{"id":{"repo_id":"cork","oai_identifier":"oai:cora.ucc.ie:10468/17517"},"canonical_url":"https://search.dev.ndltd.org/etd/cork/oai:cora.ucc.ie:10468/17517","repository":{"repo_id":"cork","name":"University College Cork","base_url":"https://cora.ucc.ie/server/oai/request"},"display":{"title":"The impact of the COVID-19 pandemic on prehospital emergency care for stroke/transient ischaemic attacks (TIAs) and implications for future policy and service delivery","abstract":"Background and aims Time plays a fundamental role in managing acute stroke and transient ischemic attack (TIA), with the minimisation of prehospital delays critical to the stroke chain of survival. The COVID-19 pandemic led to worldwide restrictions, resulting in significant societal changes, including alterations to healthcare access and delivery, which particularly impacted time-sensitive conditions. Thus, the aim of this thesis was to investigate the impact of a “shock”, such as the COVID-19 pandemic on prehospital emergency care for exemplar time-sensitive conditions; stroke and TIA, with the goal of exploring potential implications for future policy and service delivery. Methods This PhD thesis employed a mixed-methods approach, using the multilevel model of triangulation design. This approach was informed by the “Resilient Health System as a Conceptual Framework for Strengthening Public Health Disaster Risk Management”. Five studies were conducted. Firstly, a systematic review and meta-analysis synthesised existing evidence on the impact of the COVID-19 pandemic on prehospital care for suspected stroke/TIA and calculated pooled estimates for ambulance time intervals and call volume during the pandemic. Secondly a quasi-experimental study using Republic of Ireland National Ambulance Service data investigated the impact of COVID-19 on ambulance time intervals and emergency call volume for suspected stroke/TIA using linear regression and autoregressive integrated moving averages. Thirdly, a qualitative study using semi-structured interviews explored the experiences of stroke/TIA survivors, caregivers, prehospital and hospital-based practitioners of acute stroke/TIA care during the COVID-19 pandemic in Ireland. Fourthly, a benchmarking study facilitated the comparison of international terminology and definitions for ambulance times and intervals. This enabled the final study; an international comparative analysis using a quasi-experimental before and after design to compare ambulance time intervals and call volume for suspected stroke/TIA before and during COVID-19, using linear regression and times series analysis. Stakeholder involvement was included throughout all studies. Results The meta-analysis demonstrated that pre-COVID-19, the mean response interval was shorter by -1.29 minutes (95% CI: -2.19 to -0.38), and the mean total prehospital interval was shorter by -6.42 minutes (95% CI: -10.60 to -2.25), compared to during the pandemic. Additionally, there was a higher incidence rate ratio (IRR) of emergency calls for suspected stroke/TIA per day pre-COVID-19 compared to during COVID-19 (log IRR = 0.17, 95% CI: 0.02 to 0.33). In Ireland, during the pandemic period, the five included ambulance time intervals increased compared to pre-COVID-19 (all p<0.001). Overall, call volume increased during the COVID-19 period compared to the pre-COVID-19 period (p<0.001). However, dips in call volume were observed during the initial wave and wave 4. Qualitative interviews with stroke/TIA survivors, caregivers and healthcare professionals revealed that the integrity of the acute stroke/TIA pathway remained intact during the COVID-19 pandemic. However, overall patient experience and willingness to seek care for suspected stroke/TIA were negatively impacted. Significant heterogeneity in terminology and definitions for ambulance times and intervals were observed in the international benchmarking study. In the international comparative study, on-scene time increased across all seven services between 1.05-3.78 minutes (all <0.001) during the COVID-19 period. Whereas response time interval increased in six of the seven services, ranging from 0.5-9.13 minutes (all p<0.001), and decreased in New Zealand by 1.57 minutes (<0.001). Mean monthly call volume rose across all services during COVID-19, ranging