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Objectives Patients with severe intracerebral hemorrhage (ICH) often suffer from impaired capacity and rely on surrogates for decision-making. Restrictions on visitors within healthcare facilities during the pandemic may have impacted care and disposition for patient with ICH. We investigated outcomes of ICH patients during the COVID-19 pandemic compared to a pre-pandemic period. Materials and methods We conducted a retrospective review of ICH patients from two sources: (1) University of Rochester Get With the Guidelines database and (2) the California State Inpatient Database (SID). Patients were divided into 2019–2020 pre-pandemic and 2020 pandemic groups. We compared mortality, discharge, and comfort care/hospice. Using single-center data, we compared 30-day readmissions and follow-up functional status. Results The single-center cohort included 230 patients (n = 122 pre-pandemic, n = 108 pandemic group), and the California SID included 17,534 patients (n = 10,537 pre-pandemic, n = 6,997 pandemic group). Inpatient mortality was no different before or during the pandemic in either cohort. Length of stay was unchanged. During the pandemic, more patients were discharged to hospice in the California SID (8.4% vs. 5.9%, p<0.001). Use of comfort care was similar before and during the pandemic in the single center data. Survivors in both datasets were more likely to be discharged home vs. facility during the pandemic. Thirty-day readmissions and follow-up functional status in the single-center cohort were similar between groups. Conclusions Using a large database, we identified more ICH patients discharged to hospice during the COVID-19 pandemic and, among survivors, more patients were discharged home rather than healthcare facility discharge during the pandemic.

Background: Oral anticoagulant (OAC) for atrial fibrillation use remains underutilized despite evidence in favor of its utility. In a three-center study examining the efficacy of a technological intervention to improve OAC use, two sites were randomly selected to incorporate an embedded alert in the electronic health record (EHR) while the third site provided usual care. At the intervention sites, the EHR calculated each patient’s CHA 2 DS 2 -VASc score and alerted the clinician when OAC therapy was recommended. We aimed to investigate whether this system increased OAC use in elderly patients. Methods: Patient medication was tracked at the time of hospitalization, discharge, and within 30 days of discharge. Patients were categorized by age and study arm to assess medication use at last known follow-up via the Chi Square and Fisher’s Exact tests. Results: The control site contained 152 patients, 65 being 75+ years of age, while the two intervention sites contained 164 patients, also with 65 patients who were 75+ years of age. Those aged 75+ show statistically significant proclivity for prior strokes (<0.001), coronary artery disease (0.04), hypertension (0.004), and lower rate of diagnosed obstructive sleep apnea (0.001). Furthermore, they tend to be females (53.9%). The median CHA 2 DS 2 -VASC score was 4 in the elderly group and 2 in the younger group (p<0.001). Use of warfarin or OACs in these two populations did not vary at baseline. At follow-up, use of warfarin was statistically significantly higher in those 75+ (21.9% vs 12.8%, p-value=0.04) but not when partitioned by study arm or when all OAC use was considered. There was no difference in OAC use between the intervention and control sites (43% vs. 54% p=0.22). Conclusions: Despite increased CHA 2 DS 2 -VASc scores, we did not demonstrate the benefit of electronic alerts among elderly AF patients. Additional research is needed regarding methods to overcome therapeutic inertia in this area. Study support: Boehringer-Ingelheim

Introduction: The impact of the COVID-19 pandemic response on medical care for stroke is unknown. Methods: We used local “Get With The Guidelines” stroke data for patients with ischemic stroke (IS), transient ischemic attack (TIA), and intracerebral hemorrhage/subarachnoid hemorrhage (ICH/SAH) from March 20–April 14, 2020 (study period) and January 1–March 19, 2020 (control period #1) and March 20–April 14, 2019 (control period #2). We examined daily admission rates, transfers, tPA administration, thrombectomy, and time from last well to hospital arrival. Results: There were 349 patients (n=40 study period, n=225 control period #1, n=84 control period #2); 263 with IS, 37 with TIA, and 49 with ICH/SAH. Overall, 46% were female, 82% white, with median age 70 years (IQR 58-82 years). Daily admission rates were 1.4 IS/day for the study period compared to 2.1 IS/day (Incident rate ratio [IRR] 1.49 95% CI 1.05-2.13, p=0.027) and 2.2 IS/day (IRR 1.57 1.04-2.37, p=0.033) for control periods #1 and #2 ( Table ), respectively. There was only one admission for TIA in the study period compared to approximately one every 4 days in control period #1 (IRR 7.2 95% CI 1.0-53.7, p=0.053) and one every 2 days in control period #2 (IRR 14.0 95% CI 1.8-106.5, p=0.011). ICH/SAH admissions were fewer in the study period. Transfers were less common with approximately one transfer every four days in the study period compared to one each day of the control periods. Rates of tPA, thrombectomy, and time from last well to first hospital contact did not differ across the epochs. Conclusions: Our data suggest the COVID-19 pandemic response has led to reduced admission volumes for all stroke types in the University of Rochester Medical Center catchment area, partly due to decreases in hospital transfers. These data raise the question whether fewer patients sought care for stroke symptoms at the height of the COVID-19 pandemic.