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Many hospitals have taken great steps to limit admissions and nonessential services in anticipation of a large surge in visits from patients with coronavirus disease 2019 (COVID-19) for the subsequent months.1 Overtriage, the unnecessary mobilization of patients to highly specialized medical centers,2 places a significant threat on hospital capacity at receiving medical centers, many of which are the same centers at risk of overcrowding in the new era of COVID-19. Reducing overtriage for patients with neurologic disease and finding other ways to care for these patients at a distance is more important now than ever.
Neurologic Interhospital Transfers
Acute care transfer rates for neurologic disease are twice that of most other conditions.3 Stroke and intracranial trauma are among the most common indications for transfer. With the growth of tissue plasminogen activator (tPA) administration for ischemic stroke and mechanical thrombectomy for large vessel occlusion (LVO), neurologic transfers continue to increase. On average, the rate of acute care transfers from US community emergency departments was 1 in 5 visits for ischemic stroke in 2014,4 and many of these visits were for patients with small stroke or transient ischemic attack who could be cared for at community hospitals given the resources needed for routine diagnosis and management. Additionally, an increasing number of regional stroke networks have moved to community hospital bypass using decision algorithms and imperfect screening protocols that place a high value on the sensitivity of diagnosis as opposed to specificity, which may allow for an unknown degree of overtriage to tertiary care centers.5
Health Care Changes in the COVID-19 Era
As fears continue to promulgate with rising COVID-19 cases and increasing uncertainty surrounding risks to the public, patients, and clinicians, it is important to consider care alternatives that are in the best interest of everyone.6 Since the COVID-19 pandemic reached the United States, hospitals have become a drastically different place to work. While policy changes may vary by institution, most major medical centers have taken several actions to prevent the spread of disease. Many hospitals have eliminated nonessential services, postponed elective surgical procedures, and some health care systems have instituted policies to redirect low-acuity admissions away from COVID-19 hospitals. Other changes include reducing team size for social distancing, optimizing personal protective equipment, and limiting patient contact. These changes are in effect with the ultimate goal of minimizing the spread of COVID-19 and maximizing the available workforce for all patients.
Adapting to Patient-Clinician Distancing
In the wake of the pandemic, health care professionals and facilities must be nimble and innovative to limit the potential spread of disease while maintaining a high standard of neurologic care.
From a neurologic perspective, 3 initiatives are especially needed: (1) optimizing the use of telemedicine services for emergency neurological issues, (2) preventing secondary overtriage for neurological transfers, and (3) creating innovative strategies to minimize risks during and after interhospital patient transfer.
As hospitals continue to push distance between health care clinicians and patients in an effort to prevent the propagation of COVID-19, neurologists and stroke clinicians need to consider every potential to rapidly develop and grow distance services such as telemedicine. There is an urgent need to identify trained telemedicine clinicians, expand available technology, and create distance medicine relationships with community hospitals and emergency departments. Various governmental agencies, payers, and other stakeholders have made decisions to expand coverage for telehealth services and loosen some regulatory barriers related to telemedicine; this is critical in a time when clinicians should be incentivized, not disincentivized, to provide remote care.
Interhospital transfers pose a risk to infectious disease spread. With COVID-19 widespread in the United States, medical clinicians need to be increasingly cautious when deciding who to transfer and how patients are transferred from 1 health care facility to another. This presents an opportunity to focus on strategies that reduce overtriage. For stroke care, one major challenge for reducing overtriage will be changing a system from protocols favoring high sensitivity, designed to capture any and all LVO patients, to higher-specificity protocols that focus on mobilizing only those patients who absolutely need comprehensive stroke center or tertiary care services.
There are several strategies to reduce overtriage. Tertiary care centers affected by COVID-19 should place a hold on any existing bypass strategies, require community emergency department clinicians and telemedicine consultants to eliminate the routine transfer of patients with transient ischemic attack, and establish a set of prespecified criteria for qualifying and nonqualifying patient transfers. Qualifying criteria for transfer include the urgent need for intervention (eg, thrombectomy, carotid revascularization, or hemicraniectomy), highly specialized monitoring if unavailable at a distance (eg, critical care electroencephalography), or intensive care needs (eg, mechanical ventilation or shock). Nonqualifying criteria for transfer should include small stroke or transient ischemic attack with no indication for intervention (eg, those without high-grade stenosis on vascular imaging), stroke mimics such as partial seizure or migraine, minor head trauma (eg, small traumatic subarachnoid hemorrhage at low risk of hemorrhagic expansion), or any patients with an anticipated short length of stay. Additionally, those with severe disease and very poor prognosis early on may have no benefit to transfer. For example, large completed hemispheric strokes or large intracranial hemorrhage in elderly patients should have emergent goals of care discussions facilitated by experts at specialized centers to prevent burdensome transfers at the end of life.
Minimizing Risks and Maximizing Quality During and After Transfer
For patients where transfer is the only acceptable option (eg, LVO in need of mechanical thrombectomy), preestablished COVID-19 screening protocols, appropriate precautions such as donning/doffing of personal protective equipment by transport staff where indicated, and communication regarding the potentially infected to the receiving medical center are essential to limit the spread of COVID-19.7 Many hospital centers have instituted a no-visitor policy in the spirit of social distancing, and in this context, clinicians should ensure that decisions regarding resuscitation, ventilatory support, and other high-intensity interventions are communicated clearly prior to the time of transfer. Family members and other surrogates will no longer be present during work rounds, so clinicians need to adjust their approaches to maintain effective communication via telephone, video conferencing, or other means. Centers should pay close attention to their performance on evidence-based metrics and to patient experience surveys to ensure that quality of care does not decline during times of actual or potential surge.
While the number of cases for COVID-19 may be plateauing in some areas, these recommendations remain opportune owing to the potential for resurgence when governmental social distancing policies are relaxed, or the possibility of a second wave in the fall or winter months. Furthermore, while we make these suggestions in a time of pandemic, these proposed changes are relevant even in nonpandemic times. Changes adopted by health care systems across the country may result in everyday work that feels increasingly unfamiliar; however, there may be a silver lining to the transformation arising in the care of patients during the COVID-19 era. The inherent disruption to neurologic care networks accompanying these changes has the potential to inspire innovation and find ways to reduce overtriage. If successfully implemented and continued in the post-COVID era, these efforts could enjoy the welcome consequence of cost savings and efficiency.
Corresponding Author: Adam G. Kelly, MD, Department of Neurology, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642 (email@example.com).
Published Online: June 29, 2020. doi:10.1001/jamaneurol.2020.1956
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Robert G. Holloway, MD, MPH, from the University of Rochester Medical Center, for his thoughtful comments on this work. No compensation was provided for his contributions.
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George BP, Kelly AG. Rethinking Regional Neurologic Care in the Coronavirus Disease 2019 Era. JAMA Neurol. 2020;77(9):1061–1062. doi:10.1001/jamaneurol.2020.1956
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