from 1.9-9 minutes, apart from the Netherlands, which saw no change (p=0.4). Conclusion This thesis used a multistakeholder mixed methods approach to investigate the resilience of the acute stroke/TIA pathway during a public health crisis, highlighting prehospital delays and potential care avoidance by stroke/TIA survivors. It calls for stakeholder collaboration to optimise the stroke chain of survival and further studies on the pandemic's long-term impacts on stroke/TIA care.","abstract_html":"Background and aims Time plays a fundamental role in managing acute stroke and transient ischemic attack (TIA), with the minimisation of prehospital delays critical to the stroke chain of survival. The COVID-19 pandemic led to worldwide restrictions, resulting in significant societal changes, including alterations to healthcare access and delivery, which particularly impacted time-sensitive conditions. Thus, the aim of this thesis was to investigate the impact of a “shock”, such as the COVID-19 pandemic on prehospital emergency care for exemplar time-sensitive conditions; stroke and TIA, with the goal of exploring potential implications for future policy and service delivery. Methods This PhD thesis employed a mixed-methods approach, using the multilevel model of triangulation design. This approach was informed by the “Resilient Health System as a Conceptual Framework for Strengthening Public Health Disaster Risk Management”. Five studies were conducted. Firstly, a systematic review and meta-analysis synthesised existing evidence on the impact of the COVID-19 pandemic on prehospital care for suspected stroke/TIA and calculated pooled estimates for ambulance time intervals and call volume during the pandemic. Secondly a quasi-experimental study using Republic of Ireland National Ambulance Service data investigated the impact of COVID-19 on ambulance time intervals and emergency call volume for suspected stroke/TIA using linear regression and autoregressive integrated moving averages. Thirdly, a qualitative study using semi-structured interviews explored the experiences of stroke/TIA survivors, caregivers, prehospital and hospital-based practitioners of acute stroke/TIA care during the COVID-19 pandemic in Ireland. Fourthly, a benchmarking study facilitated the comparison of international terminology and definitions for ambulance times and intervals. This enabled the final study; an international comparative analysis using a quasi-experimental before and after design to compare ambulance time intervals and call volume for suspected stroke/TIA before and during COVID-19, using linear regression and times series analysis. Stakeholder involvement was included throughout all studies. Results The meta-analysis demonstrated that pre-COVID-19, the mean response interval was shorter by -1.29 minutes (95% CI: -2.19 to -0.38), and the mean total prehospital interval was shorter by -6.42 minutes (95% CI: -10.60 to -2.25), compared to during the pandemic. Additionally, there was a higher incidence rate ratio (IRR) of emergency calls for suspected stroke/TIA per day pre-COVID-19 compared to during COVID-19 (log IRR = 0.17, 95% CI: 0.02 to 0.33). In Ireland, during the pandemic period, the five included ambulance time intervals increased compared to pre-COVID-19 (all p<0.001). Overall, call volume increased during the COVID-19 period compared to the pre-COVID-19 period (p<0.001). However, dips in call volume were observed during the initial wave and wave 4. Qualitative interviews with stroke/TIA survivors, caregivers and healthcare professionals revealed that the integrity of the acute stroke/TIA pathway remained intact during the COVID-19 pandemic. However, overall patient experience and willingness to seek care for suspected stroke/TIA were negatively impacted. Significant heterogeneity in terminology and definitions for ambulance times and intervals were observed in the international benchmarking study. In the international comparative study, on-scene time increased across all seven services between 1.05-3.78 minutes (all <0.001) during the COVID-19 period. Whereas response time interval increased in six of the seven services, ranging from 0.5-9.13 minutes (all p<0.001), and decreased in New Zealand by 1.57 minutes (<0.001). Mean monthly call volume rose across