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

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.

Grantor dc:publisher

University College Cork

Year dc:date.issued

2024

Author dc:creator

• Burton, Edel

Advisors dc:contributor.advisor

• Buckley, Claire
• Kearney, Patricia M.
• Mc Carthy, Vera

• Stroke
• Transient ischaemic attack
• COVID-19
• Prehospital care

Statement dc:rights

• © 2024, Edel Mary Burton.

Licence dc:rights.uri

• https://creativecommons.org/licenses/by/4.0/

Language dc:language.iso

en

Handle dc:identifier.uri

https://hdl.handle.net/10468/17517

OAI identifier oai:identifier

oai:cora.ucc.ie:10468/17517