Abstract WP273: Evolution of a U.S. County System for Acute Comprehensive Stroke Care

Introduction: In an effort to maximize provision of acute stroke therapies, the Emergency Medical Services (EMS) in Orange County, CA (6 th most populous U.S. county) established a system of care whereby patients with suspected acute stroke are taken to hub sites with endovascular treatment (EVT) capability or to spoke hospitals. Patients at spokes with acute ischemic stroke (AIS) and suspected large vessel occlusion (LVO) are transferred by EMS to hubs. Here we examined the relationship between stroke features, hospital transfers, and mortality; and their change over time. Methods: All patients during 2013-2015 were included for whom 911 was called within 7 hours of onset, and EMS personnel declared “acute stroke" at end of initial evaluation. Results: A total of 6,188 patients (mean age 72) had suspected stroke, of which 54.9% were AIS and 19.4% hemorrhagic stroke. Across all patients, transfer rates into hub sites increased over time (OR 1.12 per 3-months, p<0.0001) and differed by diagnosis (p<0.0001), with transfer in 12.0% of hemorrhages (n=122) but only 3.5% of AIS (n=101). Among patients with AIS only, transfer rates into a hub site increased over time (OR 1.08, p<0.0001), spiking mid-2015. Acute reperfusion therapy was given to 28.3% (20.9% IV tPA only, 3.6% IA therapy only, 3.8% IV tPA+IA), but its usage was unrelated to transfer status, and only 11% of all transferred AIS patients received EVT. Across all patients, mortality during acute hospitalization was 8.2% and did not differ by transfer status, but did differ by diagnosis (p<0.0001): 23.6% of hemorrhages vs. 5.4% of AIS. Over time, mortality decreased only among patients with AIS (OR 0.95, p=0.03). Conclusions: There were several favorable features of this acute stroke care system, including that 28.3% of AIS patients received reperfusion therapy and that mortality decreased over time. However, while transfer to EVT-ready sites increased, rates of IA therapy were low. Continued efforts to optimize acute stroke systems of care should be tailored toward increasing EVT by early recognition of LVO and timely triage to hub facilities.

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Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions

Neurology ◽

10.1212/wnl.0000000000012781 ◽

2021 ◽

Vol 97 (20 Supplement 2) ◽

pp. S6-S16

Author(s):

Vasu Saini ◽

Luis Guada ◽

Dileep R. Yavagal

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Randomized Clinical Trials ◽

Time Window ◽

Systems Of Care ◽

Stroke Care ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Global Epidemiology

Purpose of the ReviewTo provide an up-to-date review of the incidence of stroke and large vessel occlusion (LVO) around the globe, as well as the eligibility and access to IV thrombolysis (IVT) and mechanical thrombectomy (MT) worldwide.Recent FindingsRandomized clinical trials have established MT with or without IVT as the usual care for patients with LVO stroke for up to 24 hours from symptom onset. Eligibility for IVT has extended beyond 4.5 hours based on permissible imaging criteria. With these advances in the last 5 years, there has been a notable increase in the population of patients eligible for acute stroke interventions. However, access to acute stroke care and utilization of MT or IVT is lagging in these patients.SummaryStroke is the second leading cause of both disability and death worldwide, with the highest burden of the disease shared by low- and middle-income countries. In 2016, there were 13.7 million new incident strokes globally; ≈87% of these were ischemic strokes and by conservative estimation about 10%–20% of these account for LVO. Fewer than 5% of patients with acute ischemic stroke received IVT globally in the eligible therapeutic time window and fewer than 100,000 MTs were performed worldwide in 2016. This highlights the large gap among eligible patients and the low utilization rates of these advances across the globe. Multiple global initiatives are underway to investigate interventions to improve systems of care and bridge this gap.

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Abstract TP244: A Successful Statewide Initiative to Designate Hospital as Remote Treatment Stroke Centers

Stroke ◽

10.1161/str.47.suppl_1.tp244 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Shelley Nichols ◽

Debbie Camp ◽

McCord Smith ◽

Chris Threlkeld ◽

James Lugtu ◽

...