all services during COVID-19, ranging from 1.9-9 minutes, apart from the Netherlands, which saw no change (p=0.4). Conclusion This thesis used a multistakeholder mixed methods approach to investigate the resilience of the acute stroke/TIA pathway during a public health crisis, highlighting prehospital delays and potential care avoidance by stroke/TIA survivors. It calls for stakeholder collaboration to optimise the stroke chain of survival and further studies on the pandemic's long-term impacts on stroke/TIA care.","abstract_has_math":false,"creators":["Burton, Edel"],"institution":"University College Cork","degree_name":null,"degree_level":null,"degree_discipline":null,"degree_department":null,"school":null,"contributors":[],"advisors":["Buckley, Claire","Kearney, Patricia M.","Mc Carthy, Vera"],"committee_chairs":[],"committee_members":[],"year":2024,"date_issued":"2024","date_published":"2024","updated_at":"2026-07-24T01:47:43Z","subjects":["Stroke","Transient ischaemic attack","COVID-19","Prehospital care"],"languages":["en"],"rights":["© 2024, Edel Mary Burton."],"rights_urls":["https://creativecommons.org/licenses/by/4.0/"],"identifier_entries":[]},"links":{"outbound_url":"https://hdl.handle.net/10468/17517","outbound_label":"Handle","outbound_source":"dc:identifier.uri"},"metadata_groups":[{"id":"people","label":"People","entries":[{"key":"dc:contributor.advisor","label":"Advisor","values":["Buckley, Claire","Kearney, Patricia M.","Mc Carthy, Vera"]},{"key":"dc:creator","label":"Author","values":["Burton, Edel"]}]},{"id":"academic_context","label":"Academic Context","entries":[{"key":"dc:date.accessioned","label":"Dc Date Accessioned","values":["2025-05-16T14:32:42Z"]},{"key":"dc:date.available","label":"Dc Date Available","values":["2025-05-16T14:32:42Z"]},{"key":"dc:date.issued","label":"Date","values":["2024"]},{"key":"dc:publisher","label":"Institution","values":["University College Cork"]},{"key":"dc:type","label":"Dc Type","values":["Doctoral thesis"]},{"key":"dc:type.qualificationlevel","label":"Dc Type Qualificationlevel","values":["Doctoral"]},{"key":"dc:type.qualificationname","label":"Dc Type Qualificationname","values":["PhD - Doctor of Philosophy"]}]},{"id":"subjects_keywords","label":"Subjects and Keywords","entries":[{"key":"dc:subject","label":"Dc Subject","values":["Stroke","Transient ischaemic attack","COVID-19","Prehospital care"]}]},{"id":"language_rights","label":"Language and Rights","entries":[{"key":"dc:language.iso","label":"Language (ISO)","values":["en"]},{"key":"dc:rights","label":"Dc Rights","values":["© 2024, Edel Mary Burton."]},{"key":"dc:rights.uri","label":"Rights URI","values":["https://creativecommons.org/licenses/by/4.0/"]}]},{"id":"identifiers","label":"Identifiers","entries":[{"key":"dc:identifier.uri","label":"Identifier URI","values":["https://hdl.handle.net/10468/17517"]}]},{"id":"additional","label":"Additional Metadata","entries":[{"key":"dc:description.abstract","label":"Abstract","values":["Background and aims Time plays a fundamental role in managing acute stroke and transient ischemic attack (TIA), with the minimisation of prehospital delays critical to the stroke chain of survival. The COVID-19 pandemic led to worldwide restrictions, resulting in significant societal changes, including alterations to healthcare access and delivery, which particularly impacted time-sensitive conditions. Thus, the aim of this thesis was to investigate the impact of a “shock”, such as the COVID-19 pandemic on prehospital emergency care for exemplar time-sensitive conditions; stroke and TIA, with the goal of exploring potential implications for future policy and service delivery. Methods This PhD thesis employed a mixed-methods approach, using the multilevel model of triangulation design. This approach was informed by the “Resilient Health System as a Conceptual Framework for Strengthening Public Health Disaster Risk Management”. Five studies were conducted. Firstly, a systematic review and meta-analysis synthesised existing evidence on the impact of the COVID-19 pandemic on prehospital care for suspected stroke/TIA and calculated pooled estimates for ambulance time intervals and call volume during the pandemic. Secondly a quasi-experimental study using Republic of Ireland National Ambulance Service data investigated