Abstract
The situation of the COVID-19 pandemic affects the modification of the public and the private healthcare system. The new normal emergency care system for patients with stroke in public and private hospitals during the COVID-19 pandemic research project aimed to 1) review literature specifically addressing emergency care models for stroke patients during the COVID-19 outbreak, 2) develop a new normal emergency care model for this particular patient group, and 3) study the effects of this proposed model that were implemented in public and private hospitals. This research and development project integrated a mixed-method design that included a systematic review and quasi-experimental research. The research instruments were the checklist for evaluating the model and semi-structured interviews. Each one of the public and private hospitals in Trang were purposely selected to participate in the study. Forty participants were recruited including ten pre-hospital patients with acute stroke, two heads of emergency departments (EDs), four ED physicians, twenty ED nurses, and four emergency medical technicians (EMTs). The findings showed that the common emergency care model for stroke patients during the COVID-19 outbreak was divided into three phases. The first phase was prehospital care which consisted of telestroke, modified code stroke with CORONA protocol, and transport team COVID-19 specific ambulances. The second one was in-hospital care at the ED which included the OVID-19 screening protocol and protected strike code. The last one was hospitalization which was focused on universal pandemic precautions and isolation. The selected hospitals developed three emergency stroke guidelines for COVID-19 that were 1) the stroke fast track for stroke patients with PUI/COVID-19 infection, 2) the mechanical thrombectomy for stroke patients with PUI/COVID-19 infection, and 3) the stroke unit (SU) admission during the COVID-19 pandemic. Both hospitals developed the new normal emergency stroke care which differed from the pre-COVID-19 pandemic protocol. The main differences between pre- and poststroke care models were 1) universal prevention for COVID-19: patient isolation, mandatory mask-wearing, and personal protective equipment for health care personnel, 2) medication: do not use rt-PA for stroke patients with severe COVID-19 infection and coagulopathy and be aware of antiplatelet and antiviral drug interaction, and 3) use telemedicine for minimizing in-person contact. Three specific protocols were established following these considerations which consisted of 1) the COVID-19 stroke fast track protocol, 2) the mechanical thrombectomy protocol for patients with PUI or COVID-19 infection, and 3) the stroke unit admission protocol during COVID-19. After the proposed model was implemented in both hospitals, the results revealed that ninety-nine percent of the respondents agreed on the appropriateness and applicability of the model content and process. Moreover, the proposed model increased patient and staff safety and reduced patient mortality rates. However, the time from stroke symptom onset to emergency room arrival was longer than usual due to the procedure for putting on the full personal protective equipment (PPE). The problem and obstacle in implementing the proposed model was the limitation of the mechanical thrombectomy for stroke patients with PUI/COVID-19 infection because there were a few neurointerventional radiologists and nurses who could help physicians performing the mechanical thrombectomy. In addition, there was a lack of a training program for neurointerventional radiologists in Thailand. Per the findings, the proposed policies for all stakeholders consisted of 1) the training program development for neurointerventional radiologists, 2) the development of nurses' competency in performing specific procedures for stroke patients, and 3) the diminishment of delay in hospital arrival and stroke treatment.