Keyword(s):

Acute Stroke ◽

Systems Of Care ◽

Standard Of Care ◽

Stroke Care ◽

Acute Stroke Care ◽

Stroke Registry ◽

Remote Treatment ◽

Stroke Systems Of Care ◽

Stroke Center ◽

Iv Tpa

Background: As treatment of acute ischemic stroke (AIS) with IV tPA has become standard of care, smaller hospitals with limited resources have struggled to conform to consensus guidelines. To fill this practice gap, stroke systems of care were developed to support smaller, often rural, hospitals in providing standard stroke care to the patients they serve. Methods: As a result of legislative support from the Coverdell-Murphy Act, the Georgia Coverdell Acute Stroke Registry (GCASR) in collaboration with the Georgia Office of EMS (GA OEMS), the Georgia Hospital Association (GHA), and other state partners, developed a method for designating hospitals as Remote Treatment Stroke Centers (RTSC). The primary focus of performance improvement was treatment with IV tPA in eligible patients. Data collection and process change were used to improve the following quality indicators: percentage of eligible AIS patients treated with IV tPA and number of stroke alert notifications. Hospitals were required to partner with an accredited stroke center and use telemedicine to support the decision for administering IV tPA. GA OEMS was charged with reviewing and surveying individual hospitals applying for RTSC status. The GCASR served as the central repository to facilitate data sharing and benchmarking across hospitals. An inter-hospital transfer tool was created for EMS providers, adopted by GA OEMS, and disseminated throughout the state to guide management of patients receiving IV tPA who required transfer from a RTSC to an accredited stroke center. Results: Starting in 2014, pertinent information was distributed and assistance provided to the 24 RTSC eligible GCASR hospitals. At present, 4 hospitals have achieved designation; 1 hospital is pending survey; and several are considering application. In 2012-13 the now 4 RTSC hospitals gave IV tPA to 8 patients. In 2014-15 as these hospitals sought and achieved designation, this number rose to 24. During this same period, stroke alerts increased from 76 to 308. Conclusion: A state-based public health stroke initiative is effective in facilitating the designation of RTSC and thereby improving the delivery of acute stroke care in underserved areas.

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Abstract 88: No Disparities in Acute Stroke Treatment in Kaiser Stroke EXPRESS Program

Stroke ◽

10.1161/str.48.suppl_1.88 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Jeffrey G Klingman ◽

Meghan Hatfield ◽

Lauren Klingman ◽

Benjamin Wilson ◽

Mai N Nguyen-Huynh ◽

...

Keyword(s):

Multivariate Analysis ◽

Acute Stroke ◽

Healthcare System ◽

Age Groups ◽

Stroke Care ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Stroke Treatment ◽

Acute Stroke Treatment ◽

Iv Tpa

Background: Prior published studies reported disparities in timely treatment with tPA for stroke patients who were older, African American or female. In 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke care work flow for the entire region, which included immediate evaluation by a stroke neurologist via video, an expedited IV tPA treatment program, rapid CT angiographic investigation, and expedited transfer of appropriate patients with large vessel occlusion (LVO) for endovascular stroke treatment (EST). We sought to evaluate whether disparities exist in acute stroke treatment within the redesigned process. Methods: KPNC is an integrated health care system with 21 certified stroke centers serving 3.9+ millions members. All centers implemented the new program by January 2016. Using clinical data from 1/1/16 to 7/10/16, we evaluated the frequency of IV tPA administration by gender, race, and age groups after implementation of the new process. We performed multivariate analysis with age, gender, race-ethnicity, Kaiser membership, mode of ED arrival (by ambulance vs. private transportation) to assess for any disparities in achieving DTN time. Results: Post implementation, we found no significant differences in the rates of IV t-pa administration in eligible patients based on race, gender, age category (<40 years, 40-64, 65-79, ≥80), Kaiser membership, or mode of ED arrival. In multivariate analysis for factors influencing DTN time, no differences were seen for DTN time <60 minutes. Age (OR=1.02, 95% CI 1.00-1.03, p=0.03) and arrival by ambulance (OR=5.01, 95% CI 3.01-8.60, p<0.001) were associated with a faster DTN time of <30 minutes. Conclusions: Thus far, we have found no disparities in the use of IV tPA or DTN time for a large integrated healthcare system after implementation of the Stroke EXPRESS program. A consistent standardized approach to acute stroke care may help to reduce disparities on the basis of race, gender, age, or even membership in healthcare system.

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Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

Cerebrovascular Diseases ◽

10.1159/000516309 ◽

2021 ◽

pp. 1-9

Author(s):

Anna Ramos-Pachón ◽

Álvaro García-Tornel ◽

Mònica Millán ◽

Marc Ribó ◽

Sergi Amaro ◽

...

