Introduction . Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on nonurban areas with minimal community transmission is less well understood. Methods . Using a prospectively maintained prehospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. Results . In January, February, March, and April 2019, 10, 11, 17, and 19 patients, respectively, were transported in comparison to 19, 14, 10, and 8 during the same months in 2020. From January through April 2019, there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020, constituting significantly different trend-line slopes (3.30; 95% CI 0.48–6.12 versus -3.70; 95% CI -5.76–-1.64, p = 0.001). Patient demographics, comorbidities, and symptom severity were mostly similar over the two time periods, and the number of patients with a final diagnosis of stroke was also similar. However, the median interval from EMS dispatch to ED arrival for patients with a final diagnosis of stroke was significantly longer in January to April 2020 (50 ± 11.7 min) compared to the same time period in 2019 (42 ± 8.2 min, p = 0.01). Discussion/Conclusion . Our data indicate a decrease in patient transport volumes and longer intervals to EMS activation for suspected stroke care. These results suggest that even in a nonurban location without widespread community transmission, patients may be delaying or avoiding care for severe illnesses such as stroke. Clinicians and public health officials should not ignore the potential impact of pandemic-like illnesses even in areas of relatively low disease prevalence.

Stroke readmissions within 30 days have been identified by the Centers for Medicare & Medicaid Services (CMS) as a measure of hospital quality. Readmitted stroke patients experience greater mortality, longer lengths of stay, and higher cost per stay. This Comprehensive Stroke Center has had a follow up program since 2010 which includes a 48 hour phone nurse call, a 7 day clinical pharmacist phone call, and stroke clinic visit/phone call at 30 days and 90 days. This process produced a 50% readmission reduction between 2013 and 2018, however opportunities to further reduce stroke readmissions remain. Methods: In 2018, a process was launched where specially-trained Community Paramedicine professionals visit stroke patients at home @ 7-10 days post discharge. This visit includes education reinforcement, social evaluation and support, medical examination, and interventions. The model was previously found to demonstrably reduce heart failure readmissions. Referrals are made to this team by coordinators for ischemic and hemorrhagic patients discharged to home or rehab. Findings and needs are communicated directly to relevant health system elements. Results: From July 2018 through June 2019, CP visited 156 (23%) of the 669 patients discharged to home and acute rehab. Only 1 patient (0.6%) of those visited was readmitted, while 52 (10%) of the 513 not visited were readmitted within 30 days. During the visits, they identified key barriers such as medication errors, absence of help in the home (despite having previously reported they would have help), lack of transportation, and overwhelmed caregivers. They ensured that pill organizers were utilized, reviewed upcoming appointments, assisted with arranging transportation, and provided education and helping strategies to caregivers. Feedback from the patients has been overwhelmingly positive. Conclusion: Stroke Centers are accountable to improve stroke patients’ transitions of care at discharge to reduce readmissions and ensure optimal recovery. Community Paramedicine personnel are well-suited to positively impact readmission rates in stroke patients.

Over the past 50 years, the Journal of Neuroscience Nursing (JNN) has grown from a neurosurgical focus to the broader neuroscience focus alongside the professional nursing organization that it supports. Stroke care in JNN focused on the surgical treatment and nursing care for cranial treatment of conditions such as cerebral aneurysm, carotid disease, arteriovenous malformation, and artery bypass procedures. As medical science has grown and new medications and treatment modalities have been successfully trialed, JNN has brought to its readership this information about recombinant tissue plasminogen activator, endovascular trials, and new assessment tools such as the National Institute of Health Stroke Scale. JNN is on the forefront of publishing nursing research in the areas of stroke caregiver needs and community education for rapid treatment of stroke and stroke risk reduction. The journal has been timely and informative in keeping neuroscience nurses on the forefront of the changing world of stroke nursing.

