative/unknown COVID-19 status.
In contrast, during the first lockdown the number of people admitted to hospital with a stroke remained stable until the second week of February 2020 when there was a steep decline. Between 23 March and 30 April 2020 there was a 12% reduction in stroke admissions compared to the same period in the three previous years (6,923 versus 7,902).
The team found that during the first lockdown stroke admissions fell more for:
- Ischaemic stroke (blockage cutting off the blood supply to the brain) than haemorrhagic stroke (bleeding in or around the brain)
- Older patients (aged over 65 years)
- Patients with less severe strokes
No change was found in the proportion of patients discharged from hospital with good outcomes.
Quality of care was preserved for all measures and in some areas improved during lockdown, such as access to stroke unit care, speed of screening for dysphagia and access to rehabilitation therapies.
We know the immediate impact of the COVID-19 pandemic was to cause a reduction in the number of people presenting to hospital with stroke, an effect that was evident from early February and well before the imposition of population-level lockdown measures. This fall in admissions was predominantly for patients with mild symptoms and particularly in patients over the age of 85 years. Whether this was because there was a reluctance to refer patients to hospital due to their increased risk if they did contract coronavirus, in an attempt to reduce the burden on the health service or because the patients were not able to alert emergency services themselves or decided against referral is not known.– Dr Abdel Douiri from the School of Population Health & Health Sciences
Dr Douiri added: “Despite maintaining high quality services, the seven-day case fatality rate for stroke increased significantly by 2.5% percentage points. It is not possible to determine if this higher mortality is explained by the high case fatality rates in patients with confirmed or suspected COVID-19 or as a result of fewer patients with milder stroke being admitted to hospital, or a combination of these effects.”
This research was supported by funding from the National Institute for Health Research (NIHR) Applied Research Collaborations (ARC) South London at King’s College Hospital NHS Foundation Trust and South West Peninsula, with support from the NIHR Biomedical Research Centre based at Guy’s and St Thomas’ NHS Foundation Trust, the Sentinel Stroke National Audit Programme (SNNAP) team and King’s.
The Sentinel Stroke National Audit Programme (SSNAP) is commissioned by the Healthcare Quality Improvement Partnership (HQIP).