Pre-hospital causes for delayed arrival in acute ischemic stroke before and during the COVID-19 pandemic: A study at two stroke centers in Egypt

Stroke awareness in Egypt: a survey-based study

Background

Awareness about stroke symptoms and management is an important and pivotal step in any stroke service as it will positively affect onset to door, which will affect rates of thrombolysis and thrombectomy, reduce mortality, and improve outcomes. The current study aimed to explore public knowledge about acute stroke in Egypt and how it is dealt with.

Methods

A cross-sectional observational survey-based study was conducted throughout 6 months starting from May 2023. An online Google form was disseminated via WhatsApp and different social media services assessing the public and healthcare professionals’ awareness about stroke symptoms, risk factors, how, where, when, and who to deal with it.

Results

2109 submissions were received. Mean age was 34.3 (± 11.8). Females represented 67.4%. Health care professionals were 12.8%. Participants with a close family history of stroke were 29.2%. Less than half of the responders gave correct answers to most of the questions. Hypertension was the only risk factor to get a consensus higher than 50%, while only 27% recognized diabetes as a risk factor. Only 14.1% realized the term ‘transient ischemic attack’ yet, 68.2% agreed upon seeking medical advice if encountered. 50.2% defined a neurologist as the one to deal with stroke. Healthcare professionals’ answers were more accurate yet still deficient in the time window, route of administration of thrombolytic therapy, and specialty to deal with stroke.

Conclusions

This study throws light on the lack of awareness about stroke that ought to be properly dealt with so as to reflect on stroke thrombolysis rates, management and outcome.

Factors associated with prehospital and in-hospital delays in acute ischaemic stroke care in Indonesia: a systematic review

OBJECTIVES

This systematic review examines prehospital and in-hospital delays in acute stroke care in Indonesia.

DESIGN

Systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

We conducted a thorough search across 11 databases, ClinicalTrials.gov registries and three preprint repositories up until October 2024.

ELIGIBILITY CRITERIA

Studies that examined risk variables associated with hospital delays in the treatment of acute stroke in Indonesian individuals were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers each carried out the data extraction and risk-of-bias evaluation separately. The quality of the study was evaluated using the Risk of Bias in Non-randomised Studies of Exposures tool. The 'combining p values' approach and albatross plots were used to synthesise the findings.

RESULTS

A total of 27 studies with 3610 patients were included. Key factors contributing to prehospital delays included low educational level (p=0.014, 6 studies), low socioeconomic status (p=0.003, 5 studies), cultural beliefs affecting decision-making (p<0.001, 3 studies), significant clinical manifestations such as a low Glasgow Coma Scale score (<8) (p<0.001, 2 studies) and a high National Institutes of Health Stroke Scale score (>16) (p=0.002, 5 studies) and transportation challenges, such as extended travel distance (>15 km) (p=0.009, 5 studies) and lack of ambulance use (p=0.005, 9 studies). In-hospital delays were prominent, with male sex (p=0.046), dyslipidaemia (p=0.045) and arrival time (p=0.007) linked to thrombolysis delays, while CT location affected door-to-CT time (p<0.05).

CONCLUSION

Socioeconomic, cultural, clinical severity and logistical factors were significantly associated with hospital delays in acute ischaemic stroke care in Indonesia. Targeted interventions can mitigate these challenges and improve stroke management and results.

PROSPERO REGISTRATION NUMBER

CRD42024494954.

Predictors and Correlates of Prehospital Delay Among Acute Stroke Patients in Thiruvananthapuram District, Kerala: A Cross-Sectional Survey

