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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: To slow the spread of the novel coronavirus (COVID-19), the Department of Homeland Security restricted access across the US-Mexico border in March 2020. During the same time period hospitals throughout the US began reporting declines in emergency department (ED) visits, especially related to stroke. As a stroke receiving center and largest hospital within a Southern California border county serving a binational population, we sought to understand the impact COVID-19 and closure of an international border might have on stroke code activations (SCA) and discharges at our facility. Methods: A retrospective analysis involving 417 cases presenting to a tertiary hospital consisting of two campuses near the US-Mexico border in Southern California was performed. Inclusion criteria: all cases with SCA in the ED arriving from March 1, 2020 to June 30, 2020 and March 1, 2019 to June 30, 2019. Exclusion criteria: cases arriving to the ED that did not have SCA and cases for which stroke codes were initiated after hospitalization. Results: Pedestrian and private auto passenger border crossings decreased by over 5 million people between April and May 2020 compared to the same period in 2019. From March to June 2020, there were 162 ED SCA compared to 255 during the same period in 2019; a 36.5% decrease in SCA in 2020. Additionally, there was a significant increase in the percentage of ED SCA resulting in actual stroke discharge diagnoses during this period. In early 2020, 68.5% of ED SCA were discharged with a stroke diagnosis compared to 60.4% in 2019, X 2 (1, N = 162) = 4.467, p < .05. However, despite the increased true positive rate, there was an overall decrease in the total number of patients with SCA who were diagnosed with stroke (111 in 2020 vs 154 in 2019). Conclusion: As the overall number of SCA decreased during the early months of the COVID-19 pandemic, so did the total number of patients discharged with a stroke diagnosis. This suggests that fewer patients with acute stroke presented as a SCA during the early COVID-19 pandemic in comparison to the same time period in 2019. It is critically important as a stroke center serving a large, binational population to ensure the population we serve is seeking appropriate and timely care for serious and complex diseases.

Background: Efficient emergency department (ED) code stroke processes lead to improved door-to-needle (DTN) times for the administration of IV tissue plasminogen activator (tPA) for qualifying acute ischemic stroke (AIS) patients. A code stroke initiation in the ED activates a cascade of actions involving multiple steps and can result in variations of processes, consequently leading to delayed treatment. Hypothesis: We sought to implement an efficient, standardized tPA ordering method, called Direct Pharmacy Ordering Process (DPOP), as part of our code stroke process to improve DTN times. Methods: A retrospective review of 401 records from our internal code stroke database was completed prior to and post implementation (June, 2013 to December, 2013 and April, 2014 to April, 2015, respectively) of DPOP. DPOP allows the ED physician to call for tPA directly to the pharmacist, who then calculates dosage, mixes and dispenses the medication. Charts were reviewed for patients’ time of ED arrival, time of CT scan results, time of tPA orders, and time of tPA administration. Inclusion criteria: AIS patients for whom an ED code stroke was initiated and who received tPA. Exclusion criteria: code strokes initiated after hospital administration, ED code stroke patients not receiving tPA, and patients receiving tPA but for whom process times could not be determined. Results: After applying criteria, a total of 46 patients’ records were included (16 pre-DPOP and 30 post-DPOP). There was a substantial reduction in all turn-around-times when pre-DPOP and post-DPOP data were compared. Mean time from CT results to time pharmacy received tPA requests decreased from 38 minutes to 17; mean time from CT results to administration of tPA, decreased from 52 minutes to 36, with a decreased median time from 54 minutes to 34. Additionally, DPOP eliminated illegible orders and orders with omissions, further improving timeliness. Conclusion: We implemented an improvement process for ordering IV tPA that led to substantial reductions in time for our code stroke process. Additionally, DPOP eliminated problems inherent to written prescriptions, thus leading to reductions in median time of tPA administration from the time of reported CT results by >20 minutes for most AIS cases receiving tPA.

Introduction: The American Heart and American Stroke Associations released their new Target: Stroke goal of IV tPA administration in under 45 minutes from arrival for all eligible patients. While many hospitals have improved with prompt IV tPA initiation, further analysis is necessary to determine reasons for ongoing delays in order to continue to improve door- to-needle (DTN) times. Hypothesis: We hypothesized that identifying trends in IV tPA initiation delays could guide development of process improvement (PI) geared toward decreasing DTN times. Methods: A retrospective cohort of 2,417 patients presenting to a five hospital campus system from January 2013 to March 2015 were studied to identify trends in IV tPA delays. Inclusion criteria: all patients presenting to the emergency department (ED) for which a code stroke was activated and IV tPA was initiated with DTN times greater than 60 minutes from arrival. Exclusion criteria: patients presenting to the ED for which a code stroke was activated but IV tPA was not administered, or IV tPA was initiated within 60 minutes of arrival. Results: Sixty-seven patients met the inclusion criteria, and the following trends were identified: seven patients (10%) required management for other life threatening conditions prior to IV tPA, such as intubation or cardioversion; IV tPA was delayed in 28 patients (42%) due to an inability to determine eligibility. This was based on waxing and waning symptoms and/or uncertainty of last time known well (LKWT). Twenty patients (30%) required IV medications for hypertension and twelve (18%) patients and/or family members initially refused the drug. Conclusion: This study revealed that 90% of IV tPA initiation delays were due to potential modifiable factors. Indicating that through implementation of PI changes, hospital systems may be able to prevent similar delays from occurring. Examples include: collaboration with emergency medical services to transport witnesses to the ED for assistance with prompt identification of LKWT, earlier management of hypertension, and a streamlined approach for risk and benefit discussions between clinicians, patients and/or family to assist in a rapid informed consent process.