Response by Khosravani et al to Letter Regarding Article, "Protected Code Stroke: Hyperacute Stroke Management During the Coronavirus Disease 2019 (COVID-19) Pandemic".

In Response:

We thank Barachinni et al for their letter in response to our article in Stroke titled “Protected Code Stroke: Hyperacute Stroke Management During the Coronavirus Disease 2019 (COVID-19) Pandemic”.[1] Stroke remains an emergency during the pandemic. We proposed the concept of a protected code stroke, highlighting the importance of vigilant screening, infection prevention and control measures, and a coordinated team response. Having this term named unites teams in a shared cause and mental model during hyperacute resuscitation. We commend Barachinni et al, our Italian colleagues, and indeed all frontline providers across the world who step up each day, face new challenges, and maintain stroke care excellence during these trying times.[2,3]

We agree that the protected code stroke must be combined with hospital/regional-level system change to provide a coordinated response. This pandemic has exposed a potential vulnerability in existing stroke pathways: emergency preparedness and the ability to quickly adapt to emergent crises. One tool as part of mitigation strategies is Crisis Resource Management (CRM), which started in aviation but has spread to several medical specialties including emergency medicine.[4] These concepts can in fact scale from the patients to systems of care promoting rapid adaptability to a changing landscape. CRM helps affect change in the behavior of teams that are the core engine of systems of care. Central to CRM are the following core competencies: situational awareness, triage and prioritization, awareness of team cognitive load, role clarity, effective communication, and debriefing. Simulation training is the bedrock of CRM to enhance team performance.

In emergency preparedness measures, much like resuscitation, the number of tasks can be overwhelming and often not congruent with resources immediately available to complete them. There can be bias and lack of situational awareness. Prioritization of patients, resources, and nontechnical skills of communication including debriefings are essential. Triage and prioritization strategies must evolve with the pandemic for on-going effective mitigation strategies and avoidance of task saturation. Communication between and within levels of care systems is essential to maintaining high-quality hyperacute stroke care. Frequent and effective debriefing between teams, management, and policymakers brings people together, unify care components, and foster a culture of quality and patient safety.

Collectively, the therapeutic tools we have in stroke are only as good as the teams working together to deliver them—central to this are themes embodied by CRM.[4,5] The time is now to implement CRM in stroke care.

This epoch highlights the need to have systems and protocols in place, at the ready, to be implemented at a rapid pace. Emergency preparedness must be done without compromising core stroke care functions and the integrity of stroke care pathways. Increasingly, this includes leveraging remote technologies to expand the reach/scope of providers. Depending on the nature and height of the pandemic, stroke care resources may need to be re-deployed to support other clinical needs. Similarly, other clinical areas may be called to assist in stroke care. Just-in-time training modules and local/regional emergency protocols developed now will help inform our future strategies.

As stroke evolves so must our situational awareness and evaluation of processes that are a value-add and those that may require pruning and refinement moving forward. Our systems of care may forever be altered by this pandemic. CRM and its implementation are uniquely situated on the precipice of our current state—keeping us on the ready now and for future emergencies.

Disclosures

None.