Introduction Stroke is a significant global public health challenge, contributing to high mortality rates and long-term disability. Beyond its physiological impact, stroke imposes a substantial socioeconomic burden on patients, families, and healthcare systems. Timely intervention, particularly through the prompt administration of reperfusion therapies, is crucial in reducing adverse outcomes. However, delays in reaching a healthcare facility after symptom onset often prevent patients from receiving these lifesaving treatments. Understanding the prevalence and factors contributing to prehospital delays is essential for improving stroke care and patient outcomes. This study aimed to assess the prevalence of prehospital delays and their correlates among stroke patients in Thiruvananthapuram district, Kerala, while also exploring the situational challenges patients face in accessing healthcare facilities. Materials and methods A hospital-based cross-sectional survey was conducted among 170 patients with confirmed acute stroke who presented to the emergency departments of four hospitals in Thiruvananthapuram district. Patients arriving within four and a half hours of symptom onset were classified as "early arrivals," while those arriving after this period were categorized as "delayed/late arrivals." Data collection was facilitated using Open Data Kit software and analyzed with IBM SPSS Statistics for Windows, Version 22.0 (Released 2013; IBM Corp., Armonk, NY, USA). Univariate and multivariate analyses were performed to identify associations. Additionally, freewheeling interviews were coded to complement and validate the quantitative findings. Results The median time from symptom onset to hospital arrival was 6.75 hours (IQR: 2.27-17.48 hours), with 40% of stroke patients experiencing prehospital delays. Bivariate analysis revealed significant associations between delay and factors such as age, housing type, income source, occupation, socioeconomic status, presence of dependents, choice of healthcare facility, number of facilities approached, and Modified Rankin Scale score. Multiple regression analysis identified housing type and the number of facilities approached as significant predictors of prehospital delay. Freewheeling interviews further indicated that, regardless of sociodemographic characteristics, hesitation, reluctance, and self-assessment were the primary reasons for delayed hospital arrival. Conclusions The study identified a high prevalence of prehospital delay (40%) among acute stroke patients in Thiruvananthapuram, the capital city of Kerala. These findings emphasize the need for health promotion strategies aimed at increasing public awareness of early stroke symptoms, ensuring the direct transfer of patients to hospitals equipped with CT scan and thrombolysis facilities, and standardizing referral processes with uniform protocols to minimize delays and improve patient outcomes.

Help-seeking and access to care for stroke and heart attack during the COVID-19 pandemic: A qualitative study

In this article we explore how people who experienced a stroke, transient ischaemic attack, or heart attack sought health care during the COVID-19 lockdown periods. Semi-structured interviews were conducted with 27 patients admitted to hospital between March 2020 and May 2021, and one carer who was recruited from cardiac and stroke rehabilitation services in two large acute NHS trusts in England. Drawing on concepts of candidacy, illness and moral work, we discuss how people's sense-making about their symptoms fundamentally shaped both their decisions about seeking help and the impact of COVID-19 on help seeking. Risk perception and interactional ritual chain theory allow further exploration of constructing symbols of national identity in times of crises, managing risk and levels of acceptable risk and critique of ambiguous national messaging over accessing health-care services for people with emergency health-care needs. Our findings have wider implications for supporting access into health care for those with life-threatening conditions under highly publicised strain on the health system, including winter pressure and staff strikes, as well as policymaking and public messaging.

Delays in Cardiovascular Emergency Responses in Africa: Health System Failures or Cultural Challenges?

Delays in receiving care for debilitating cardiovascular emergencies, such as myocardial infarction and stroke, are multifaceted and include personal, systemic, and health facility-related factors, which must all be addressed to successfully improve cardiovascular emergency outcomes.

Role of the Critical Care Resuscitation Unit in a Comprehensive Stroke Center: Operations for Mechanical Thrombectomy During the Pandemic

Introduction

Standard of care for patients with acute ischemic stroke from large vessel occlusion (AIS-LVO) includes prompt evaluation for urgent mechanical thrombectomy (MT) at a comprehensive stroke center (CSC). During the start of the coronavirus 2019 pandemic (COVID-19), there were reports about disruption to emergency department (ED) operations and delays in management of patients with AIS-LVO. In this study we investigate the outcome and operations for patients who were transferred from different EDs to an academic CSC's critical care resuscitation unit (CCRU), which specializes in expeditious transfer of time-sensitive disease.

Methods

This was a pre-post retrospective study using prospectively collected clinical data from our CSC's stroke registry. Adult patients who were transferred from any ED to the CCRU and underwent MT were eligible. We compared time intervals in the pre-pandemic (PP) period between January 2018- February 2020, such as ED in-out and CCRU arrival-angiography, to those during the pandemic (DP) between March 2020-May 31, 2021. We used classification and regression tree (CART) analysis to identify which time intervals, besides clinical factors, were associated with good neurological outcome (90-day modified Rankin scale 0-2).