Introduction: Stroke patients have complex discharge needs and benefit from strong care transition models. A common care transition model is to perform discharge phone calls to eliminate gaps that may have occurred after discharge. Institutions often struggle with performing discharge phone calls - who should perform this task and what the optimal timeframe should be. Ninety percent of this institution’s 30-day readmissions occur within the first 7 days of hospital discharge, with majority due to medication misunderstanding and poor communication. Hospital readmissions have negative consequences for patients and are costly, accounting for $15 billion of Medicare dollars annually. Methods: In 2014, stroke discharges to home received a 48 hour phone call from an outpatient Registered Nurse (RN) Care Manager. In 2015, to address the medication challenges, a Pharmacist was added to the discharge follow-up team, making phone calls within 7 days of discharge. Results: In 2016, 233(61%) of the 48-hour calls by RNs connected successfully with stroke patients discharged to home. Pharmacist calls reached a higher percentage of patients discharged to home at 83% (n=321). There were 53% (n=208) receiving both calls, and 25% (n=97) of patients being unable to reach after three attempts. The resultant 30-day readmission rate has declined from 8-10% in 2013 and 2014 (when we first started tracking 30-day readmission rates) to 2-3% in 2015. This low rate has remained consistent for 2016 and 2017. Conclusion: Although post-discharge calls can be very labor intensive and time consuming, it is possible to clarify communication, ensure understanding of discharge instructions, and intervene before medication errors occur. The unique combination of an RN and Pharmacist performing the discharge phone calls has been shown to be quite effective; the RN triages acute issues, while the Pharmacist ensures accurate medication list and compliance - and ensures no medication changes were inadvertently made at a primary care provider appointment post-discharge. These interventions reduce readmissions by closing the post-discharge gaps in care that can occur, resulting in a win for both the patient and the institution.

Introduction: Endovascular Therapy (ET) has become the new standard of care for treating acute ischemic stroke (AIS) patients with Emergent Large Vessel Occlusion (ELVO). There are numerous tools that predict outcomes of ischemic stroke patients including those given IV tPA, however, there are no published tools for predicting outcomes after ET. Methods: From January 2015-March 2017, 109 AIS patients received ET. Patients with unsuccessful ET (TICI 0-2a) or with incomplete 90 day follow-up data were excluded, leaving 42 for final analysis. Primary outcome was defined as MRS at 90 days (good outcome MRS <=3, bad outcome MRS >3). Of the variables analyzed, 90 day outcomes correlated with age, diabetes, thrombolytic use, onset to groin time, and NIHSS scores. Numerical values were assigned to each variable based on OR analysis and the resulting score (range 0-8) was plotted against 90 day MRS and ROC analysis defined a cutoff value. Results: The relative score for each non-binary variable was approximated based on the corresponding OR identified during ROC analysis. Using the DamAGE cONTrol scoring tool (figure 1), a cut off of 4 points yielded Sn 0.82, Sp 0.95, p <0.001, & AUC 0.94 . Conclusion: DamAGE cONTrol represents a novel scoring tool which uses pre-intervention characteristics to predict outcome after successful ET. This type of tool may facilitate more informed discussions regarding the value of performing ET, as well as control unnecessary transfers.

Background: In 2015 guidelines regarding endovascular treatment (ET) of Large Vessel Occlusion (LVO) in acute ischemic stroke (AIS) were changed, leading to more patients being transferred to comprehensive stroke centers (CSC) for ET in selected patients, sometimes bypassing primary stroke centers. In the era of ET, there is a need for a simple yet sensitive pre-hospital tool to triage appropriate patients to CSCs. Many prehospital stroke scales predicting LVO are not in widespread clinical use because they are complex and not reliable. A recently published Denmark study demonstrated the PASS tool (Score range 0-3) for detecting LVO where a score of ≥2 was considered to be optimal in predicting LVO with sensitivity of 0.66. Methods: A retrospective analysis of AIS patients with confirmed anterior circulation LVO by catheter-based cerebral angiography between January 2015 and June 2016 was conducted. PASS scores were calculated and correlated with NIHSS to assess for severity of the stroke. Results: Fifty-four patients received ET during the study period. Those who had posterior circulation LVO were excluded, leaving 44 patients for final analysis. Only 5 (11.4%) patients had PASS score of <2 while 39 patients (88.6 %) had a score of ≥2 showing sensitivity of 0.89 for those patients with LVO. Average NIHSS scores were 11 (95% CI 6.6-15) for PASS <2 and 20 (95% CI 18.5-22.5) for PASS ≥2 (p value 0.005). Conclusion: The PASS tool is simple, quick, and easy to perform and has high sensitivity in AIS patients with LVO. To assess its value and efficacy in real time it should be implemented into EMS systems and be performed in the pre-hospital setting.