Keyword(s):

Acute Stroke ◽

Functional Outcome ◽

Stroke Care ◽

Care Quality ◽

Point Of View ◽

Stroke Severity ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Prehospital Delays ◽

The Impact

Introduction: The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system’s bottlenecks from a territorial point of view. Methods: Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15–May 2, 2020) and an immediate prepandemic period (January 26–March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days. Results: Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = −0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05–2.4], p 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4–0.9], p 0.015) during the pandemic period. Conclusion: During the COVID-19 pandemic, Catalonia’s stroke system’s weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system’s analysis is crucial to allocate resources appropriately.

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Implementation of a provincial acute stroke pathway and its impact on access to advanced stroke care in Saskatchewan

BMJ Open Quality ◽

10.1136/bmjoq-2020-001214 ◽

2021 ◽

Vol 10 (3) ◽

pp. e001214

Author(s):

Jessalyn K Holodinsky ◽

Vivian N Onaemo ◽

Ruth Whelan ◽

Gary Hunter ◽

Brett R Graham ◽

...

Keyword(s):

Acute Stroke ◽

Control Charts ◽

Systems Of Care ◽

Stroke Care ◽

High Variability ◽

Weighted Mean ◽

Improvement Project ◽

Outcome Severity ◽

The Mean ◽

Over Time

BackgroundFor ischaemic stroke, outcome severity is heavily time dependent. Systems of care need to be in place to ensure that patients with stroke are treated quickly and appropriately across entire health regions. Prior to this study, the province of Saskatchewan, Canada did not have a provincial stroke strategy in place.MethodsA quality improvement project was undertaken to create and evaluate a provincial stroke strategy. The Saskatchewan Acute Stroke Pathway was created using a multidisciplinary team of experts, piloted at five stroke centres and then implemented provincially. The number of stroke alerts, door-to-imaging, door-to-needle, door-to-groin puncture times and treatment rates were collected at all centres. Improvements over time were analysed using run charts and individuals control charts.ResultsThe number of stroke alerts province-wide trended upwards in the last 6 months of the study. There were no clear trends or shifts in the proportion of stroke alerts treated with alteplase or endovascular therapy. Across the province, the weighted mean door-to-imaging time decreased from 21 to 15 min, the weighted mean door-to-needle time decreased from 62 to 47 min and the mean door-to-groin puncture time decreased from 83 to 70 min. There was high variability in the degree of improvement from centre to centre.ConclusionsThe implementation of a province wide acute stroke pathway has led to improvement in stroke care on a provincial basis. Further work addressing intercentre variability is ongoing.

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Epidemiological Surveillance of the Impact of the COVID-19 Pandemic on Stroke Care Using Artificial Intelligence

Stroke ◽

10.1161/strokeaha.120.031960 ◽

2021 ◽

Author(s):

Raul G. Nogueira ◽

Jason M. Davies ◽

Rishi Gupta ◽

Ameer E. Hassan ◽

Thomas Devlin ◽

...

Keyword(s):

Artificial Intelligence ◽

Acute Stroke ◽

Systems Of Care ◽

Ct Perfusion ◽

Stroke Care ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Number Of Patients ◽

The Impact

Background and Purpose: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform. Methods: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (−22.8%; 1.39–1.07 patients/day per hospital, P <0.001) and CT perfusion (−26.1%; 0.50–0.37 patients/day per hospital, P <0.001) as well as in the incidence of large vessel occlusion (−17.1%; 0.15–0.13 patients/day per hospital, P <0.001) and severe strokes on CT perfusion (−16.7%; 0.12–0.10 patients/day per hospital, P <0.005). The sampled cohort showed similar declines in the rates of large vessel occlusions versus thrombectomy (18.8% versus 19.5%, P =0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P =0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

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Abstract P278: Improving Stroke Systems of Care in Nebraska

Stroke ◽

10.1161/str.52.suppl_1.p278 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Marco A Gonzalez Castellon ◽

James A BOBENHOUSE ◽

David Franco ◽

Beth L Malina ◽

Mindy Cook ◽

...