Results

We analyzed 203 patients: 135 (66.5%) in the PP group and 68 (33.5%) in the DP group. Time from ED triage to computed tomography (difference 7 minutes, 95% confidence interval [CI] -12 to -1, P < 0.01) for the DP group was statistically longer, but ED in-out was similar for both groups. Time from CCRU arrival to angiography (difference 9 minutes, 95% CI 4-13, P < 0.01) for the DP group was shorter. Forty-nine percent of the DP group achieved mRS ≤ 2 vs 32% for the PP group (difference -17%, 95% CI -0.32 to -0.03, P < 0.01). The CART identified initial National Institutes of Health Stroke Scale, age, ED in-and-out time, and CCRU arrival-to-angiography time as important predictors of good outcome.

Conclusion

Overall, the care process in EDs and at this single CSC for patients requiring MT were not heavily affected by the pandemic, as certain time metrics during the pandemic were statistically shorter than pre-pandemic intervals. Time intervals such as ED in-and-out and CCRU arrival-to-angiography were important factors in achieving good neurologic outcomes. Further study is necessary to confirm our observation and improve operational efficiency in the future.

Acute care pathway assessed through performance indicators during the COVID-19 pandemic in OECD countries (2020-2021): a scoping review

BACKGROUND

The COVID-19 pandemic severely impacted care for non-COVID patients. Performance indicators to monitor acute care, timely reported and internationally accepted, lacked during the pandemic in OECD countries. This study aims to summarize the performance indicators available in the literature to monitor changes in the quality of acute care in OECD countries during the first year and a half of the pandemic (2020-July 2021) and to assess their trends.

METHODS

Scoping review. Search in Embase and MEDLINE (07-07-2022). Acute care performance indicators and indicators related to acute general surgery were collected and collated following a care pathway approach. Indicators assessing identical clinical measures were grouped under a common indicator title. The trends from each group of indicators were collated (increase/decrease/stable).

RESULTS

A total of 152 studies were included. 2354 indicators regarding general acute care and 301 indicators related to acute general surgery were included. Indicators focusing on pre-hospital services reported a decreasing trend in the volume of patients: from 225 indicators, 110 (49%) reported a decrease. An increasing trend in pre-hospital treatment times was reported by most of the indicators (n = 41;70%) and a decreasing trend in survival rates of out-of-hospital cardiac arrest (n = 61;75%). Concerning care provided in the emergency department, most of the indicators (n = 752;71%) showed a decreasing trend in admissions across all levels of urgency. Concerning the mortality rate after admission, most of the indicators (n = 23;53%) reported an increasing trend. The subset of indicators assessing acute general surgery showed a decreasing trend in the volume of patients (n = 50;49%), stability in clinical severity at admission (n = 36;53%), and in the volume of surgeries (n = 14;47%). Most of the indicators (n = 28;65%) reported no change in treatment approach and stable mortality rate (n = 11,69%).

CONCLUSION

This review signals relevant disruptions across the acute care pathway. A subset of general surgery performance indicators showed stability in most of the phases of the care pathway. These results highlight the relevance of assessing this care pathway more regularly and systematically across different clinical entities to monitor disruptions and to improve the resilience of emergency services during a crisis.

Deciphering the contextual barriers to mainstreaming the implementation of stroke thrombolysis in a Ghanaian hospital: Findings from the activate mixed-methods study

BACKGROUND

Each year, stroke-related death and disability claim over 143 million years of healthy life globally. Despite accounting for much of the global stroke burden, acute stroke care in Low-and-Middle-Income Countries remains suboptimal. Thrombolysis, an effective treatment option for stroke, is only received by a minority of stroke patients in these settings.

AIM

To determine the context-specific barriers and facilitators for the implementation of mainstream stroke thrombolysis in a Ghanaian hospital.

METHODS

We employed a mixed-methods approach involving key stakeholders (recipients, providers, and leaders) in the acute stroke care continuum. Surveys were administered to acute stroke patients, and in-depth key informant interviews were conducted with experts in stroke care, including a neurologist, medical director, neurology residents, a stroke nurse, emergency physicians, a radiologist, and a pharmacist. The data collected from these interviews were transcribed and analysed using content analysis with the CFIR (Consolidated Framework for Implementation Research) model as a guiding template. Two independent coders were involved in the analysis process to ensure reliability and accuracy.

