In March 2020, at the onset of the coronavirus disease 2019 (COVID-19) pandemic in the United States, the Southern California Extracorporeal Membrane Oxygenation (ECMO) Consortium was formed. The consortium included physicians and coordinators from the four ECMO centers in San Diego County. Guidelines were created to ensure that ECMO was delivered equitably and in a resource effective manner across the county during the pandemic. A biomedical ethicist reviewed the guidelines to ensure ECMO utilization would provide maximal community benefit of this limited resource. The San Diego County Health and Human Services Agency further incorporated the guidelines into its plans for the allocation of scarce resources. The consortium held weekly video conferences to review countywide ECMO capacity (including census and staffing), share data, and discuss clinical practices and difficult cases. Equipment exchanges between ECMO centers maximized regional capacity. From March 1 to November 30, 2020, consortium participants placed 97 patients on ECMO. No eligible patients were denied ECMO due to lack of resources or capacity. The Southern California ECMO Consortium may serve as a model for other communities seeking to optimize ECMO resources during the current COVID-19 or future pandemics.

Introduction: In the early months of the COVID-19 pandemic, decreased numbers of stroke code activations were reported nationwide. In San Diego County, a diverse region that borders Mexico with over 4500 square miles and population 3.3 million, trends in COVID-19 cases varied geographically. We saw an overall decrease in stroke cases across our systems and aimed to better understand if high COVID infection rates in subregions affected stroke code activations. Methods: Stroke code activation data from 15 Stroke Receiving Centers were matched with COVID-19 case rates by patient home zip code. Patients arriving via emergency medical services (EMS) or private transportation were included. Patients with home zip codes outside of San Diego County were excluded. Data represented the cumulative rate of stroke codes and COVID-19 cases per 100,000 population per zip code for the period of March 1 through June 30, 2020. Results: We counted 1,927 stroke code activations across 106 zip codes in San Diego County. The average stroke code activation rate was 58.4 per 100,000 (range: 0-310.6) The median stroke code activation rate was 55.95 (IQR=32.1-73.1) per 100,000 population. The median COVID rate per zip code was 244.9 (IQR=177-448.4) per 100,000 population. There were 958 (49.7%) non-stroke diagnoses, 576 (29.9%) AIS, 272 (14.1%) TIA, 104 (5.4%) ICH and 17 (.9%) SAH. We did not identify a correlation between stroke code activation rates and COVID rates across zip codes (r=.17, p=.09, 95% CI(-.02, .35)). Conclusions: Across a large and diverse single-county region, no correlation was found between COVID positivity rate per zip code and stroke code activations. We found no decreases in stroke code activations in areas with high COVID rates.

Introduction: Many healthcare systems reported a decline in stroke admissions in the early months of the COVID-19 pandemic. We used real-time hospital admission data from Stroke Receiving Centers (SRCs) across San Diego County to quantify changes in stroke patients accessing healthcare with the onset of the COVID-19 pandemic. Rather than waiting for months-delayed discharge data, real-time stroke code data was used to understand the impact on healthcare utilization which may better inform mitigation strategies to encourage accessing care for acute stroke. Methods: We analyzed the total number of patients presenting to any of the 18 San Diego County SRCs for which a stroke code was activated between January 1, 2019 and July 31, 2020; and separated the times into: pre-pandemic (PP) as January 2019 thru February 2020, early-pandemic (EP) as March and April 2020, and mid-pandemic (MP) as May-July 2020. Patients arriving via emergency medical services or private transport were included. A public messaging campaign regarding the safety of accessing care for acute stroke started in early May 2020. Results: A total of 14,028 stroke codes were initiated between January 2019 and July 2020. An average of 43.2 stroke codes were activated per stroke center per month (range=39.6 to 46.7 activations per stroke center per month) during PP, 30.6 during EP and 37.7 during MP (p=.019). Overall, 30% fewer stroke code activations occurred during EP compared to the same months in the PP (p=.012). Mid-pandemic, there were 14.6% fewer stroke code activations compared to the same months pre-pandemic (p=.095). Conclusion: Stroke code activations decreased by 30% across San Diego County SRCs in the EP period compared to the previous year. It is unclear if this is primarily due to decreased healthcare utilization at the start of the COVID-19 pandemic or if there were changes in stroke incidence. MP showed stroke code activations increased compared to EP. This may be partially due to the public messaging campaign initiated after an analysis of PP to EP stroke code activations. We will continue to analyze stroke code data to better understand the impact of public messaging campaigns and determine when activations have returned to PP levels.

