The COVID19 pandemic and its impact on healthcare systems is rapidly changing. Similarly, there is impact on code stroke operational parameters and safety aspects for clinical providers.

Hyperacute assessment and management of patients with stroke, termed “code stroke”, is a time-sensitive and high-stakes clinical scenario. In the context of the current COVID-19 pandemic caused by the SARS-CoV-2 virus, the ability to deliver timely and efficacious care must be balanced with the risk of infectious exposure to the clinical team. Furthermore, rapid and effective stroke care remains paramount to achieve maximal functional recovery for those needing admission and to triage care appropriately for those that may be presenting with neurologic symptoms but have an alternative diagnosis.

Available resources, COVID-19 specific infection prevention and control recommendations, and expert consensus were used to identify clinical screening criteria for patients and provide the required nuanced considerations for the healthcare team thereby modifying the standard code stroke processes in order to achieve a “protected” designation.

A protected code stroke (PCS) algorithm was developed. Features specific to pre-notification and clinical status of the patient were used to define pre-code screening. These include primary infectious symptoms, clinical, and examination features. A focused framework was then developed with regards to a PCS.

The framework has the following key components:

A) Screening - focused around infectious symptoms, and historical/clinical features[*]

[*] as community spread becomes more established, travel history is no longer considered a key ingredient of screening, hence it is less emphasized. Nonetheless, travel history confers a higher degree of risk. Furthermore, some patients may present with extra-respiratory symptoms such as GI, without much else initially. Similarly, there is sufficient suspicion that COVID19 illness can either co-present along with or have neurologic features as primary - there are already 2 pre-print articles suggesting this.

B) Action - the protected code stroke (PCS) - with appropriate PPE, mask on the non-intubated patient, and crisis resource management/human performance factor considerations (e.g. who is in/out of the room, team communication, safety lead)

The below protocol is presented as suggestions for adaptation as is or modified to adapt your local parameters and operational protocols.

If you need any assistance in facilitating the use of these protocols to for your site-specific needs, please reach out: houman@stroke.dev ; I am also happy to do a virtual talk for your residents/fellows/staff and/or to help them along with you for local/site-specific adaption.

Figure 1. Protected Code Stroke (PCS) framework. Two key sections are outlined: screening and PCS operational parameters. These parameters are use of personal protective equipment (1) with and without aerosol-generating medical procedures, placing a surgical mask on the non-intubated patient (2), and utilization of crisis resource management principles (3).

Figure 2. Suggested approach to team designation in a Protected Code Stroke (PCS). Minimize team members in the resuscitation room – use a lean team approach. MD1 should be either an attending, fellow, or experienced trainee able to effectively obtain an NIH Stroke Scale. In some cases, two RNs may be required for patient care. Any team member can be the designated Safety Lead (including RN, RT, additional MD or other staff with knowledge of donning and doffing). The safety lead ensures proper technique and inspection of the equipment. When present, MD2 or alternate can gain collateral history through existing health records and family members. Required personal protective equipment (PPE) is as described, fit-tested N95 masks should be used for members inside the room if aerosol-generating medical procedures are occurring. The PCS team can proceed with the patient to imaging before doffing with the safety lead facilitating transit (to and from imaging) and PPE procedures.

Please see this slide deck for modifications made to the Stroke Inpatient service - for maximal resident/trainee protection. These are not evidence-based recommendations but rather common-sense approach to risk mitigation. These were presented to our residents March 23, 24, 2020. Any questions - please email: houman@stroke.dev

March 20, 2020 - Academic Half-day Session - Protected Code Stroke - Audio Only MP3

This talk occurred on March 20, 2020 - as an emergency Academic Half-day Session for U o f T Neurology. The information provided, along with number of cases and characteristics was up-to-date at that time. Given the nature of the COVID-19 pandemic this information is evolving and portions of the talk may not be accurate. These are not evidence-based recommendations but rather common-sense approach to risk mitigation. Any questions - please email: houman@stroke.dev (Stroke Neurology/Critical Care)

Podcast - Emergency Podcasts on COVID-19

• S01E10 Stroke.FM Protected Code Stroke

• S01E11 Stroke.FM COVID-19 Orientation