Abstract 1122‐000242: Effect of Covid‐19 on Stroke Treatment in Australia and New Zealand

Introduction : In general, compared to the rest of the world, the impact of Covid‐19 in the Australia and New Zealand regions has been minimal and this may be attributed to their early adoption of social distancing, stable governments, national wealth and geographic isolation. However, this research was designed to validate this perception amongst the stakeholders. Methods : This research included: primary and secondary research. First, secondary research about Covid‐19 and stroke treatment and Australia and New Zealand in particular was conducted and compiled in a Google spreadsheet. Research sources include Stroke Foundation, Brain Foundation, and World Meters. Data collected included the number of stroke and Covid‐19 cases in Australia and New Zealand as well as a list of stakeholders with their contact information. The stakeholders included neurosurgeons, hospitals, neurologists, interventionists, and vascular surgeons. A survey tool and an interview questions were prepared next. The survey request was emailed to stakeholders, requesting the stakeholders for an interview and survey response. Over the following weeks, survey results came in and interviews were conducted. Since only a small subset of stakeholders responded to the survey (6 survey responses and 4 interviews), this study must be considered to be primarily qualitative in nature. The interviews were conducted online using Zoom. After the interviews, I replayed the interviews and took notes of important details. Results : The survey showed that 83% of the doctors worked in a hospital that had a separate stroke unit and that they perform mechanical thrombectomies most often as a treatment for stroke. Most of the doctors suggested that the stroke numbers have not changed significantly since Covid‐19. Yet, 50% of the doctors said that there had been delays in admitting stroke patients. One third believed Covid‐19 may have made an impact on mortality of stroke patients. One of the interviewees revealed that the main barriers to access to stroke care are the time it takes to treat the patient, fewer locations that treat strokes or perform mechanical thrombectomy, and patients’ reluctance to go to the hospital during the pandemic. Another confirmed that she did think there had been delays due to Covid‐19. Conclusions : Counter to widespread perception, Covid‐19 pandemic DID worsen many barriers for stroke treatment in Australia and New Zealand. These regions have insufficient stroke centers and these are not spread out widely enough for accessibility. Stroke deaths have increased during the Covid‐19 pandemic. Barriers such as time, accessibility, and the patient’s fear of hospitals have affected stroke treatment during the pandemic. Several measures can alleviate the impact: stroke awareness is critical. Every hospital needs to have the ability to assess and treat stroke. Hospitals must run simulations to practice and prepare for different scenarios that they could encounter when dealing with stroke patients. In conclusion, stroke treatment has been affected by the Covid‐19 pandemic and it is critical to minimize and overcome these barriers as stroke is one of the leading causes of death in Australia and New Zealand.

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Abstract P293: Disparate Outcomes for Stroke Patients With Documented Substance Use Compared to Those Without Substance Use

Stroke ◽

10.1161/str.52.suppl_1.p293 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Leslie Corless ◽

Tamela L Stuchiner ◽

Cameron Garvin ◽

Alexandra C Lesko ◽

Elizabeth Baraban

Keyword(s):

