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University physicians pioneer new stroke and medical emergency guidelines for COVID-19 pandemic

Telemedicine takes center stage in treatment of emergencies during COVID-19

While the new stroke and emergency guidelines take special care to limit COVID-19 spread through hospital visits, experts urge that calling 911 and going to the hospital for necessary treatment are still the best practices in emergencies.
While the new stroke and emergency guidelines take special care to limit COVID-19 spread through hospital visits, experts urge that calling 911 and going to the hospital for necessary treatment are still the best practices in emergencies.

While hospitals across the country continue to be inundated with COVID-19 patients, physicians are working to limit unnecessary hospital visits while still treating medical emergencies safely. The University Health System is implementing new guidelines to balance speedy treatment of medical emergencies, like stroke, with prevention of COVID-19 spread.

New guidelines from the American Heart Association, written in part by Andrew Southerland, University stroke expert and associate professor of medicine, urge for enhanced communication between emergency responders and physicians before a stroke patient reaches hospital doors. Emergency responders should now screen stroke patients for potential concurrent COVID-19 infections — which has implications for treating the patient and for limiting spread of the virus.

Pre-hospital communication between emergency medical service crews and physicians, or mobile telemedicine, has long been a priority for the University Health System. Prior to the pandemic, Southerland and others at the University had placed tablets in ambulances — allowing physicians to receive audiovisual information on a patient’s condition, assessing a patient’s stroke severity during hospital transport.

Physicians then determine where a patient should be treated, based on the time of transport, the type of care needed and resources of nearby hospitals. In cases where patients have the most severe form of stroke, where large blood vessels in the brain are affected, invasive treatment is needed, and transport to a large Comprehensive Stroke Center like the University Hospital is preferred, even if the facility is farther away.

Choosing the correct facility to treat a severe stroke patient using telemedicine saves time, which is paramount, Southerland explained.

“We know that for every one minute that goes by in a large vessel stroke, you lose about a million neurons, and for about every five minutes that goes by, it equates to about a 15 percent difference in the likelihood of them being independent after you treat them,” Southerland said.

Now, COVID-19 has added a layer of complexity to forming an immediate healthcare response when treating strokes, requiring further reliance on telemedicine.

One concern is that incoming stroke patients may be COVID-19 positive since research has identified a link between COVID-19 infection and stroke. The new guidelines, written in part by Southerland, warn that if COVID-19 positive, stroke patients may require intensive respiratory care in addition to neurological surveillance, which may impact where a patient is transported, even if a patient is not suffering from the most severe form of stroke.

“A patient who may have stroke and COVID-19 might get triaged to a larger center where they have more equipment and capability to care for that patient, and [choosing the right hospital initially] reduces the exposure of that patient going in and out of other hospitals when it may not be necessary,” Southerland said.

Cutting back on hospital transfers reduces COVID-19 exposure for both patients and surrounding healthcare workers, Southerland explained.

Thus, EMS personnel are using free online tools to assess stroke patients for likelihood of concurrent COVID-19 infection. Respiratory symptoms, travel history and the number of COVID-19 cases in a patient’s location should be taken into account, the guidelines suggest.

If COVID-19 infection is suspected, EMS is advised to begin addressing a patient’s respiratory needs during transport. Emergency responders are in constant communication with hospitals to choose the appropriate medical facility and alert the facility that an incoming patient may be infected with the novel coronavirus.

COVID-19 also has implications for treatment of other medical emergencies, like acute heart issues. Recently published guidelines — written in part by William Brady, University Health System emergency physician — warn of co-incidence of COVID-19 infection and heart attack. Brady and colleagues instruct other physicians to be aware that some patients will need to be treated for both respiratory and cardiovascular issues.

Additionally, all emergency room patients at the University Hospital are being screened for potential COVID-19 infection before entry. Patients who are suspected or confirmed of having COVID-19 are placed in separate waiting areas.

Despite hospital measures to prevent COVID-19 spread, there has been a nationwide drop in patients reporting medical emergencies in recent months, including at U.Va. Health where there was a 40 percent drop in patients reporting strokes in April. Physicians are increasingly concerned that patients are not seeking emergency care for fear of contracting COVID-19.

The University Health System urges patients to continue to report all medical emergencies to 911.

“If you are having a stroke, the likelihood that you will remain disabled from that stroke or worse is much greater than your risk of exposure [to COVID-19] by going to the hospital,” Southerland said, addressing individuals who may be experiencing stroke symptoms. “We have the resources to limit the amount of exposure [to COVID-19] as best we can, and one of those ways is through telemedicine.”

University Student Health is also turning to telemedicine at this time — using it to limit in-person student visits and prevent COVID-19 spread. 

So far, using telemedicine has been successful in treating the majority of student needs.  

“Remote care delivery (phone and telehealth) has allowed Student Health and Wellness to continue to provide services even when students are away from grounds,” Director of Student Health Meredith Hayden said in an email to The Cavalier Daily. “Even for students in Charlottesville, remote care delivery has been a good option.”

To limit infectious spread when students return to Grounds, Hayden mentions that only the most urgent health issues requiring physical procedures such as acute pain and bleeding will be treated in person. Students with medical emergencies will continue to be treated in the ER while all other students will be treated remotely.  

The current success of telemedicine may inform future healthcare after the COVID-19 pandemic subsides.

“83 percent of students [that have received remote care from Student Health] said that they would like to have the option, if clinically appropriate, to complete their visit via telehealth (video or phone) in the future after the COVID pandemic is resolved,” Hayden said. 

In this way, telemedicine may give students easier access to care in a timely fashion. Southerland echoed the sentiment and mentioned that telemedicine has received increased funding during the pandemic. 

“[COVID-19] really has disrupted our lives in so many tragic ways … but there are going to be things we can learn from it that will improve our society, improve our healthcare system, make us more resilient and build a better system for any future pandemics and crises,” Southerland said.