Stroke care in Italy at the time of COVID-19
A snapshot in February 2021
NCD care and
COVID-19
When the first wave of COVID-19 hit Italy in 2020, hospitals with over 500 beds had to set up COVID-19 units and COVID-19-free areas to admit and quarantine COVID-19-positive patients. Intensive care unit (ICU) beds were dedicated to them and additional ICU beds found. In some places, entire hospitals were assigned to treat only COVID-19 patients. Smaller institutions were often temporarily closed because patients and personnel had acquired COVID-19 in the hospital.1
Italy has 21 organizationally
independent health regions, so practice between them can differ. A key measure in all regions was to ensure that
suspected COVID-19 patients should be kept separated from all other patients. Due to the pressure on the system, stroke units in
Lombardy region, where COVID-19 took an enormous toll and the hospital system needed to be reorganized to prioritize COVID-19 patients, were reduced from 38 to 10.
The remaining 28 were given over to COVID-19 treatment. In the most affected regions, changes were needed to prioritize the ongoing emergency, and stroke management had to change. The closure of departments and hospitals led to a complete reorganization of previously functioning stroke networks.
Lazio region was not as severely affected during the first wave. By January 2021, however, hospitals with stroke units had rearranged stroke care, acute stroke treatment pathways and rehabilitation services to facilitate timely and safe delivery of care.
Dr Francesca Romana Pezzella is a stroke neurologist at San Camillo-Forlanini Hospital in Rome, a stroke network hub.
“COVID-19 patients have a higher risk of stroke, and with both stroke and COVID-19 together, the prognosis is of course worse,” she says, “There can also be other neurological complications which are rarer, such as neuromuscular disorders and encephalopathy.”
The stroke pathway was adapted quickly in Dr Pezzella’s hospital. Ambulance crews contact the hospital to alert them to a stroke patient’s arrival and then transport the patient straight to a so-called shock room. Once there, every patient is treated as a possible COVID-19 patient, immediately tested for COVID-19 and triaged. Staff wear full protection up to this point. If test-negative patients have a high fever, they continue to be treated as suspect cases.
COVID-19 did not stop stroke treatment. No urgent patients who were due for thrombolysis, thrombectomy or carotid surgery had their operations postponed. Although other treatments could be delayed, stroke patients still receive
1 Zedde M, Pezzella FR, Paciaroni M, Corea F, Reale N, Toni D et al. Stroke care in Italy:
an overview of strategies to manage acute stroke in COVID-19 time. Eur Stroke J.
2020;5(3):222–9. doi:10.1177/2396987320942622. Epub 2020 Jul 26.
physiotherapy and speech therapy, with full protective equipment used. Hospitals run iterative tests to protect staff and patients: patients may even be tested as they move
from one part of the hospital to another. Body- temperature tests are also omnipresent in the
community, when people enter shops or institutions, in the hospital and within the
hospital from department to department and, of course, at patients’ admission,
discharge or transfer.
When the COVID-19 pandemic started, people who suffered symptoms of a stroke did not seek help, particularly for a transient ischaemic attack or a minor stroke. In some cases, the ambulance would turn up and the patient could not be persuaded to come to the hospital: this led to a decrease in admissions. A video therefore was made and published online to get over to the public the message that stroke is always an emergency and cannot be treated at home. This video was distributed extensively. By the autumn of 2020, people were more likely to come to the hospital.
Because of the risk, visits from family initially were blocked.
“Relatives were told not to come to the hospital, but they could be called at any time if there were developments,”
says Dr Pezzella. “We spend a lot of time on the phone. We issue patients an information sheet so they understand what we do, who we are, who they can call and when. If appropriate and feasible, we recommend that every patient should have their own smartphone so they can contact their families, with our help if necessary. However, relatives still turn up at the door, anxious and pressurizing us to talk to them.
“They want to see our face, and they can feel frustrated and sometimes become aggressive toward staff,” she
continues. “The lack of contact with family members has psychological and functional consequences, even on the levels of pain the patient experiences, which we monitor daily on the patient’s record. No longer can family members come at lunchtime and stay all afternoon by the patient’s side, talking together and keeping them company. Nor can staff spend time having long chats with relatives to reassure them about the future or perhaps choose rehabilitation hospitals together. The burden on the nursing staff is greater, and the loss to the patients is significant.
Sometimes the stroke associations can help answer questions, or families can talk to volunteers or medical students. We think it would be helpful to have a mediator who could invest time in the communication between both sides, both of whom are stressed.”
COVID-19 extracts a human cost from everyone. “So far, I haven’t contracted COVID-19”, says Dr Pezzella. “But a large number of nurses and doctors in the hospital had it in the first months. Staff in the emergency room have been We
have learnt how to use our resources better, how and where to expand services, how to invest in our health system – particularly
primary care – how to create alliances with patients, how to support professionals, and how to use the Internet to bring people
together to talk to each other quickly and without hesitation.
– Dr Francesca Romana Pezzella
©WHO/Iliana Colonna
affected most. It was only with the start of staff vaccination that we could see a slowing and finally stopping, at least among hospital personnel. With the country in lockdown, I considered myself lucky to be able to go out and work in the hospital every day, working in that community. Medical and nursing staff got closer, sharing our experiences and concerns. This is a transformative experience for all of us.
Some extra funds have now been planned for staff working in COVID-19 services or in emergency settings.”
Other positive changes will endure. Telemedicine is now widely used within the hospital and to communicate with smaller hospitals in the region to swiftly assess patients or give expert advice. Physicians use a dedicated platform with access to all necessary information, including
hi-resolution imaging; other colleagues join in, increasing the circle of expertise. Consultations are posted on the system and patients can then be referred, transferred or prescribed treatment, as appropriate. This platform is used in outpatient clinics for patients with many other conditions, such as
multiple sclerosis, Parkinson’s disease and diabetes, and in emergency settings for consultations around infectious diseases, neurosurgery and eye trauma. Web-based communication tools are also useful for international work, such as holding online webinars and focus groups with other European countries.
Dr Pezzella is researching the neurological complications of COVID-19, and her research has also had to adapt.
Participating in clinical trials had to be modified to ensure patient safety, leading to more difficulties in recruiting patients for randomized trials. Research into rehabilitation has been hampered by movement restrictions.
The reduction in COVID-19 cases in the summer of 2020 gradually allowed some regions to go back to pre-COVID-19 organization of services. This was rapidly followed by a resurgence in infections related to the onset of SARS-CoV-2 variants. While this hit Italy later than other European countries, a new unanticipated peak in cases pushed authorities to re-establish restrictions on movement and impose organizational measures to contain the outbreak.
Even with the experience gained during the COVID-19 pandemic, hospital capacity is again under strain, reaching the occupational ceilings that trigger lockdown measures.
Dr Pezzella says, “At the moment the number of cases is slowly decreasing, thanks to social distancing, lockdown and the vaccination campaign. The work is still double what it was, as people are using hospitals as much as ever, but we have moved from overwhelming COVID-19 in 2019, to testing in 2020 and now to vaccination in 2021. This period has been a big lesson. We have learnt how to use our resources better, how and where to expand services, how to invest in our health system – particularly primary care – how to create alliances with patients, how to support professionals, and how to use the Internet to bring people together to talk to each other quickly and without hesitation.
In my region, we now have a network of COVID-19 expert health workers who talk to each other every Tuesday. We are leapfrogging into better practices. I like it. It has also helped us to value human contact and family care all the more”.
Document number: WHO/EURO:2021-2773-42531-59088.
© World Health Organization 2021. Some rights reserved.
This work is available under the CC BY-NC-SA 3.0 IGO license.