Substance Use ◽

Patient Characteristics ◽

Stroke Care ◽

Stroke Patients ◽

Chi Square ◽

Stroke Treatment ◽

Discharge Disposition ◽

Healthcare Settings ◽

Medical Histories ◽

The Impact

Background: Few studies have shown the impact of substance use (SU) on treatment and outcomes of stroke patients. Research suggests stigma related to SU impacts patient experience in healthcare settings. In this study we assessed whether there were differences in patient characteristics and outcomes for stroke patients with SU compared to those with no substance use (NSU). Methods: Retrospective data from two Oregon hospitals included patients admitted with stroke diagnosis, 18 years or older, who discharged between October 2017 and May 2019. Patients with documented SU and specific SU type were compared to patients with NSU with regard to demographics, medical history, stroke subtypes, treatment, discharge disposition and length of stay (LOS). SU was defined as any documented abuse of alcohol (ETOH), methamphetamine (MA), cannabis, opiates, cocaine, benzodiazepines, and Methyl-enedioxy-methamphetamine (MDMA). Non parametric median tests and Pearson’s chi square tests were used. Results: Among 2,030 patients included in the analysis, 13.8% (n=280) were SU and 86.2% (n=1,750) were NSU. Patients with SU were significantly younger, median age (61 vs. 73, p <.001) and less were female (35.4% vs. 53.6%, p <0.001). Those with SU had lower prevalence of dyslipidemia (43.6% vs. 59.5%, p <0.001), AFIB (12.5% vs. 22.2%, p <0.001), and previous TIA (6.1% vs 10.8%, p=0.02), and more smoked (54.3% vs 13.3% p <0.001). More patients with SU arrived via transfer (38.4% vs 27.4%, p=.001). Fewer patients with SU expired or were discharged to hospice (8.9% vs 13.7%) and a greater percent left against medical advice (AMA) (3.2% vs 0.6%) (p<.001). When comparing specific SU types to NSU, all SU groups were younger, had similar medical histories and a greater proportion left AMA. Only MA users had differentiating stroke diagnoses with a higher percent of SAH (14.5% vs 5.6%) (p=.003) in addition to longer LOS (6 vs 4 days, p=.006). No differences were found in acute stroke treatment rates. Conclusion: Patients with SU were demographically different from the NSU population and did differentiate on some stroke care outcomes and processes, potentially indicating opportunities to address stigma around substance use to meet the needs of patients with both stroke and substance use.

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Abstract 3379: Benefiting the Community; The Impact of Joining a Regional Stroke Network

Stroke ◽

10.1161/str.43.suppl_1.a3379 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Nancy D Papesh ◽

James Gebel

Keyword(s):

Acute Stroke ◽

Care Center ◽

Tertiary Care ◽

Cleveland Clinic ◽

Stroke Care ◽

Stroke Patients ◽

Acute Stroke Care ◽

Stroke Treatment ◽

The Impact ◽

Iv Tpa

Background: The Cleveland Clinic Health System (CCHS) consists of a large tertiary care center and 10 regional hospitals. It is organized both clinically and administratively into multispecialty organ based Institutes rather than departments. The CCHS re-introduced a regional initiative to standardize stroke care in 2008. Medina Hospital is a 118-bed community hospital in rural North-eastern Ohio, where there is a high stroke burden and previously minimal IV tPA use. Medina Hospital joined the CCHS Stroke Network in November 2009. Hypothesis: We hypothesized that after joining the formally organized stroke CCHS system of care, the proportion of stroke patients receiving IV tPA and the timeliness of administration of acute thrombolytic therapy would both significantly increase. Methods: Data was analyzed from our prospective participation in the Get with the Guidelines-Stroke and the Ohio Coverdell Stroke Registries. Baseline data regarding quality, outcomes and stroke performance measures were reviewed. CCHS initially supported acute stroke care in early 2010 with a telemedicine cart and then introduced 24/7 emergency, on-site, CCHS neurologist, acute stroke call coverage in late 2010. Standardized CCHS stroke care pathways and order sets were also introduced in 2010. The proportion of stroke patients treated with IV tPA in 2010 and 2011 (post- joining CCHS) was compared to 2009 (2-sided Fisher’s exact test), and door-to-needle times were compared from 2010 to 2011 (unpaired t-test). Results: IV tPA treatment utilization increased from 0/69 patients (0%) in 2009 to 9/67 patients (11.8%) in 2010 [exact p=.0033] and 11/46 (19.3%) in the first 7 months of 2011 [exact p=.0001]. Door-to-needle times improved from a mean of 81.4 (95%CI 66.4 to 96.4) minutes in 2010 to 61.7 (95% CI 52.7 to 70.8) minutes in 2011 (p=.0158). Conclusions: Participation in an organized formal collaborative regional hospital stroke treatment network resulted in dramatic improvements from zero IV tPA utilization to greatly exceeding the national benchmark averages for both percentage treatment with IV tPA and door-to-needle time in a rural area where patients previously had minimal access to acute stroke expertise.

