Tanusri Gudavalli, Mission San Jose High School, Fremont, California, USA
Acute ischemic stroke (AIS) is a common neurological disease associated with cognitive, physical, and emotional damages to the nervous system. Treatments for AIS can include alteplase IV r-tpa or thrombectomy. However, due to COVID-19, hospitals are facing challenges to treat their patients. This study aims to determine and analyze the barriers hospitals were facing in response to the COVID-19 pandemic. In our study, we contacted 100 neurologists and neurosurgeons across Latin America. Out of the 100 doctors contacted, 20 doctors participated by scheduling an interview with us and 16 doctors participated by filling out a survey. Using the data we received, we ordered the barriers from greatest effect to least effect. About 50% of the doctors mentioned that there was no proper rehabilitation, transportation delays, and a lack of basic knowledge on stroke. These were the main barriers we decided to focus on to design our intervention. Currently, we are working with a doctor in Peru to design an app that allows patients to connect with doctors online and perform rehabilitation exercises from home. This study shows that COVID-19 has disrupted stroke treatment and created barriers in hospitals that urgently need solutions.
Stroke is a common neurological condition that affects around 15 million people worldwide and is the leading cause of mortality and disability in most parts of the world. It occurs when blood supply to the brain gets interrupted or reduced, preventing the brain from receiving oxygen and other nutrients. Brain cells start to deteriorate and die off in minutes (“About Stroke,” 2021). There are three different types of stroke: acute ischemic stroke, hemorrhagic stroke, and transient ischemic attack. Acute ischemic strokes occur when blood clots in an artery block the blood supply to the brain; almost 87% of strokes are acute ischemic strokes (“Stroke,” 2021). There are two main treatment options for individuals who experienced an acute ischemic stroke: alteplase IV r-tpa and mechanical thrombectomy. Alteplase IV r-tpa is a drug that doctors administer through an IV in the arm (“Ischemic Stroke,” n.d.). This drug dissolves the clot in the artery and allows blood to flow to the brain. It is crucial to administer alteplase IV r-tpa within 4.5 hours of stroke onset for the drug to be as effective as possible (“Approach to,” n.d.). On the other hand, mechanical thrombectomy is a surgical treatment where surgeons remove a clot in patients with a large vessel occlusion (LVO). An LVO is where the blood clot closes up major arteries and stops blood flow to significant portions of the brain (“Ischemic Stroke,” n.d.). Mechanical thrombectomy allows doctors to extract the clot in the brain so that blood flow to the brain can resume. Stroke patients should receive the following treatments within 6 hours after onset, although they can still benefit from treatment if they receive treatment within 24 hours (“Approach to,” n.d.).
Prior to the pandemic, stroke treatment in Latin America was higher than stroke treatment during the pandemic. Hospitals mostly used intravenous thrombolysis with alteplase to treat patients with AIS. Around 75% of the doctors mentioned that they had mechanical thrombectomy available in their hospitals for patients. Contrarily, 25% of doctors said that they do not use mechanical thrombectomy treatment at all. The second most popular treatment used for stroke patients with AIS was intravenous alteplase. Unfortunately, when the pandemic hit, treatment options decreased, and mechanical thrombectomy was barely used to save patients’ lives.
Over 33 million people have suffered from COVID-19 in Latin America since the pandemic began. The impact of the pandemic on the overall healthcare in the region has worsened. Research states that “other structural factors creating the humanitarian crisis include corruption, political instability, and weak health systems” (Seervai & Shah, 2021). Specifically, Brazil spends $848 on health per capita which is less than the world average. The pandemic has crowded hospitals and intensive care units (“Latin America’s,” n.d.). Furthermore, the lack of medical supplies has caused many individuals to not receive treatment on time. Overall, the healthcare system has deteriorated, and countries are trying to combat these challenges to improve healthcare in their areas.
In Latin America, stroke is one of the leading 3 causes of death. As the number of coronavirus patients surge in hospitals, stroke patients coming into hospitals have decreased. In the International Journal of Stroke, researchers stated that “in our center, the COVID-19 pandemic was associated with a reduction of more than 40% in the number of stroke admission and with stroke deaths compared to our historical data” (Silva et al., 2020). Furthermore, there has been a delay in receiving AIS treatment for more than 4 hours. According to data, 64.3% of the doctors mentioned that there has been a delay in receiving stroke care and 44.4% of them said that the delay has been 4 or more hours. Since there has been a high number of COVID-19 patients, these outcomes were anticipated and hospitals have been trying to quickly adjust to situations they have been facing. Moreover, a doctor from Costa Rica stated “we have limitations with thrombectomy 24/7 and now it has worsened, so we are mainly relying on thrombolysis.” Mechanical thrombectomy treatment for AIS patients has also worsened due to the lack of staff and medical supplies. There are not enough doctors to perform this surgery, so hospitals are mainly relying on thrombolysis. In this study, we study these challenges in detail and devise an intervention to help hospitals in this region.