RESULTS

The stroke thrombolysis rate over a 6-month period was 0.83% (2 out of 242), with an average door-to-needle time among thrombolyzed patients being 2 hours, 37 minutes. Only 12.8% of patients (31 out of 242) presented within 4.5 hours of stroke symptom onset. The most significant obstacle to the implementation of acute stroke thrombolysis was related to the characteristics of the individuals involved, notably delays in presenting to the hospital among stroke patients due to a lack of knowledge about stroke symptoms and cultural beliefs. Additionally, a significant bottleneck that contributed to the discrepancy between the number of patients who presented within the 4.5-6 hour window and the number of patients who actually received thrombolysis was the inability to pay for the cost of thrombolytic agents. This was followed by challenges in the implementation processes.

CONCLUSIONS

Addressing challenges related to stroke awareness, and financial constraints via multi-level stakeholder engagement, and enactment of stroke protocols are crucial steps in ensuring a successful implementation of a stroke thrombolysis program in a resource-limited setting.

Applying the World Stroke Organization roadmap in planning a model for stroke service implementation in Matrouh Governorate-Egypt: a World Stroke Organization young future stroke leaders’ analytical study

Background

The global incidence of stroke is on the rise, primarily due to an increase in the aging population and the prevalence of vascular risk factors among the elderly. However, stroke is a treatable condition if promptly recognized and managed effectively. To optimize stroke management, it is crucial to establish a well-prepared infrastructure comprising adequately trained physicians working in collaboration with multidisciplinary teams. Equipped stroke units, easily accessible emergency medical services with a stroke code, and interconnected telestroke networks, further enhance stroke care delivery. Along with the current study, conducted by a task force from the World Stroke Organization’s Future Stroke Leaders Program, an assessment of the stroke infrastructure within Matrouh governorate in Egypt for stepwise implementation of stroke services, based on the World Stroke Organization’s stroke roadmap took place. The study consisted of two levels: Level One involved analyzing existing gaps that may impede the implementation of stroke services, while Level Two proposed strategies to address these gaps using a problem-solving approach.

Results

The study identified the Matrouh governorate as a suitable region for stroke service implementation. The region exhibits a blend of urban and rural areas and is geographically distant from major healthcare centers. Matrouh also possesses a diverse population, subject to seasonal variations. Currently, it offers a mix of minimum and essential stroke services, which can be expanded and improved through a step-by-step approach guided by the World Stroke Organization’s stroke roadmap.

Conclusions

Mapping stroke infrastructures allows for the identification of potential gaps to optimize the potential for implementation of stroke services.

Gender disparity versus equality in acute stroke: a Middle Eastern country hospital-based study

BACKGROUND

Acute stroke management is well-established in developed countries with no gender difference. Yet, in developing countries there are reports on gender disparity in medical services including stroke services. Egypt, a developing low-middle-income country, heavily populated, in the Middle East is a good example to answer whether acute ischemic stroke service is provided equally to males and females or there is disparity in risk factors, onset to door (OTD), door to needle (DTN), and outcome. The current study was prospective observational analytical hospital-based study, on acute ischemic stroke cases admitted to Nasr city insurance hospital stroke unit between September 2020 and September 2022.

RESULTS

350 cases were included, 257 males and 93 females. Hypertension was the commonest risk factor 66% males and 81% females P = 0.011, atrial fibrillation was predominant in females P < 0.001, smoking was predominant in males P < 0.001. Median OTD in hours was 8.0 among both genders with minimum zero and maximum 96 h in males compared to minimum 1 and maximum 120 h in females, DTN was around 30 min with no significant difference. Median NIHSS on which rtPA was administered was 12.5 (6-13) in females compared to 10 (6-12) in males. Males who did not receive rtPA had a better mRS on discharge and on 90 days P = 0.01, 0.009, respectively, while there was no significant difference on discharge and 90 days between both genders on receiving rtPA.

CONCLUSIONS

No gender disparity was found in DTN, discharge outcome, and 90 days among rtPA recipients. Females tended to have higher NIHSS and relatively delayed presentation to ER with less favorable outcome at discharge and 90 days in case of not receiving rtPA. Encouraging earlier arrival and conducting awareness campaigns for risk factors management is warranted.

Reasons withholding intravenous thrombolysis for acute ischemic stroke in an Indonesian Tertiary Center

Background

Intravenous thrombolysis is the current therapy of choice in patients with acute ischemic stroke (AIS). While highly effective, the rate at which the procedure is employed is low. Studies evaluating the causes withholding thrombolytic treatment in developing nations remain scarce. We aim to determine the factors withholding thrombolytic treatment in AIS patients.