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Abstract 1122‐000240: The Effect of COVID‐19 on Stroke Treatment in Africa

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000240 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Anshul Chiranth

Keyword(s):

Mechanical Thrombectomy ◽

Effective Solution ◽

Neurological Damage ◽

Stroke Patients ◽

Stroke Treatment ◽

Time Period ◽

Receive Treatment ◽

Survey Responses ◽

The Impact ◽

To Receive

Introduction : One of the most common neurological sicknesses in healthcare today is acute ischemic stroke. Stroke is associated with symptoms such as neurological damage, and can only be effectively treated with a few methods. One such treatment is mechanical thrombectomy, and in this study, research was done on how the COVID‐19 pandemic affected stroke treatments (specifically MT) in Africa. Methods : Initially, data of 58 countries in Africa was compiled and put in a spreadsheet. Soon after, the countries that would be most desirable for the study were found. These “target countries” had the highest populations (as of 2020), number of COVID‐19 cases (as of October 2020) and number of incident stroke cases (in 2016) in Africa. This group consisted of countries such as Nigeria, Ethiopia, Egypt, and South Africa. Afterwards, neurologists, neurosurgeons, professors of neurology, and neurointerventionalists from the “target countries” were contacted via email. This email invited these individuals to hold an interview or fill out a survey regarding the impact COVID‐19 on stroke treatment in their hospital. After sending approximately 50 emails, 3 survey responses were received and 3 interviews were held. Results : Following the interviews and after reading survey responses, impairments to mechanical thrombectomy appeared to be the frontrunner of the barriers mentioned. Other important barriers mentioned were: time barriers, rehabilitation barriers, as well as fear of seeking treatment in places of high COVID‐19 concentration. The practice of MT is well‐ established in North America and Europe; however, it is still rather undeveloped in Africa. All doctors interviewed and surveyed indicated that the pandemic practically brought operations to a halt (only one doctor recorded two successful procedures during the pandemic). In Egypt specifically, there has been a lack of equipment and PPE. This is mainly because hospitals are dedicating staff and equipment to COVID‐infected patients. The secondary barriers also contributed to problems in hospitals. Due to more screenings and less staff during the pandemic, time for patients to receive treatment has increased. Rehabilitation for stroke patients has been impacted by a lack of prescriptions from pharmacies. Finally, in certain parts of Africa people are too afraid to visit hospitals due to the risk of possibly being infected with COVID‐19. The barriers imposed by the pandemic have made stroke treatment significantly more difficult. Conclusions : In conclusion, the COVID‐19 pandemic has negatively affected stroke treatment in certain areas of Africa. Doctors have faced several key barriers that has limited the effectiveness of stroke treatment during the time period. Based on doctor recommendations, improving in the practice of mechanical thrombectomy is the most effective solution to ensuring stroke treatment is proficient. This could be done through awareness, education, and better equipment.

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Abstract WP282: Protecting Stroke Patients from Aspiration and Mortality through a Bedside Aspiration Screen

Stroke ◽

10.1161/str.44.suppl_1.awp282 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Edith Matesic

Keyword(s):

Organizational Learning ◽

Aspiration Pneumonia ◽

The Body ◽

Kappa Statistics ◽

Evidence Based ◽

Stroke Patients ◽

Rater Reliability ◽

Stroke Treatment ◽

Risk Of Death ◽

The Impact

Background: Stroke patients initially experience dysphagia approximately 42-76% of the time, putting them at high risk for developing aspiration pneumonia and increasing the risk of death threefold in the first 30 days following onset of the condition. Interventions to identify risk for aspiration pneumonia are key to reducing mortality in hospitalized patients. However, no generally recognized bedside aspiration screen exists, and few have been rigorously tested. The Edith-Huhn-Matesic Bedside Aspiration Screen (EHMBAS) TM was developed as an evidence-based RN bedside aspiration screening protocol. Purpose: This study analyzed the sensitivity and inter-rater reliability of EHMBAS TM , assessed the efficacy of training methods, evaluated patient feedback, and looked at the impact of organizational learning. Methods: RNs were trained to apply the EHMBAS TM . An evaluation study assessed the sensitivity, specificity and predictability of the screen to detect aspiration in the stroke population study group. Cohen’s Kappa statistics was applied to test inter-rater reliability. Pre- and post-implementation Likert surveys examined patient and staff satisfaction on the education plan and screening process, respectively. Lastly, an analysis of organizational learning examined whether changes enhanced adherence to screening requirements. Results: Results showed that the EHMBAS TM demonstrated strong validity (94% sensitivity) and high inter-rater reliability (Kappa = .92, p<.001). Pre- and post- staff training survey results demonstrated a significant positive change in knowledge gained, feelings of preparedness, and satisfaction with teaching methods. Further, 92.3% of patients surveyed had positive screening experiences. The hospital received Silver recognition from The American Heart Association for following stroke treatment guidelines 85% of the time for at least 12 months, demonstrating the positive impact of the protocol on organizational change. Conclusions: This study contributes to the body of work aimed at establishing a reliable evidence-based, bedside aspiration screen. Patient safety is enhanced, because screen results help determine when patients can safely receive medication and nutrition by mouth.

