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This COVID-19 Practice: A Global Pandemic Fuels Neurology Guidance Papers—When Time Is of the Essence

David Hess, MD, dean and professor of neurology at Georgia Medical College, was emailing in March with a former colleague in Italy about COVID-19 when a question came up about whether it was wise to use tissue plasminogen activator (tPA) in COVID patients with stroke.

 Reports were emerging that some patients with COVID-19 developed what seemed to be sepsis-induced hypercoagulability, which could lead to stroke. But it was not clear whether the stroke drug tPA and standard anticlotting drugs such as heparin were suited to the pathology underlying COVID-19.

The emails with the Italian neurologist, who had done a fellowship at Georgia Medical College, prompted Dr. Hess to consider the question of COVID-related stroke in a more systematic way. He started reading everything he could about the workings of the SARS CoV-2 virus and then developed a rationale for managing COVID-19 related stroke.

Dr. Hess said he hoped that the resulting piece, published online May 7 in Translational Stroke Research, would "reassure doctors to continue to use tPA. I would hate to miss the opportunity to treat people with stroke," even when it comes amid the many complexities of treating COVID patients, he said

Dr. Hess's paper, coauthored with two colleagues at Medical College of Georgia, is among a number of guidance papers, recommendations, and consensus statements published by neurologists and subspecialty societies during the pandemic, each meant to provide some clarity for treating a novel coronavirus that has killed more than 116,000 people in the US and more than 428,000 globally. Many of them were published in about half the time they would normally require.

At first COVID-19 appeared to be largely a severe respiratory illness, but now it is apparent that organs and systems throughout the body can be impacted. Neurologists are being called upon to treat neurologic complications both in the acute phase of COVID-19 and in its aftermath. Neurologists have also grappled with how to care for their regular patients during the pandemic-prompted shutdown of outpatient offices.

One of the new papers by neurologists serves as a guide for providing care using telemedicine, which was largely unknown to many neurologists when the pandemic began. Another statement addresses ethical issues around the use of limited resources such as ventilators—a much discussed dilemma as hospitals began to fill with COVID patients.

There are also new papers on how to manage specific neurologic conditions such as multiple sclerosis and myasthenia gravis during the pandemic. Among questions addressed: Should patients be kept on existing immune modulatory therapies?

Authors of the various guidance papers said they considered time to be of the essence as they researched, wrote, and submitted the articles for publication. They also recognized that the papers could not be all encompassing.

Ethical Considerations in the Pandemic

"We realized it was important to get this out as quickly as possible," said Michael A. Rubin, MD, MA, FAAN, lead author of a new AAN position statement on COVID-19 and the ethical duties of the neurologist. It was put together on behalf of the Ethics, Law, and Humanities Committee, a joint committee of the AAN, American Neurological Association, and Child Neurology Society. The statement was done in collaboration with the Neurocritical Care Society Ethics Committee.

Dr. Rubin, chair of the clinical ethics committee at University of Texas Southwestern Medical Center, said the position paper took form in March as discussions unfolded among his colleagues and around the country about what should be done if the demand for ICU beds, ventilators, and other equipment surpassed availability.

"Few of us had personal experience adapting to a pandemic," said Dr. Rubin.

While individual institutions began to consider the ethical and practical questions around allocating limited resources, including personal protective equipment, Dr. Rubin and his writing team thought it would be useful to provide a general ethical framework that could be adapted for decision-making at individual settings and circumstances.

"One challenge we had in designing the statement was that there was a wide variety of scarce resource allocation policies out there and we did not see it as our place to say that one is better than another, but rather what elements were inherently problematic for neurology patients," he said. Another challenge was "figuring out what we were going to talk about and what we weren't going to talk about" in the paper.

While wanting the statement to be timely, "it was clear the pandemic was going to go for a long period and we wanted to be sure it (the statement) could stand the test of time and be helpful," said Dr. Rubin, who said the first draft of the paper was written in about 10 days.

He said that while the COVID-19 pandemic is unlike anything hospitals and doctors have seen in contemporary medicine, basic well-founded principles of medical ethics can be applied.

"This time of troubles has forced us to consider the fundamental obligations that neurologists have to our own individual patients as well as the greater community," the statement said. Among the topics are balancing your duties as a physician; competing clinical assignments and practicing outside of your usual scope of care; and scare resource allocation.

Dr. Rubin said he found the project fulfilling because it felt as though he was making a contribution to the pandemic even though he wasn't providing patient care to COVID-19 patients.

"It's a good time to reflect and write and engage with your societies and your journals," he said.