the impact of COVID-19 on ambulance time intervals and emergency call volume for suspected stroke/TIA using linear regression and autoregressive integrated moving averages. Thirdly, a qualitative study using semi-structured interviews explored the experiences of stroke/TIA survivors, caregivers, prehospital and hospital-based practitioners of acute stroke/TIA care during the COVID-19 pandemic in Ireland. Fourthly, a benchmarking study facilitated the comparison of international terminology and definitions for ambulance times and intervals. This enabled the final study; an international comparative analysis using a quasi-experimental before and after design to compare ambulance time intervals and call volume for suspected stroke/TIA before and during COVID-19, using linear regression and times series analysis. Stakeholder involvement was included throughout all studies. Results The meta-analysis demonstrated that pre-COVID-19, the mean response interval was shorter by -1.29 minutes (95% CI: -2.19 to -0.38), and the mean total prehospital interval was shorter by -6.42 minutes (95% CI: -10.60 to -2.25), compared to during the pandemic. Additionally, there was a higher incidence rate ratio (IRR) of emergency calls for suspected stroke/TIA per day pre-COVID-19 compared to during COVID-19 (log IRR = 0.17, 95% CI: 0.02 to 0.33). In Ireland, during the pandemic period, the five included ambulance time intervals increased compared to pre-COVID-19 (all p<0.001). Overall, call volume increased during the COVID-19 period compared to the pre-COVID-19 period (p<0.001). However, dips in call volume were observed during the initial wave and wave 4. Qualitative interviews with stroke/TIA survivors, caregivers and healthcare professionals revealed that the integrity of the acute stroke/TIA pathway remained intact during the COVID-19 pandemic. However, overall patient experience and willingness to seek care for suspected stroke/TIA were negatively impacted. Significant heterogeneity in terminology and definitions for ambulance times and intervals were observed in the international benchmarking study. In the international comparative study, on-scene time increased across all seven services between 1.05-3.78 minutes (all <0.001) during the COVID-19 period. Whereas response time interval increased in six of the seven services, ranging from 0.5-9.13 minutes (all p<0.001), and decreased in New Zealand by 1.57 minutes (<0.001). Mean monthly call volume rose across all services during COVID-19, ranging from 1.9-9 minutes, apart from the Netherlands, which saw no change (p=0.4). Conclusion This thesis used a multistakeholder mixed methods approach to investigate the resilience of the acute stroke/TIA pathway during a public health crisis, highlighting prehospital delays and potential care avoidance by stroke/TIA survivors. It calls for stakeholder collaboration to optimise the stroke chain of survival and further studies on the pandemic's long-term impacts on stroke/TIA care."]},{"key":"dc:format.mimetype","label":"Dc Format Mimetype","values":["application/pdf"]},{"key":"dc:title","label":"Title","values":["The impact of the COVID-19 pandemic on prehospital emergency care for stroke/transient ischaemic attacks (TIAs) and implications for future policy and service delivery"]}]}],"canonical_facts":{"dc:contributor.advisor":["Buckley, Claire","Kearney, Patricia M.","Mc Carthy, Vera"],"dc:creator":["Burton, Edel"],"dc:date.accessioned":["2025-05-16T14:32:42Z"],"dc:date.available":["2025-05-16T14:32:42Z"],"dc:date.issued":["2024"],"dc:description.abstract":["Background and aims Time plays a fundamental role in managing acute stroke and transient ischemic attack (TIA), with the minimisation of prehospital delays critical to the stroke chain of survival. The COVID-19 pandemic led to worldwide restrictions, resulting in significant societal changes, including alterations to healthcare access and delivery, which particularly impacted time-sensitive conditions. Thus, the aim of this thesis was to investigate the impact of a “shock”, such as the COVID-19 pandemic on prehospital emergency care for exemplar time-sensitive conditions; stroke and TIA, with the goal of exploring potential implications for future policy and service delivery. Methods This PhD thesis employed a