Background: Urinary tract infections (UTIs) in ischemic stroke patients are a common occurrence and the frequent focus of quality improvement initiatives. However, many UTIs are community-acquired and the impact of such infections on patient outcomes remains controversial.Methods: We conducted a retrospective analysis of our Stroke Center Database and electronic medical records to determine the incidence of both community-acquired UTI (CA-UTI) and hospital-acquired UTI (HA-UTI) in hospitalized ischemic stroke patients. We assessed risk factors for UTI, as well as clinical outcome, the length of stay (LOS), and hospital charges.Results: In our study sample of 395 patients, UTIs were found in 11.7% and the majority of these (65%) were found on admission. Patients admitted from another hospital were more likely to be diagnosed with a UTI of any type compared to those arriving from home (odds ratio (OR) 2.42 95%, confidence interval (CI) 1.18, 4.95) and were considerably more likely to have an HA-UTI than a CA-UTI (OR 12.06 95% CI 2.14, 95.32). Those with a Foley catheter were also more likely to have a UTI (OR 2.65 95% CI 1.41, 4.98). In the multivariable analysis, we did not find a statistically significant relationship between any UTI or a specific UTI subtype and discharge modified Rankin Score (mRS), LOS, or hospital charges. Admission stroke severity remained associated with higher odds of discharge in poor condition (adjusted odds ratio (aOR) 6.23 95% CI2.33, 16.62), an extended LOS (6.84 vs 5.07, p = 0.006), and higher hospital charges ($18,305 vs $12,162, p = 0.001).Conclusions: Urinary tract infections remain a common occurrence in stroke patients. However, the majority of UTIs are present on admission and may have little impact on discharge clinical condition, LOS, or hospital charges. These results may have implications for quality improvement (QI) initiatives that focus on the prevention and treatment of hospital-acquired UTIs.

Background: Recently, five randomized control trials have demonstrated superiority of endovascular therapy (ET) to medical management in acute ischemic stroke (AIS) patients with anterior circulation large vessel occlusion (LVO). Some concerns have arisen in subset and meta analyses of the pivotal trials regarding the negative effect of advanced age (>80 years) on outcomes after ET. Methods: A retrospective analysis of patients with proven LVO who underwent ET was conducted from January 2015 to June 2016. Patients were divided in two groups based on age (≤80 and >80 years) and were analyzed for degree of revascularization (TICI score) and functional status at discharge using the modified Rankin Scale (mRS). Results: Fifty-four patients received ET during the study period. Those who had posterior circulation LVO and/or treated after 6 hours from last known normal were excluded, leaving 34 patients for final analysis. Twenty-two (64%) patients were ≤80 and 12 (36%) were >80. Seventy-seven percent of patients ≤ 80 had favorable recanalization (TICI ≥ 2b) while 66 % of patients > 80 had TICI ≥ 2b ( p value 0.69). Of patients >80 years, 0 % had a mRS ≤2 at discharge versus 36.3% ≤80 years ( p value 0.03). Similarly, 25% of patients > 80 and 54.5% of ≤80 had mRS 3 or 4 ( p value 0.15). Only 9% of ≤ 80 had mRS >4, as compared to >80 at 75% ( p value <0.01). No statistically significant differences were found in the average time to revascularization, admitting NIHSS or administration of tPA. Conclusion: Age above 80 is a predictor of poor outcome after ET irrespective of successful recanalization. Our results confirm the questions raised in previous subset analyses. The reason octogenarians do poorly remains unclear, but our data suggests factors other than TICI score and time to revascularization. Although ET has shown superiority in AIS with LVO, further consideration and careful selection is recommended in patients above age of 80. More focused randomized control trials are needed to get a definitive answer.

A recently published Denmark study demonstrated the PASS tool (Score range 0–3) for detecting LVO where a score of ≥2 was considered to be optimal in predicting LVO with sensitivity of 0.66. We wanted to validate in US population.