Sarah Bird Nelson, JD, associate counsel for the AAN, served as a liaison between the various professional societies that reviewed and signed onto the statement, and she helped shepherd it through to its online publication in Neurology on May 15. She said that typically it takes several months or longer to craft a position paper, with time consumed by various authors and societies weighing in, followed by the journal review.

"It was definitely challenging," Nelson said of the speedy turnaround on the ethics position statement. "But if a situation warrants it, I think this experience proves that it is entirely possible. Everyone involved in this project understood that we would need to combine certain steps and shorten review timelines in the development/approval process to get the paper out in a timely fashion, and they rose to the challenge."

Telemedicine for Neurology

Christopher Tarolli, MD, assistant professor of neurology at University of Rochester, was already experienced at telemedicine when the pandemic forced doctors to switch to seeing patients remotely.

"Many neurologists looked at telemedicine and said right off the bat 'This is not possible. I cannot do this,'" Dr. Tarolli said. "As neurologists, we think of our (neurologic) exam as being sacrosanct and in the mind of many neurologists that exam needs to be done in person."

Dr. Tarolli set out to write a paper, along with colleagues at Johns Hopkins University and University of Rochester, that would provide practical advice to neurologists on how to implement telemedicine and conduct patient evaluations remotely. The recommendations, published online May 21 in Neurology: Clinical Practice, include suggestions on what kind of equipment and software to use and how to establish expectations for the televisit with the patient.

The guidance, assembled in two weeks, note that many portions of the neurological exam can be done as usual or be conducted with modifications. For instance, finger-to-nose testing can be done between the patient and a helper or between the patient and a stationary object visible on the screen. Assessing swallowing can be done by asking the patient to take a sip of water. But assessing reflexes from afar is difficult, the recommendations said.

"For the vast majority of patients, you can do a reasonable exam to triage patients," Dr Tarolli said, though there may be shortcomings.  "Every visit has to start with telling the patient 'There are limitations to this visits, 'I can't do everything I can do in the office and because of that it may limit my ability to make a diagnosis or form a treatment plan."

He said telemedicine works especially well for follow-up care.

"With a lot of movement disorders, what we do in follow-up is get the patient's report on how things are going, If they are telling you things are much better or much worse, that's what matters," he said.

Dr. Tarolli expects the recommendations to stay relevant after the pandemic because many doctors have come to realize that telemedicine has a place in their practice. The biggest obstacle, Dr. Tarolli said, is reimbursement from insurance companies.

Neurocritical Care

A position statement by the Neurocritical Care Society (NCS) was prompted by member questions about the role of neurocritical care specialists during the pandemic. Asma Moheet, MD, a neurointensivist at OhioHealth Riverside Methodist Hospital and a board member of NCS, said practitioners were torn between their usual job of taking care of patients with neurologic issues such as stroke and traumatic brain injury and new responsibilities that arose as COVID-19 patients filled ICUs.

There were two key issues. "How can we take care of COVID patients but how can we make sure we still take care of the patients coming in with neurologic problems?" Dr. Moheet said.

The NCS surveyed its leaders about what issues they would like addressed in a position statement and a request was sent out for members to participate in the project. A virtual brainstorming session with about 20 volunteers led to a game plan, a divvying of tasks and a document that was being revised and edited even as it was still being composed. At one point, the document had nearly 3,000 revisions, Dr. Moheet said.

"We had a very committed and passionate group of folks," who were representative of the NCS membership, which includes doctors, nurses, advanced practice providers and pharmacists, she said.

Dr. Moheet, who led the project, said she told the group that it needed to come up with "some guidance on what neurocritical care should look like in this time of COVID, but that being said we cannot produce a document that will only be relevant to this period of time."

The position statement was published May 28 online in Neurocritical Care. "By necessity and also by intent, it wasn't as specific as you would be in a guideline-type approach," Dr. Moheet said.  But despite constrictions imposed by the short deadline, "it was an incredibly rewarding experience and the feedback had been incredibly positive."

Disclosures: Drs. Rubin, Tarolli, and Moheet had no relevant disclosures.

Link Up for More Information

Rubin MA, Bonnie RJ, Epstein L, et al. AAN position statement: The COVID-19 pandemic and the ethical duties of the neurologist. Neurology 2020; Epub 2020 May 29.

Tarolli CG, Biernot JM, Creigh PD, et al. Practicing in a pandemic. A clinician's guide to remote neurological care. Neurol Clin Pract 2020; Epub 2020 May 21.

Moheet AM, Shapshak AH, Brissie MA, et al. Neurocritical care resource utilization in pandemics: A statement by the Neurocritical Care Society. Neurocrit Care 2020; Epub 2020 May 28.