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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.

Introduction: Mood disorders after stroke are common, with up to one-third of patients developing depression and/or anxiety. Identifying those at greatest risk may be challenging in the acute care setting. We sought to better understand post-hospital barriers impacting emotional well-being for those who suffered a stroke and to evaluate needs for additional resources post hospital discharge. Methods: A Stroke Transitional Care Program (STCP) was initiated at a large two-campus hospital in Southern California in October 2020. All patients discharged home with acute ischemic stroke (AIS), hemorrhagic stroke (HS), and transient ischemic attack (TIA) received a follow-up phone within 3-7 days of hospital discharge from a community health worker familiar with the community and language. An initial needs assessment was completed over the phone to evaluate barriers for post-hospital care, address social and economic needs, and help patients navigate the healthcare system. Data from the initial needs assessment results were analyzed and 30-day readmission data reviewed. Results: A total of 145 patients with a stroke diagnosis were discharged home between October 2020 and June 2021. Of those, 68.3% were discharged with AIS, 21.4% with TIA, and 10.3% with HS. Initial assessments of the 100 patients accepting enrollment into the STCP were reviewed. Fifty-six patients required additional resources, of which 55% required counseling, emotional support, and/or mental health resources. Nine percent of patients were readmitted to the hospital within 30 days. Of these, 22% were admitted for isolated psychiatric issues. Conclusion: A large portion of the stroke patients in our analysis required additional resources post discharge to support emotional well-being, and 22% of patients who required hospital readmission were admitted for psychiatric issues. As a result of these findings, our STCP incorporated the PHQ-2 screening as a standard part of initial post-discharge assessment and implemented a referral process to mental health services. Our results suggest the need for stroke programs to consider implementing processes to assess emotional/psychiatric needs for stroke patients post discharge by incorporating community-based models of care.

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.