Keyword(s):

Acute Stroke ◽

Rural Areas ◽

Systems Of Care ◽

Stroke Care ◽

The United States ◽

Advisory Council ◽

Management Tool ◽

Acute Stroke Care ◽

Stroke Systems Of Care ◽

Get With The Guidelines

Introduction: Stroke is a leading cause of disability in the United States. Disparities in stroke care between metropolitan and rural areas have long been recognized. Access to high-level timely stroke expertise improves outcomes, but in rural areas this is limited by sparse availability of stroke specialists. Since 2006, the Nebraska Stroke Advisory Council, a statewide coalition of stroke experts and stakeholders, began implementing strategies to improve stroke care. In 2016, the Nebraska legislature approved Bill 722, mandating the development of stroke systems of care. In 2018, the AHA and the Helmsley Charitable Trust launched Mission: Lifeline Stroke, a coordinated 3-year program to enhance stroke systems of care in Nebraska. Purpose: To assess advances in acute stroke care in Nebraska after implementing a statewide stroke system of care focused on rural areas. Methods: The Council joined with AHA to expand public and professional stroke education offerings including workshops, conferences, and EMS trainings. They developed state specific treatment guidelines and created educational reinforcement materials. From 2016 to 2019 Get With The Guidelines® (GWTG) was used for stroke data collection and quality improvement in Nebraska. GWTG participating hospitals expanded from 7 to 40 sites (21 critical access). Results: The number of stroke and Transient Ischemic Attack cases reported more than doubled from 2016 to 2019 (1848 to 3987 cases). The door to CT initiated in < 25 minutes improved by 13%. IV alteplase therapy gains included: utilization increased from 8.7% to 11.3%; median door to drug time reduced from 54 to 42 minutes; and door to drug within 60 minutes of arrival increased from 67% to 80.4%.The number of alteplase monitored patients doubled and mechanical thrombectomy cases increased from 77 in 2017 to 138 in 2019. Conclusion: Implementation of strategies in Nebraska, with an emphasis on rural critical access hospitals, led to significant improvements in acute stroke care. This work represents the authors’ independent analysis of local or multicenter data gathered using the AHA Get With The Guidelines® Patient Management Tool but is not an analysis of the national GWTG dataset and does not represent findings from the AHA GWTG National Program

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Ten Years of Improving Acute Stroke Management in a Metropolitan Area: A Population-Based Quantification of Quality Indicators

European Neurology ◽

10.1159/000518428 ◽

2021 ◽

pp. 1-11

Author(s):

Anna Alegiani ◽

Michael Rosenkranz ◽

Leonie Schmitz ◽

Susanne Lezius ◽

Günter Seidel ◽

...

Keyword(s):

Acute Stroke ◽

Quality Indicators ◽

Metropolitan Area ◽

Stroke Care ◽

Care Quality ◽

Acute Stroke Care ◽

Stroke Units ◽

Stroke Treatment ◽

Acute Stroke Treatment ◽

Over Time

Background and Purpose: Rapid access to acute stroke treatment improves clinical outcomes in patients with ischemic stroke. We aimed to shorten the time to admission and to acute stroke treatment for patients with acute stroke in the Hamburg metropolitan area by collaborative multilevel measures involving all hospitals with stroke units, the Emergency Medical Services (EMS), and health-care authorities. Methods: In 2007, an area-wide stroke care quality project was initiated. The project included mandatory admission of all stroke patients in Hamburg exclusively to hospitals with stroke units, harmonized acute treatment algorithms among all hospitals, repeated training of the EMS staff, a multimedia educational campaign, and a mandatory stroke care quality monitoring system based on structured data assessment and quality indicators for procedural measures. We analyzed data of all patients with acute stroke who received inhospital treatment in the city of Hamburg during the evaluation period from the quality assurance database data and evaluated trends of key quality indicators over time. Results: From 2007 to 2016, a total of 83,395 patients with acute stroke were registered. During this period, the proportion of patients admitted within ≤3 h from symptom onset increased over time from 27.8% in 2007 to 35.2% in 2016 (p < 0.001). The proportion of patients who received rapid thrombolysis (within ≤30 min after admission) increased from 7.7 to 54.1% (p < 0.001). Conclusions: Collaborative stroke care quality projects are suitable and effective to improve acute stroke care.

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Abstract 184: Drivers of Costs Associated With Reperfusion Therapy in Acute Stroke: The IMS III Trial

Stroke ◽

10.1161/str.45.suppl_1.184 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Kit N Simpson ◽

Annie N Simpson ◽

Patrick D Mauldin ◽

Michael D Hill ◽

Sharon D Yeatts ◽

...