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Barriers to Providing Prehospital Care to Ischemic Stroke Patients: Predictors and Impact on Care

Prehospital and Disaster Medicine ◽

10.1017/s1049023x18000766 ◽

2018 ◽

Vol 33 (5) ◽

pp. 501-507 ◽

Cited By ~ 1

Author(s):

Timmy Li ◽

Jeremy T. Cushman ◽

Manish N. Shah ◽

Adam G. Kelly ◽

David Q. Rich ◽

...

Keyword(s):

Ischemic Stroke ◽

Barriers To Care ◽

Prehospital Care ◽

Heart Association ◽

Living Alone ◽

Stroke Patients ◽

Publication Type ◽

Stroke Treatment ◽

Significant Difference ◽

The Impact

AbstractIntroductionIschemic stroke treatment is time-sensitive, and barriers to providing prehospital care encountered by Emergency Medical Services (EMS) providers have been under-studied.Hypothesis/ProblemThis study described barriers to providing prehospital care, identified predictors of these barriers, and assessed the impact of these barriers on EMS on-scene time and administration of tissue plasminogen activator (tPA) in the emergency department (ED).MethodsA retrospective cohort study was performed using the Get With The Guidelines-Stroke (GWTG-S; American Heart Association [AHA]; Dallas, Texas USA) registry at two hospitals to identify ischemic stroke patients arriving by EMS. Variables were abstracted from prehospital and hospital medical records and merged with registry data. Barriers to care were grouped into themes. Logistic regression was used to identify predictors of barriers to care, and bi-variate tests were used to assess differences in EMS on-scene time and the proportion of patients receiving tPA between patients with and without barriers.ResultsBarriers to providing prehospital care were documented for 15.5% of patients: 29.6% related to access, 26.7% communication, 23.0% extrication and transportation, 20.0% refusal, and 14.1% assessment/management. Non-white and non-black race (OR: 3.69; 95% CI, 1.63-8.36) and living alone (OR: 1.53; 95% CI, 1.05-2.23) were associated with greater odds of barriers to providing care. The EMS on-scene time was ≥15 minutes for 70.4% of patients who had a barrier to care, compared with 49.0% of patients who did not (P<.001). There was no significant difference in the proportion of patients who were administered tPA between those with and without barriers to care (14.1% vs 19.2%; P=.159).ConclusionsBarriers to providing prehospital care were documented for a sizable proportion of ischemic stroke patients, with the majority related to patient access and communication, and occurred more frequently among non-white and non-black patients and those living alone. Although EMS on-scene time was longer for patients with barriers to care, the proportion of patients receiving tPA in the ED did not differ.LiT, CushmanJT, ShahMN, KellyAG, RichDQ, JonesCMC. Barriers to providing prehospital care to ischemic stroke patients: predictors and impact on care. Prehosp Disaster Med.2018;33(5):501–507.

