The impact of the COVID-19 pandemic on prehospital emergency care for stroke/transient ischaemic attacks (TIAs) and implications for future policy and service delivery

Burton, Edel

The impact of the COVID-19 pandemic on prehospital emergency care for stroke/transient ischaemic attacks (TIAs) and implications for future policy and service delivery

dc.check.chapterOfThesis	Page 274 to 354 and 388 to 427	en
dc.contributor.advisor	Buckley, Claire
dc.contributor.advisor	Kearney, Patricia M.
dc.contributor.advisor	Mc Carthy, Vera
dc.contributor.advisorexternal	Merwick, Aine
dc.contributor.author	Burton, Edel	en
dc.contributor.funder	Health Research Board
dc.date.accessioned	2025-05-16T14:32:42Z
dc.date.available	2025-05-16T14:32:42Z
dc.date.issued	2024
dc.date.submitted	2024
dc.description.abstract	Background and aims Time plays a fundamental role in managing acute stroke and transient ischemic attack (TIA), with the minimisation of prehospital delays critical to the stroke chain of survival. The COVID-19 pandemic led to worldwide restrictions, resulting in significant societal changes, including alterations to healthcare access and delivery, which particularly impacted time-sensitive conditions. Thus, the aim of this thesis was to investigate the impact of a “shock”, such as the COVID-19 pandemic on prehospital emergency care for exemplar time-sensitive conditions; stroke and TIA, with the goal of exploring potential implications for future policy and service delivery. Methods This PhD thesis employed a mixed-methods approach, using the multilevel model of triangulation design. This approach was informed by the “Resilient Health System as a Conceptual Framework for Strengthening Public Health Disaster Risk Management”. Five studies were conducted. Firstly, a systematic review and meta-analysis synthesised existing evidence on the impact of the COVID-19 pandemic on prehospital care for suspected stroke/TIA and calculated pooled estimates for ambulance time intervals and call volume during the pandemic. Secondly a quasi-experimental study using Republic of Ireland National Ambulance Service data investigated the impact of COVID-19 on ambulance time intervals and emergency call volume for suspected stroke/TIA using linear regression and autoregressive integrated moving averages. Thirdly, a qualitative study using semi-structured interviews explored the experiences of stroke/TIA survivors, caregivers, prehospital and hospital-based practitioners of acute stroke/TIA care during the COVID-19 pandemic in Ireland. Fourthly, a benchmarking study facilitated the comparison of international terminology and definitions for ambulance times and intervals. This enabled the final study; an international comparative analysis using a quasi-experimental before and after design to compare ambulance time intervals and call volume for suspected stroke/TIA before and during COVID-19, using linear regression and times series analysis. Stakeholder involvement was included throughout all studies. Results The meta-analysis demonstrated that pre-COVID-19, the mean response interval was shorter by -1.29 minutes (95% CI: -2.19 to -0.38), and the mean total prehospital interval was shorter by -6.42 minutes (95% CI: -10.60 to -2.25), compared to during the pandemic. Additionally, there was a higher incidence rate ratio (IRR) of emergency calls for suspected stroke/TIA per day pre-COVID-19 compared to during COVID-19 (log IRR = 0.17, 95% CI: 0.02 to 0.33). In Ireland, during the pandemic period, the five included ambulance time intervals increased compared to pre-COVID-19 (all p<0.001). Overall, call volume increased during the COVID-19 period compared to the pre-COVID-19 period (p<0.001). However, dips in call volume were observed during the initial wave and wave 4. Qualitative interviews with stroke/TIA survivors, caregivers and healthcare professionals revealed that the integrity of the acute stroke/TIA pathway remained intact during the COVID-19 pandemic. However, overall patient experience and willingness to seek care for suspected stroke/TIA were negatively impacted. Significant heterogeneity in terminology and definitions for ambulance times and intervals were observed in the international benchmarking study. In the international comparative study, on-scene time increased across all seven services between 1.05-3.78 minutes (all <0.001) during the COVID-19 period. Whereas response time interval increased in six of the seven services, ranging from 0.5-9.13 minutes (all p<0.001), and decreased in New Zealand by 1.57 minutes (<0.001). Mean monthly call volume rose across all services during COVID-19, ranging from 1.9-9 minutes, apart from the Netherlands, which saw no change (p=0.4). Conclusion This thesis used a multistakeholder mixed methods approach to investigate the resilience of the acute stroke/TIA pathway during a public health crisis, highlighting prehospital delays and potential care avoidance by stroke/TIA survivors. It calls for stakeholder collaboration to optimise the stroke chain of survival and further studies on the pandemic's long-term impacts on stroke/TIA care.	en
dc.description.status	Not peer reviewed	en
dc.description.version	Accepted Version	en
dc.format.mimetype	application/pdf	en
dc.identifier.citation	Burton, E. M. 2024. The impact of the COVID-19 pandemic on prehospital emergency care for stroke/transient ischaemic attacks (TIAs) and implications for future policy and service delivery. PhD Thesis, University College Cork.
dc.identifier.endpage	702
dc.identifier.uri	https://hdl.handle.net/10468/17517
dc.language.iso	en	en
dc.publisher	University College Cork	en
dc.relation.project	Health Research Board([CDA-2019-001; Collaborative Doctoral Award (CDA) 2020-2024])
dc.rights	© 2024, Edel Mary Burton.
dc.rights.uri	https://creativecommons.org/licenses/by/4.0/
dc.subject	Stroke
dc.subject	Transient ischaemic attack
dc.subject	COVID-19
dc.subject	Prehospital care
dc.title	The impact of the COVID-19 pandemic on prehospital emergency care for stroke/transient ischaemic attacks (TIAs) and implications for future policy and service delivery	en
dc.type	Doctoral thesis	en
dc.type.qualificationlevel	Doctoral	en
dc.type.qualificationname	PhD - Doctor of Philosophy	en