A retrospective review of AIS treatment pathways was done for Latin America during the initial stages of the COVID-19 pandemic using 2018 as the comparator. The following methodologies were applied.
Secondary Data Collection
A google spreadsheet was used to organize the data collected and PubMed, Google Scholar, and CDC websites. The keywords used were “stroke” and “COVID-19.” The data was organized on a Google Spreadsheet. The spreadsheet collected data on specific stroke and COVID-19 information in each country. Using this useful data, we categorized the countries into 3 groups. Group one consisted of the countries with extensive stroke cases, COVID-19 cases, and established Stroke Care Delivery systems. A group of countries that had a high stroke rate and COVID-19 cases, but poor treatment modalities ranked second. The last group, group 3, had little information about stroke or COVID-19, and there was little research on stroke treatment.
We formed surveys for the doctors and created email templates to email each stakeholder asking them for an interview. After creating the surveys and email templates, we sent out emails to over 100 doctors in Latin America. Interviews were conducted to gain primary insights on stroke care services in specific regions. After each immersion, we organized the data on a document and analyzed the barriers that each doctor had mentioned. In the end, we were able to take the recommendations from each doctor as well as form our own recommendation in order to see the effects of COVID-19 on stroke treatment. However, even while we were in the primary research phase, we still continued to read more articles to gain a deeper comprehension of any common statements that were being said by papers and the doctors.
Figure 1: Primary Research Survey Question: This is a screenshot of the data we received for one of our questions through the survey. Out of the nine neurologists that filled out the survey throughout Latin America, 64% of them said that there has been a delay in receiving stroke care due to the pandemic.
Below are the survey questions that each doctor filled out which helped us get an understanding of the stroke treatment situation in each hospital.
Table 1: Survey Questions - This table shows all the questions to the survey. We divided the survey into 4 sections (shown in the first column): General Information, Stroke and Thrombectomy Questions, Barriers for Stroke Treatment, and Optional Contact Information. The 2nd column shows all the questions listed in each section.
Stroke Data via Secondary Research
We organized our secondary research stroke data based on many different categories including mortality, COVID-19 cases, world rank, etc. We prioritized the countries based on which country has the largest number of coronavirus cases. As of right now, the top
three countries with the highest number of COVID-19 cases in Latin America are Brazil, Peru, and Colombia.
Table 2: Stroke and COVID-19 Statistics - This table shows all the stroke and COVID-19 statistics for the countries in Latin America (“Stroke Death,” n.d.).
Throughout the immersions, we were able to collect informative data that helped us understand the situation of stroke treatment in Latin America. Many barriers such as treatment delay, a lack of equipment and general knowledge on stroke, shortages of staff, and more have affected stroke treatment tremendously. The delay in bringing stroke patients to the hospitals has increased significantly, affecting the prognosis of the treatment as well. Furthermore, educational barriers show that there must be an increase in the understanding of stroke by the population of each country. By the same token, many hospitals do not have proper equipment or staff which creates a barrier in staff and equipment. These barriers are heavily restricting access to treatment for stroke patients during the pandemic, resulting in higher risks of mortality. More information about the barriers will be listed in the data table below:
Figure 2: Barriers in Stroke Treatment Due to Covid-19 in Latin America - This image above shows a graph on the analysis of the data we received from doctors across Latin America. Specifically, the bar graph shows the important barriers hospitals are facing.
The results above show the significant number of barriers that hospitals have been battling since the pandemic. Around 50% of the hospitals do not have a full stroke unit because of the overpopulated COVID-19 patients in their hospitals. Stroke units have been turned into COVID-19 units which automatically decreases the availability for stroke patients as there are not enough stroke beds. By the same token, the lack of staff due to COVID-19 has affected stroke treatment, specifically mechanical thrombectomy the most. Many interventional neurologists had to shift their jobs and work in the COVID-19 unit which decreases the staff that can perform mechanical thrombectomy, tPA, and other stroke protocols. Moreover, 75% of the hospitals said there is a transportation delay because there are limited ambulances or taxis so patients are unable to reach their destinations on time. Additionally, due to COVID-19, patients are required to take a COVID-19 test which adds extra time after entering the hospital. About 40% of the hospitals have reported that there has been a delay due to COVID-19 testing as many do not have a fast testing site. As mentioned before, 62.5% of the people are scared to come to hospitals which increases the delay time and the risk of mortality. Also, people are unaware of stroke symptoms which increases the delay time as well. Around 50% of the hospitals have mentioned this situation which has a direct negative effect on the patients health and recovery. Recovery rates have decreased as 50% of the hospitals mentioned that rehab has been affected the most. Rehab hospitals have been converted to COVID-19 hospitals and there has been a decrease in rehab technicians. Although hospitals have been trying to overcome these barriers, COVID-19 keeps getting worse and affecting patients even more.