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Abstract TMP86: Telestroke Improves Guideline-Based Comprehensive Stroke Care: The TELECAST Trial

Stroke ◽

10.1161/str.51.suppl_1.tmp86 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Christopher D Streib ◽

Oladi Bentho ◽

Kathryn Bard ◽

Eric Jaton ◽

Sarah Engkjer ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Composite Score ◽

Stroke Recurrence ◽

Acute Stroke Care ◽

Specialist Service ◽

Stroke Treatment ◽

Chi Squared ◽

Secondary Outcomes ◽

The Impact

Introduction: Limited access to stroke specialist expertise produces disparities in inpatient stroke treatment. The impact of telestroke on the remote delivery of guideline-based inpatient stroke care is yet to be comprehensively studied. The TELECAST trial (NCT03672890) prospectively examined the impact of a 24-7 telestroke specialist service dedicated to inpatient acute stroke care spanning admission to discharge. Methods: AHA stroke guidelines were used to derive outcome metrics in the following acute stroke inpatient care categories: diagnostic stroke evaluation (DSE), secondary stroke prevention (SSP), health screening and evaluation (HSE), and stroke education (SE). Adherence to AHA guidelines for stroke inpatients pre-telestroke (July 1, 2016-June 30, 2018) and post-telestroke intervention (July 1, 2018-June 30, 2019) were studied. The primary outcome was a composite score of all guideline-based stroke care. Secondary outcomes consisted of subcategory composite scores in DSE, SSP, HSE, and SE. Chi-squared tests were utilized to assess primary and secondary outcomes. Statistical analysis was performed using STATA 15.0. Results: Following institution of a comprehensive inpatient telestroke service, overall adherence to guideline-based metrics improved (composite score: 85% vs 94%, p<0.01) as did adherence to DSE guidelines (subgroup score: 90 vs 95%, p<0.01). SSP, HSE, and SE subgroup scores were not significantly different. See Table 1. Conclusion: The implementation of a 24-7 inpatient telestroke service improved adherence to AHA guidelines for inpatient acute stroke care. Dedicated inpatient telestroke specialist coverage may improve inpatient stroke care and reduce stroke recurrence in hospitals without access to stroke specialists.

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The stroke mothership model survived during COVID-19 era: an observational single-center study in Emilia-Romagna, Italy

Neurological Sciences ◽

10.1007/s10072-020-04754-2 ◽

2020 ◽

Vol 41 (12) ◽

pp. 3395-3399

Author(s):

Andrea Zini ◽

Michele Romoli ◽

Mauro Gentile ◽

Ludovica Migliaccio ◽

Cosimo Picoco ◽

...

Keyword(s):

Ischemic Stroke ◽

Treatment Time ◽

Combined Treatment ◽

Temporal Trends ◽

Stroke Care ◽

Minor Stroke ◽

Care Organization ◽

Stroke Patients ◽

Stroke Center ◽

The Impact

Abstract Introduction A reduction of the hospitalization and reperfusion treatments was reported during COVID-19 pandemic. However, high variability in results emerged, potentially due to logistic paradigms adopted. Here, we analyze stroke code admissions, hospitalizations, and stroke belt performance for ischemic stroke patients in the metropolitan Bologna region, comparing temporal trends between 2019 and 2020 to define the impact of COVID-19 on the stroke network. Methods This retrospective observational study included all people admitted at the Bologna Metropolitan Stroke Center in timeframes 1 March 2019–30 April 2019 (cohort-2019) and 1 March 2020–30 April 2020 (cohort-2020). Diagnosis, treatment strategy, and timing were compared between the two cohorts to define temporal trends. Results Overall, 283 patients were admitted to the Stroke Center, with no differences in demographic factors between cohort-2019 and cohort-2020. In cohort-2020, transient ischemic attack (TIA) was significantly less prevalent than 2019 (6.9% vs 14.4%, p = .04). Among 216 ischemic stroke patients, moderate-to-severe stroke was more represented in cohort-2020 (17.8% vs 6.2%, p = .027). Similar proportions of patients underwent reperfusion (45.9% in 2019 vs 53.4% in 2020), although a slight increase in combined treatment was detected (14.4% vs 25.4%, p = .05). Door-to-scan timing was significantly prolonged in 2020 compared with 2019 (28.4 ± 12.6 vs 36.7 ± 14.6, p = .03), although overall timing from stroke to treatment was preserved. Conclusion During COVID-19 pandemic, TIA and minor stroke consistently reduced compared to the same timeframe in 2019. Longer stroke-to-call and door-to-scan times, attributable to change in citizen behavior and screening at hospital arrival, did not impact on stroke-to-treatment time. Mothership model might have minimized the effects of the pandemic on the stroke care organization.