mixed-methods approach, using the multilevel model of triangulation design. This approach was informed by the “Resilient Health System as a Conceptual Framework for Strengthening Public Health Disaster Risk Management”. Five studies were conducted. Firstly, a systematic review and meta-analysis synthesised existing evidence on the impact of the COVID-19 pandemic on prehospital care for suspected stroke/TIA and calculated pooled estimates for ambulance time intervals and call volume during the pandemic. Secondly a quasi-experimental study using Republic of Ireland National Ambulance Service data investigated the impact of COVID-19 on ambulance time intervals and emergency call volume for suspected stroke/TIA using linear regression and autoregressive integrated moving averages. Thirdly, a qualitative study using semi-structured interviews explored the experiences of stroke/TIA survivors, caregivers, prehospital and hospital-based practitioners of acute stroke/TIA care during the COVID-19 pandemic in Ireland. Fourthly, a benchmarking study facilitated the comparison of international terminology and definitions for ambulance times and intervals. This enabled the final study; an international comparative analysis using a quasi-experimental before and after design to compare ambulance time intervals and call volume for suspected stroke/TIA before and during COVID-19, using linear regression and times series analysis. Stakeholder involvement was included throughout all studies. Results The meta-analysis demonstrated that pre-COVID-19, the mean response interval was shorter by -1.29 minutes (95% CI: -2.19 to -0.38), and the mean total prehospital interval was shorter by -6.42 minutes (95% CI: -10.60 to -2.25), compared to during the pandemic. Additionally, there was a higher incidence rate ratio (IRR) of emergency calls for suspected stroke/TIA per day pre-COVID-19 compared to during COVID-19 (log IRR = 0.17, 95% CI: 0.02 to 0.33). In Ireland, during the pandemic period, the five included ambulance time intervals increased compared to pre-COVID-19 (all p<0.001). Overall, call volume increased during the COVID-19 period compared to the pre-COVID-19 period (p<0.001). However, dips in call volume were observed during the initial wave and wave 4. Qualitative interviews with stroke/TIA survivors, caregivers and healthcare professionals revealed that the integrity of the acute stroke/TIA pathway remained intact during the COVID-19 pandemic. However, overall patient experience and willingness to seek care for suspected stroke/TIA were negatively impacted. Significant heterogeneity in terminology and definitions for ambulance times and intervals were observed in the international benchmarking study. In the international comparative study, on-scene time increased across all seven services between 1.05-3.78 minutes (all <0.001) during the COVID-19 period. Whereas response time interval increased in six of the seven services, ranging from 0.5-9.13 minutes (all p<0.001), and decreased in New Zealand by 1.57 minutes (<0.001). Mean monthly call volume rose across all services during COVID-19, ranging from 1.9-9 minutes, apart from the Netherlands, which saw no change (p=0.4). Conclusion This thesis used a multistakeholder mixed methods approach to investigate the resilience of the acute stroke/TIA pathway during a public health crisis, highlighting prehospital delays and potential care avoidance by stroke/TIA survivors. It calls for stakeholder collaboration to optimise the stroke chain of survival and further studies on the pandemic's long-term impacts on stroke/TIA care."],"dc:format.mimetype":["application/pdf"],"dc:identifier.uri":["https://hdl.handle.net/10468/17517"],"dc:language.iso":["en"],"dc:publisher":["University College Cork"],"dc:rights":["© 2024, Edel Mary Burton."],"dc:rights.uri":["https://creativecommons.org/licenses/by/4.0/"],"dc:subject":["Stroke","Transient ischaemic attack","COVID-19","Prehospital care"],"dc:title":["The impact of the COVID-19 pandemic on prehospital emergency care for stroke/transient ischaemic attacks (TIAs) and implications for future policy and service delivery"],"dc:type":["Doctoral thesis"],"dc:type.qualificationlevel":["Doctoral"],"dc:type.qualificationname":["PhD - Doctor of Philosophy"]},"updated_at":"2026-07-24T01:47:43Z"}