Background: Despite proven outcome improvements after acute ischemic stroke (AIS), adoption of intravenous tPA has been slow, particularly in non-academic medical centers. In 2010, San Diego County established a comprehensive stroke registry to benchmark stroke care across our region. We analyzed the change in tPA use frequency, treatment rate over time, and treatment variance between receiving facilities. Methods: The San Diego County EMS Stroke Registry includes all 16 stroke receiving centers in San Diego County, from which we analyzed mode of arrival (EMS, walk-in), door-to-needle (tPA) times (DTN), and treatment rate (ischemic stroke cases receiving tPA divided by total ischemic stroke cases) over time (January 2010- June 2017). Results: We captured a total of 23,913 discharges with AIS ( Table ). Of these, 58.5% arrived via EMS (41.5% walk-ins). The use of tPA increased from 7.5% in 2010 to 15.2% in 2017. The stroke incidence varied little; DTN reduced over time (2010: 128.8(±426.2) minutes; 2017: 58.4(±31.2) minutes); the variance of DTN between hospitals decreased (DTN SD: 2010: 426.2 minutes; 2017: 31.2 minutes). Conclusion: We show, across a large regional stroke registry, that tPA use increased and time to treatment decreased. This effect was similar across variant sized hospitals and seen in academic and non-teaching facilities. Through collaborative data-sharing, analysis and internal benchmarking, overall tPA treatment rates and times improved.

Background: Endovascular thrombectomy (EVT) after Acute Ischemic Stroke (AIS) has shown to improve outcomes in multiple large clinical trials. Most participating centers, however, were large academic hospitals. We studied EVT use in a community setting covering a population of 3.2 million that includes 16 teaching and non-teaching facilities of variable sizes across San Diego County. This provides one of the first comprehensive community-based analyses on early adoption of EVT. Methods: We included all AIS cases treated at an EVT-capable stroke receiving center from the San Diego County EMS Stroke Registry from July 2016 through June 2017. Documented groin puncture date and time indicated EVT treatment. We analyzed the frequency of EVT by center, baseline demographics, admission source, treatment times, use of tPA and discharge disposition. Results: In total, 3,033 AIS patients were treated from July 2016 through June 2017; 266 (8.8%) underwent EVT. The rate per center varied from 1.7 to 17.5%. The mean (±SD) initial NIHSS was 18.0 (±8.4); mean age 74.4(±14.2) years; 48.9% women, 64.7% arrived by EMS, 29.0% by interfacility transfer, 55.3% received tPA, in-hospital mortality was 15.0%, discharge to home 20.7%, to nursing facility 24.4%. Last known well (LKW) was documented in 249 cases (93.6%) of which 201 (80.7%) received EVT within 6 hours of LKW. Mean (±SD) LKW to EVT time for EMS cases was 4.9(±5.9) hours versus 5.8(±6.4) hours for interfacility transfers. The range of mean LKW to EVT was 0.7 hours to 71.4 hours (IQR=2.7-5.3 hours). Arrival to EVT time was documented in 253 cases (95.1%), of which 40.3% received EVT within 90 minutes of arrival at the treating center. The frequency of treatment within 90 minutes from arrival varied between centers from 0.0% to 63.0%. The mean (±SD) time from arrival to EVT was 2.5(±3.9) hours, ranging from 1.6 hours to 11.5 hours between centers (IQR=1.2-2.5 hours). Conclusion: Endovascular thrombectomy treatment rates vary across centers within San Diego County. The overall treatment rate is 8.8%. Nearly three in ten patients arrived to an embolectomy capable center via interfacility transfer, with slightly longer last known well to treatment times. Continued analysis will provide data to support future policy and protocol changes.