There are many recommendations that we received from doctors in order to try to improve stroke procedure during these times. Below is the table that consists of all the recommendations from each doctor.
Table 3: Doctor Recommendations - This table above shows the several recommendations doctors mentioned in order to solve the challenges they are facing in hospitals.
Furthermore, some recommendations suggest that there must be more awareness about stroke in every country. As we listened to all the doctors speak, many patients weren’t coming easily to the hospitals because they did not recognize the symptoms of stroke. Another recommendation would be to develop protocols so that thrombectomy can be conducted in a lot more hospitals. This helps patients receive better treatment and improves the outcomes for stroke patients. Moreover, another very important recommendation that we suggest is to provide better transportation in order to decrease the delay for stroke patients. These are just some recommendations that can help better stroke treatment in Latin America, especially during the pandemic. It is necessary to keep promoting mechanical thrombectomy and make it a priority treatment in large hospitals so that more stroke patients can have hope and have greater access to this better treatment.
From the various barriers doctors mentioned, I chose to tackle some of the top barriers which include the transportation delay, no proper rehabilitation, and the lack of adequate
education on stroke. I am working with a doctor in Peru to design an app that tackles these three barriers. The app will have multiple rehabilitation exercises for patients to practice after they receive stroke treatment as well as an educational page with information about stroke and some latest news for patients to read about. Patients will also be able to chat and connect with doctors online if they are unable to reach the hospital during that time. Furthermore, there will also be a map on the app that indicates the nearest hospital from the patient’s home in case of emergency. These features will allow patients to have a safe stroke recovery at home.
Overall, stroke treatment has been greatly affected due to the pandemic. Barriers including delay, education, staff, and equipment have decreased stroke treatment throughout Latin America, having a large effect on patients, increasing their mortality rate and recovery of this condition. Hospitals have been trying to overcome these barriers, but in Latin America, it has been difficult as many people are not as educated with these types of diseases. It is very important to campaign and post on social media the effects and symptoms of stroke to create more awareness and save lives. Additionally, protocols must be developed in order to run the treatment, especially for mechanical thrombectomy. This treatment must become part of all large hospitals in order to improve stroke treatment in Latin America and have a greater impact on the prognosis of stroke.
About Stroke. (2021, August 2). Centers for Disease Control and Prevention. https://www.cdc.gov/stroke/about.htm
Approach to Reperfusion Therapy for Acute Ischemic Stroke. (n.d.). UpToDate. https://www.uptodate.com/contents/approach-to-reperfusion-therapy-for-acute-ischemic-stroke
Ischemic Stroke Treatment. (n.d.). American Stroke Association. https://www.stroke.org/en/about-stroke/types-of-stroke/ischemic-stroke-clots/ischemic-stroke-treatment
Latin America’s COVID-19 Crisis and Implications for the Rest of the World. (n.d.). Commonwealth Fund. https://www.commonwealthfund.org/blog/2021/latin-americas-covid-19-crisis-and-implications-rest-world
Stroke. (2021, February 9). Mayo Foundation for Medical Education and Research. https://www.mayoclinic.org/diseases-conditions/stroke/symptoms-causes/syc-20350113
Stroke Death Rate by Country. (n.d.). World Life Expectancy.
Silva, M.T., Quintanilha, G., Giesel, L. Soldati, A.B., Jabarra, C., Almeida, C., Rocha, L., Romão, T., Sptiz, C., Soares, C., Ribeiro, A.S., Damasceno, M., Araujo, A., Lima, M. (2020, July 14). The impact of the COVID-19 pandemic on a stroke center in Latin America. International Journal of Stroke, 15(7), 813–814. https://doi.org/10.1177/1747493020941637
Article Thumbnail: Stroke Summary: Mechanical Thrombectomy Helps Marathoner, 47, Recover from Stroke. (2021, August 4). Norton Healthcare. https://nortonhealthcareprovider.com/news/stroke-summary-mechanical-thrombectomy-helps-marathoner-47-recover-from-stroke/