Keyword(s):

Acute Stroke ◽

General Anesthesia ◽

Endovascular Therapy ◽

Stroke Care ◽

Reperfusion Therapy ◽

Hospital Charges ◽

Acute Stroke Care ◽

Initial Hospital ◽

Initial Hospitalization ◽

Mean Cost

Importance: The annual costs of stroke to the nation have been estimated to be over $38 billion, with nearly $22 billion attributed to direct medical costs. Objective: To understand cost drivers during the initial hospitalization for acute ischemic stroke subjects in the IMS III Trial. Design, Setting and Participants: Prospective cost analysis of subjects from U.S. centers treated with IV t-PA alone or IV t-PA followed by endovascular therapy in the IMS III trial. Cost of initial hospital admission was estimated from the actual hospital charges on UB04 billing forms provided by the treating hospitals. Cost profiles of the IMS III treatment groups were compared to profiles of a sample of US patients from the HCUP National Inpatient Sample (NIS) for 2010. Interventions: IV t-PA alone as compared to IV t-PA followed by endovascular therapy. Main Outcome Measure: Costs of hospitalization for acute stroke subjects. Results: The adjusted cost of a stroke admission in the study was $35,130 for subjects treated with endovascular therapy following IV t-PA and $25,630 for subjects treated with IV t-PA alone (p<0.0001). The higher cost in the endovascular therapy following IV t-PA treatment arm was largely explained by the costs of the devices. Significant factors related to costs included treatment group (higher costs with endovascular therapy), baseline NIH Stroke Scale (higher costs with higher severity), time from stroke onset to IV t-PA (lower costs with earlier treatment), age (higher costs with older age), stroke location (higher cost with right hemispheric location) and comorbid diabetes (higher costs with diabetes). The mean cost for subjects who had routine use of general anesthesia as part of endovascular therapy was $46,444 as compared to $30,350 for those who did not have general anesthesia. The costs of embolectomy for IMS III subjects and patients from the NIS cohort exceeded the Medicare DRG payment in more than 75% of hospitalized patients. Conclusions and Relevance: Changing the processes of acute stroke care, such as minimizing the time to start of IV t-PA and decreasing the use of routine general anesthesia, may improve the cost-effectiveness of medical and endovascular therapy for acute stroke.

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Abstract TP259: Accuracy of EMS Identification of Acute Strokes Eligible for tPA Treatment in Kaiser Stroke EXPRESS Program

Stroke ◽

10.1161/str.48.suppl_1.tp259 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Jeffrey G Klingman ◽

Sunil Bhopale ◽

Meghan Hatfield ◽

Benjamin Wilson ◽

Lauren Klingman ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Work Flow ◽

Initial Assessment ◽

Stroke Therapy ◽

Acute Stroke Care ◽

Kaiser Permanente ◽

Vessel Occlusion ◽

Stroke Mimic

Background: Field-based diversion for potential stroke patients who may qualify for endovascular stroke therapy (EST) has been proposed more widely in 2015. In 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke care work flow for all its 21 stroke centers, which included rapid evaluation of all stroke alerts by a stroke neurologist via teleneurology. We investigated the accuracy of EMS-activated stroke alerts. Methods: From 1/1/16 to 7/10/16, all acute strokes presenting to an ED between 7 AM and midnight were assessed upon arrival by a teleneurologist. We reviewed all telestroke cases to determine the frequency of tPA given, cancelled stroke alerts, and the reasons for not treating with IV t-PA, particularly among ambulance arrivals. Multivariate logistic regression was used to assess age, gender, race, Kaiser membership, and mode of ED arrival as predictors of stroke alert cancellation. Results: There were 2192 stroke alerts activated. Of these, 1332 (60.7%) arrived by EMS and 860 (39.2%) by non-EMS transport. Of patients arriving by EMS, 651 (48.9%) were cancelled and deemed ineligible for IV t-PA. Most common reasons for cancellation were: last time known well (LTKW) out of range (23%), stroke mimic (33%), symptom resolution (19%), new data regarding goals of care (2%), and other (22.5%). The remaining 681 (51.1%) ambulance arrivals were potential candidates for IV tPA. Subsequently, 334 (50.4%) of them received tPA. Reasons for tPA not given included subsequent resolution of symptoms, concerning CT findings (such as bleed), INR>1.7 in patients on warfarin, further information clarifying time of onset. Among those who arrived by EMS and received IV t-PA, all had CTA and 103 (30.8%) were found to have a large vessel occlusion and 74 (71.8%) underwent EST. In multivariate analysis for all cancelled stroke alerts, arrival by non-EMS transport (OR=1.74, 95% CI 1.44-2.10, p<0.001) was more likely to be cancelled. Conclusions: Close to half of EMS-activated stroke alerts were cancelled upon initial assessment. Only 5% of patients initially identified by EMS as having a potential acute stroke ultimately underwent EST. Better determination of LTKW and stroke symptoms would improve the accuracy of EMS-initiated stroke alerts.

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