Introduction: The Bundled Payments for Care improvement (BPCI) initiative was launched by the Centers for Medicare and Medicaid Services (CMS) in 2014. Our organization contracted for Model 2, making us responsible for all costs associated with index hospital stay plus 90 days post discharge for straight Medicare patients. It was anticipated that we would find opportunity for reduction in readmission rates, which would lead to reduced cost of care. Analysis of Q1 & Q2 2014 data revealed other opportunities. First, cases coded as non-traumatic Subdural Hematoma (SDH) - regardless of readmission - accounted for significant financial deficit. Second, 67% of patients utilized Post-Acute Care (PAC - SNF, acute rehab, home health) at least once and 54% utilized a second PAC. All patients discharged to acute rehab who then transitioned to SNF exceeded the target price for the bundle. Methods: A case review of SDH episodes revealed that many were traumatic but not documented as such. A summary of these cases was presented to providers with recommendations for appropriate wording to ensure appropriate coding. Education was also provided to coders related to BPCI regarding the impact of clarifying traumatic cause of SDH. Protocols for post-acute management were developed with partners in acute rehab & SNF’s in the region and gain-sharing agreements were developed. Partner facilities reviewed each bundled stroke patient for opportunities to reduce post-acute care LOS. Results: Analysis of Q3 2015 demonstrated that the number of SDH cases in the bundle dropped significantly, improving the financial picture six-fold. A reduction in SNF LOS of 25% was appreciated. Conclusion: Stroke is a leading cause of disability in the United States and post-acute care for a 90 day episode carries a prohibitive cost. Accurate documentation and partnering with post-acute facilities does improve the financial position. Ultimately though, post-acute care - not readmissions - is the major driving force for dollars spent in Stroke BPCI.

Background: Stroke patients are at a significant risk of inconsistent care and adverse events after discharge from the hospital. Follow-up contact has been thought to facilitate continuity and compliance with the discharge plan of care, but evidence is lacking as to optimal timing and intensity of follow-up. Our organization established a stroke clinic in 2009 with a schedule for follow up at 30 days, 90 days, and 1 year. In 2014, in effort to increase follow-up volume, the process was amended to ensure that appointments were made prior to discharge. Method: Analysis of 2014 follow-up appointments was conducted by the Stroke Clinic Process Improvement Group. The appointment order was added to the stroke admission order sets so that appointments would display on discharge paperwork. Discussion: There was a 55% increase in patients who followed-up from 2013 to 2014. This improvement continued through 2015. However, despite the successful increase in appointments, the clinic reported an atypical no-show rate of 29% for 2014 and 40% for 2015, a loss of $51,165, in addition to the cost of provider down-time. A deeper analysis of appointment type revealed a significant drop in 1-year visits. Since the data also revealed that most patient visits are at either 30-days, or 30 and 90-days, our process was amended once again to exclude 1-year visits. In addition, the follow-up appointments are now ordered 48 hours prior to discharge, ensuring appointments continue to display on discharge paperwork. Conclusion: Process improvements sometimes result in unexpected downstream effects. We determined that the increase in follow-up appointments did not justify the financial and productivity loss to the clinic. Monitoring of no-show data and stroke clinic volume will be essential as this stroke clinic process evolves. Until we find a way to make patients come for stroke clinic follow-up visits, we will continue to be challenged to find a way to support them through their post-stroke recovery.

Introduction: In 2014, the Centers for Medicare and Medicaid Services (CMS) launched the Bundled Payment for Care Improvement (BPCI) program. Our institution is contracted for a 90 day stroke bundle, making us responsible for all Medicare stroke patient costs. Quarterly review of 2015 financial data (DRG 64 & 65) revealed a significant spend occurs in the post-acute care phase. Methods: Detailed analysis and sequencing revealed that of the 40% of patients discharged to an Inpatient Rehab Facility (IRF) 31% were unsuccessful in rehabilitation and instead transitioned to a Skilled Nursing Facility (SNF). Had SNF been initially selected, a cost avoidance of $292,650 would have been appreciated. Conclusion: Involvement in the BPCI program has provided insight into the post-acute care of stroke patients. With the advent of BPCI, institutions will be increasingly held fiscally responsible for post-acute care delivery. Ongoing retrospective chart review and collaboration with Physical Medicine and Rehabilitation colleagues is underway to identify key indicators that would project successful rehabilitation. Analysis will include comparison between those who were successfully discharged home after an IRF stay to those that needed a SNF after an IRF stay. This would provide inpatient teams with strategies for predicting the optimal discharge location for stroke patients.

