The impact of COVID-19 pandemic in stroke code activation and time from symptom onset to hospital arrival in a Portuguese comprehensive stroke centre

Introduction. Coronavirus disease 2019 (COVID-19) impacted emergency services worldwide. Aim. We aimed to evaluate COVID-19 effect on the number of stroke code activations and timings during the first two months of the pandemic. Material and methods. We reviewed the stroke code database of a single comprehensive stroke centre in Portugal for the number of activations through 2019-2020. We compared the pathway timings between March and April 2020 (COVID-19 period) and the homologous months of the previous four years (pre-COVID-19 period), whilst using February as a control. Results. Monthly stroke code activation rates decreased up to 34.2% during COVID-19 pandemic. Compared to the pre-COVID-19 period, we observed an increase in the time from symptom onset to emergency call, with a significant number of patients waiting more than four hours (March 20.8% vs. 6.8%, p = 0.034; April 23.8% vs. 6%, p = 0.01); as well as an increase in the time from symptom onset to hospital arrival (March: median 136 minutes [IQR 106-410] vs. 100 [IQR 64-175], p = 0.001; April: median 188 [IQR 96-394] vs. 98 [IQR 66-168], p = 0.007). No difference between both periods was found concerning in-hospital times, patient characteristics, stroke/mimic diagnosis, stroke severity, and mortality. Conclusion. COVID-19 related factors probably reduced healthcare services utilization, and delayed emergency calls and hospital arrival after stroke onset. These highlight the importance of health education to improve the effectiveness of medical assistance. The preservation of in-hospital times validates the feasibility of the protected stroke code protocol.