Methods

This is a retrospective study of AIS patients at Siloam Hospitals Lippo Village, Indonesia, in a 10-month period between April 2019 to February 2020. Patient data were collected from the medical records.

Results

One hundred and forty-five cases of AIS were found within a 10-month period (April 2019 to February 2020). Thrombolysis was performed in 6.90% of all patients with AIS (21.28% when adjusted for eligible patients with onset ≤ 4.5 h). Prehospital delay exceeding 4.5 h was the most common cause of withholding thrombolytic treatment (68.28% of patients present above 4.5 h or with unknown onset). Among patients presenting ≤ 4.5 h, causes withholding thrombolysis include clinical improvement (35.14%), mild non-disabling symptoms (32.43%), patient/family refusal (18.92%), extensive infarction (5.41%), seizures at onset (2.7%), as well as history of acute bleeding diathesis (2.7%) and gastrointestinal bleeding (2.7%).

Conclusions

Prehospital delay constitutes the primary obstacle toward receiving thrombolytic therapy for AIS, especially in developing countries. Among patients with onset below 4.5 h, other notable causes include clinical improvement, mild non-disabling symptoms, and patient/family refusal. Of note, the rate of patient/family refusal in our study was much higher compared to previous findings, which may reflect possible socio-economic, communication, or educational issues.

In-Hospital Emergency Treatment Delay Among Chinese Patients with Acute Ischaemic Stroke: Relation to Hospital Arrivals and Implications for Triage Pathways

Introduction

Timely access to emergency treatment during in-hospital care phase is critical for managing the onset of acute ischaemic stroke (AIS), particularly in developing countries. We aimed to explore in-hospital emergency treatment delay and the relation of door-to-needle (DTN) time to ambulance arrivals vs walk-in arrivals.

Methods

Data were collected from 1276 Chinese AIS patients admitted to a general, tertiary-level hospital for intravenous thrombolysis. Information on patients' characteristics and time taken during in-hospital emergency treatment was retrieved from the hospital registry data and medical records. Ambulance arrival was defined as being transported by emergency ambulance services, while walk-in arrival was defined as arriving at hospital by regular vehicle. In-hospital emergency treatment delay occurred when the DTN time exceeded 60 minutes. We performed multivariable logistic regression analysis to explore the association between hospital arrivals (by ambulance vs by walk-in) and treatment delay after adjustment for age, sex, education, marital status, residence, medical insurance, number of symptoms, clinical severity and survival outcome.

Results

Over half (53.76%) of patients aged over 60 years. Around one-fifth (20.61%) of patients admitted to hospital through emergency ambulance services, while their counterparts arrived by regular vehicle. Overall, the median time taken from the hospital door to treatment initiation was 86.0 minutes. Patients arrived by ambulance (adjusted odds ratio [aOR] = 1.744, 95% confidence interval [CI] = 1.185-2.566, p = 0.005), had higher socio-economic status (aOR = 1.821, 95% CI = 1.251-2.650; p = 0.002), or paid out-of-pocket (aOR = 2.323, 95% CI = 1.764-3.060; p < 0.001) had an increased likelihood of in-hospital emergency treatment delays.

Conclusion

In-hospital emergency treatment delay is common in China, and occurs throughout the entire emergency treatment journey. Having a triage pathway involving hospital arrival by ambulance seems to be more likely to experience in-hospital emergency treatment delay. Further efforts to improve triage pathways may require qualitative evidence on provider- and institutional-level factors associated with in-hospital emergency treatment delay.

Outcome and characteristics of COVID-19 patients associated with stroke: a multicenter hospital-based study in Egypt

Background

 Nearly 55 percent of patients are said to be affected by the neurological effects of COVID-19. COVID-19 was shown to be related with stroke in 0.9 to 5% of people. It's critical to assess the impact of COVID-19 on the outcomes of acute ischemic stroke. The goal of this study was to look at the outcomes and characteristics of patients who had an acute ischemic stroke due to covid-19 infection.

Results

 The participants in this study were 399 people who had had a stroke. COVID-19 positivity was confirmed in 77 cases, while COVID-19 negativity was confirmed in 322. In the COVID-19 and control groups, the average age of the patients was 65.4 ± 10.2 and 65.3 ± 11.8, respectively. The Covid-19 and control groups had a mean stroke onset of 5.2 ± 2.1 and 5.7 ± 3.8 h, respectively (P = 0.12). There was a high in-hospital mortality rate among patients with COVID-19 with a rate of 11.7% compared to 4.04% among the control group (P = 0.02). At discharge, the number of patients with mRS > 2 was higher (P = 0.001) among the COVID-19. There was a correlation between the mean levels of D-Dimer (r = 0.668, P < 0.001), the severity of COVID-19 (r = 0.802, P < 0.001), and mRS > 2.

