Process Changes for Stroke Care and Electroencephalography on a Neurology Service in a Hospital at the Epicenter of the COVID-19 Pandemic

Abstract

The United States, with over 11 million cases and ~250,000 deaths (1), has become the epicenter of the COVID-19 worldwide pandemic since the first case was identified in Washington State on January 19, 2020. In New York City the first case of community acquired COVID-19 was identified on March 1, 2020 and the number of known cases increased rapidly making the city the epicenter of COVID-19 in the United States. Public hospitals became deluged with patients as the communities they serve, urban poor and minority, were disproportionately affected by the disease. COVID-19 often affects the nervous system with both central and peripheral sequalae, neurology services had to adapt to a new landscape (2–6). This paper will report on the process changes for the neurology service, in particular for stroke and electroencephalography (EEG) services, at King County Hospital Center (KCHC), a 637 bed, public, university-affiliated, teaching hospital in central Brooklyn, New York, which serves a predominantly African American community. Implementing those changes resulted in maintaining our pre-COVID structure and quality of care despite the workflow, economic, and technical challenges induced by the virus. The first known COVID-19 patient was admitted to KCHC on March 13, 2020, almost 2 weeks after the first known case of COVID-19 was identified in New York City. The number of cases rapidly increased first in Manhattan and then in Brooklyn before in Queens and then in the Bronx. In March and April as case numbers surged at KCHC, strategies to protect patients and staff were developed and implemented rapidly as we learned first-hand about the disease. Initially, COVID-19 was thought to be a respiratory disease. However, in the first few days of the surge of patients, multiple Neurology and Emergency Medicine personnel were exposed to COVID-19 patients who presented with strokes but without respiratory complaints. The Neurology Service responded by promptly instituting a policy that full personal protective equipment (PPE) including N95 masks and face shields be used for performing stroke codes, adapting procedures for performing neurologic examinations, and changing the workflow for EEG. We also reorganized our services and participated in many facets of the hospital-wide COVID-19 response As was the case in many other hospitals when COVID-19 arrived, our Neurology Department made staffing changes to support the COVID-19 effort. We disbanded our Neuro Critical Care Service and sent the attendings into the Intensive Care Unit (ICU) attending pool as the hospital expanded its ICU bed capacity from 40 to 200 ICU beds. The Neurology Consultation Service provided neurology guidance on critically ill patients with neurologic conditions. Our Neuro Critical Care attendings graciously answered our questions on difficult to manage patients. Our current stroke fellow is also an Emergency Medicine attending and he put his fellowship on hold and went full time to the Emergency Department (ED) during the peak of the crisis. The inpatient Neurology Service expanded to become a combined Neurology-COVID service caring for patients with neurological conditions, COVID-19, or both. We received training on the evolving management of COVID-19 from Infectious Disease and ICU attendings. We also held a journal club on the neurologic manifestations of COVID-19 and regularly emailed pertinent articles to the entire Neurology faculty and all trainees. The Pulmonary Service consulted regularly on our patients on mechanical ventilation and BIPAP. The infectious disease attendings came by on a daily basis to advise us on both the management of COVID-19 and multiple other medical issues. Our Adult Neurology residents and attendings also rotated onto the Medicine services which were almost all COVID-19 wards. Of the two approaches, expanding the scope of the Neurology-COVID-Medicine service worked better. We maintained our pre-COVID structure and were better able to maintain the morale of our teams. On the outpatient side, we rapidly transitioned from in-person visits to telephone visits (televisits) and eventually our Stroke Clinic instituted video visits. Electromyography and outpatient EEG studies were suspended until the surge passed. Our Pediatric Neurology fellows performed nasopharyngeal swabs for outpatient and employee testing. Our Adult and Pediatric Neurology attendings helped out Employee Health with the phone calls to quarantined staff. Our Pediatric Neurology fellows also rounded with the ICU teams and served as the liaison with the families who were not allowed to visit their loved ones. Our Stroke Nurse Practitioner became the PPE trainer for stroke codes but also for trauma codes. She quickly trained all of the staff on both Trauma and Neurology in proper PPE donning, use, and doffing. In addition, she developed Stroke code kits comprised of N-95 masks, face shields, gowns, bonnets, and gloves, so the responder had a pre-assembled set of PPE and could rapidly prepare to safely answer a stroke code. We also analyzed and adapted the workflow of the stroke code and neuro exam. Prior to the pandemic, we used laminated pocket cards for aphasia testing. During the pandemic we blew up the pocket cards used for aphasia testing onto 8.5 × 11 sheets of paper that were discarded after each use. Pen lights were encased in sealed plastic bags to facilitate repeated cleanings with gel before and after each patient encounter. Fundoscopic examinations were halted due to the prolonged close interaction. Pupil examinations and cranial nerve examinations are also performed in close proximity to the patient's face, so we required N-95 mask and face shield use for all patient encounters in order to perform these procedures safely. Throughout the hospital patients were cohorted into “hot zones” for COVID-19 positive patients and “cold zones” for COVID-19 negative ones. As much as possible hot and...