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Role of the Neurosurgeon in Acute Ischemic Stroke Treatment From Triage to Intensive Care Unit

Neurosurgery ◽

10.1093/neuros/nyz013 ◽

2019 ◽

Vol 85 (suppl_1) ◽

pp. S47-S51

Author(s):

Kimberly P Kicielinski ◽

Christopher S Ogilvy

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Stroke Care ◽

Stroke Patients ◽

Acute Setting ◽

Stroke Treatment

Abstract As ischemic stroke care advances with more patients eligible for mechanical thrombectomy, so too does the role of the neurosurgeon in these patients. Neurosurgeons are an important member of the team from triage through the intensive care unit. This paper explores current research and insights on the contributions of neurosurgeons in care of acute ischemic stroke patients in the acute setting.

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Abstract TP350: Protecting Stroke Patients from Aspiration and Mortality through a Bedside Aspiration Screen

Stroke ◽

10.1161/str.44.suppl_1.atp350 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Edith Matesic

Keyword(s):

Organizational Learning ◽

Aspiration Pneumonia ◽

The Body ◽

Kappa Statistics ◽

Evidence Based ◽

Stroke Patients ◽

Rater Reliability ◽

Stroke Treatment ◽

Risk Of Death ◽

The Impact

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Abstract P651: Should I Stay or Go: Seeking Stroke Care During Covid-19

Stroke ◽

10.1161/str.52.suppl_1.p651 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Kathyrn J Libby ◽

Linda Couts ◽

Paige Schoenheit-Scott ◽

Lindsay L Olson-Mack ◽

Amelia Kenner Brininger ◽

...

Keyword(s):

San Diego ◽

Arrival Time ◽

Stroke Care ◽

Time Frame ◽

San Diego County ◽

Stroke Patients ◽

Discharge Data ◽

Hospital Arrival ◽

The Impact ◽

At Home

Introduction: On March 16, 2020 San Diego County implemented a stay at home order in response to COVID-19 pandemic; followed by the state of California instituting a shelter in place order. Locally, San Diego County’s stroke receiving centers (SRC) determined a 30% drop in stroke code activations between March-April 2020 compared to the same time in 2019 indicating a possible delay in seeking care. Utilizing discharge data, we sought to understand the impact of the stay at home order on the timeliness of seeking care. Hypothesis: We hypothesized an increase in last known normal (LKN) to hospital arrival time and a decrease in alteplase (tPA) and endovascular therapy (EVT) treatment rates between March 16-June 30 2020 compared to March 16-June 30 2019. Methods: AIS patients presenting to one of 16 SRC in San Diego County between March 16-June 30 in 2019 and 2020, discharged from the hospital or treated in the ED and transferred to another facility were included. Patients arriving as transfers from another facility were excluded. Results: In 2019, of 1,342 AIS cases LKN time was recorded for 85.6% of cases; of 1,092 cases in 2020 86.4% of cases had a LKN. Average LKN to arrival was 20.5 hours in 2019 and 32.4 hours in 2020 (p = .001, 95% CI [4.79, 18.93]). In 2019, 209 (15.6%) received tPA and 91 (6.8%) had EVT. In 2020, 144 (13.2%) received tPA and 75 (6.9%) had EVT. Odds that a case in 2019 received tPA was 1.21 times that of cases in 2020 (p=.09). Odds that a case in 2019 had EVT was .99 times that of cases in 2020 (p=.93). Conclusion: Ischemic stroke patients arriving between March 16-June 30, 2020 had a longer LKN to arrival time compared to the same time frame in 2019. The longer time to arrival may have been due to patients waiting longer to seek care, as anecdotal information from patients eluded to. The odds of receiving tPA or EVT treatment in 2020 compared to 2019 were not statistically significant. This may be due to patients experiencing acute symptoms accessing healthcare at the same rate in 2020 as 2019. Analysis of percent of patients arriving within 4 hours of LKN and average NIHSS are important next steps to determine this. Regardless, during a time of community crisis, it is important to broadcast community messaging focusing on the importance of seeking emergency care for stroke-like symptoms.

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