Conclusion

Despite receiving equal acute care as non-COVID-19 patients, COVID-19 patients had more severe strokes and had worse outcomes. This includes a high chance of death while in the hospital as well as a significant level of disability. Neurologists should use timely and effective therapies, particularly for patients who are at a higher risk of having a stroke. This includes elderly patients, patients with severe COVID-19, patients with high levels of D-Dimer, and those with high NIHSS.

Global burden of the COVID-19 associated patient-related delay in emergency healthcare: a panel of systematic review and meta-analyses

Background

Apart from infecting a large number of people around the world and causing the death of many people, the COVID-19 pandemic seems to have changed the healthcare processes of other diseases by changing the allocation of health resources and changing people’s access or intention to healthcare systems.

Objective

To compare the incidence of endpoints marking delayed healthcare seeking in medical emergencies, before and during the pandemic.

Methods

Based on a PICO model, medical emergency conditions that need timely intervention was selected to be evaluated as separate panels. In a systematic literature review, PubMed was quarried for each panel for studies comparing the incidence of various medical emergencies before and during the COVID-19 pandemic. Markers of failure/disruption of treatment due to delayed referral were included in the meta-analysis for each panel.

Result

There was a statistically significant increased pooled median time of symptom onset to admission of the acute coronary syndrome (ACS) patients; an increased rate of vasospasm of aneurismal subarachnoid hemorrhage; and perforation rate in acute appendicitis; diabetic ketoacidosis presentation rate among Type 1 Diabetes Mellitus patients; and rate of orchiectomy among testicular torsion patients in comparison of pre-COVID-19 with COVID-19 cohorts; while there were no significant changes in the event rate of ruptured ectopic pregnancy and median time of symptom onset to admission in the cerebrovascular accident (CVA) patients.

Conclusions

COVID-19 has largely disrupted the referral of patients for emergency medical care and patient-related delayed care should be addressed as a major health threat.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00836-2.

Effects of the COVID-19 pandemic on stroke response times: a systematic review and meta-analysis

OBJECTIVES

COVID-19 presents a risk for delays to stroke treatment. We examined how COVID-19 affected stroke response times.

METHODS

A literature search was conducted to identify articles covering stroke during COVID-19 that included time metrics data pre- and post-pandemic. For each outcome, pooled relative change from baseline and 95% CI were calculated using random-effects models. Heterogeneity was explored through subgroup analyses comparing comprehensive stroke centers (CSCs) to non-CSCs.

RESULTS

38 included studies reported on 6109 patients during COVID-19 and 14 637 patients during the pre-COVID period. Pooled increases of 20.9% (95% CI 5.8% to 36.1%) in last-known-well (LKW) to arrival times, 1.2% (-2.9% to 5.3%) in door-to-imaging (DTI), 0.8% (-2.9% to 4.5%) in door-to-needle (DTN), 2.8% (-5.0% to 10.6%) in door-to-groin (DTG), and 19.7% (11.1% to 28.2%) in door-to-reperfusion (DTR) times were observed during COVID-19. At CSCs, LKW increased by 24.0% (-0.3% to 48.2%), DTI increased by 1.6% (-3.0% to 6.1%), DTN increased by 3.6% (1.2% to 6.0%), DTG increased by 4.6% (-5.9% to 15.1%), and DTR increased by 21.2% (12.3% to 30.1%). At non-CSCs, LKW increased by 12.4% (-1.0% to 25.7%), DTI increased by 0.2% (-2.0% to 2.4%), DTN decreased by -4.6% (-11.9% to 2.7%), DTG decreased by -0.6% (-8.3% to 7.1%), and DTR increased by 0.5% (-31.0% to 32.0%). The increases during COVID-19 in LKW (p=0.01) and DTR (p=0.00) were statistically significant, as was the difference in DTN delays between CSCs and non-CSCs (p=0.04).

CONCLUSIONS

Factors during COVID-19 resulted in significantly delayed LKW and DTR, and mild delays in DTI, DTN, and DTG. CSCs experience more pronounced delays than non-CSCs.