Background: Tissue plasminogen activator (tPA) remains the only FDA approved drug treatment for acute ischemic stroke, and research continues to provide evidence that the earlier treatment brings better outcomes. In 2013, the stroke team at this Comprehensive Stroke Center was treating 24% of patients with tPA in less than 60 minutes and 8% in less than 45 minutes. In order to meet the increasingly challenging DTN benchmarks, the program leadership recognized the need to re-invigorate the acute stroke process and to address reasons for delay: staff disengagement, lack of knowledge of stroke core measures, and little incentive to meet the benchmark. Hypothesis: Consistent presence by a stroke coordinator during acute stroke events results in improved outcomes through identification of barriers, focused recognition of nurses and providers, competitive use of data, and facilitation of relevant team education. Methods: A report card was developed for providers, identifying their average DTN, and personal best and worst times. A stacked bar graph showed the critical time frames for each case. Staff involved with good DTN times were promptly recognized publicly, via same-day group email and received ID badge holders that read “Bustin’ clots faster than you can say tPA”. The stroke coordinator and a provider “champion” developed mock brain attack scenarios utilizing simulation technology which are now available to EMS, ED and ICU nurses and providers, CT staff, and neuroscience residents. The education focused on a standardized process for the first 5 minutes. Results: In 2014, tPA was administered 66% of the time under 60 minutes- a 57% improvement. In 2015, 94% under 60 minutes and 69% under 45 minutes. In addition, 5/16 (31%) were under 20 minutes, the fastest being 9 minutes. All patients who received tPA in 20 minutes or less were back to baseline by discharge. Conclusion: Stroke coordinator’s consistent presence during acute strokes promotes: 1) healthy competition as staff become aware of the data and benchmark goals, 2)timely feedback, and 3) relevant hands-on education to appropriate team members with the ultimate outcome being significantly reduced DTN times which leads to better patient outcomes.

Background: Stroke care evolution has been remarkable since 2000, when the Brain Attack Coalition published their recommendations for Primary Stroke Centers. For the first time, hospitals had evidence-based standards to improve patient outcomes. Today, many states require emergency responders to take suspected stroke patients only to certified stroke centers. As a result, many hospitals have established the role of stroke coordinator to oversee the myriad facets of stroke care. Coordinators are overwhelmed with the opportunities - and responsibilities - to improve care processes. Method: In 2009, the stroke program manager at a Magnet academic medical center established a regional stroke coordinators’ group. Eight coordinators met and established milestones for success. Information has been shared and nurses have traded services, providing education for each other’s organization. The group of now 28 coordinators meets every other month. Results: Positive outcomes of membership in this dynamic group include a 65% increase in professional membership in American Association of Neuroscience Nurses. In addition, the coordinators report confidence and empowerment to impact change in their own organization that improved care and outcomes. Aggregate group data demonstrates improvement in the following measures: thrombolytic administration 44%; door-to-needle time 16%; & patient education 12%. Nine additional hospitals (from 6 to 17, a 183% increase) have attained Advanced Primary Stroke certification and the host organization achieved Comprehensive Stroke certification. Conclusion: Neuroscience nurses are influential leaders - not just within their own organization. These outcomes demonstrate the mutual benefit of stroke coordinator colleagues working together and sharing best practice strategies. Through multi-organizational collaboration, they have become empowered to establish programs and become experts within their organization, able to guide and improve the care provided by their own direct-care nurses.

Background: The Post Stroke Checklist (PSC) is an easily administered tool to identify unmet needs in stroke patients. The relative value of the PSC compared to other outcome measures has yet to be determined. We have evaluated the utility of the PSC at 30 days post-stroke, and now report the use of the PSC at 90 days post-stroke. Methods: We evaluated 213 ischemic stroke patients 90 days post discharge in our Stroke Clinic. The PSC was administered as well as the Barthel Index (BI) and modified Rankin Scale (mRS) - scored by a nurse and reviewed by a stroke physician. We stratified each scale according to severity and identified actionable PSC items. Using Fisher’s Exact Test we tested for differences in each of the 11 individual items across the two mRS and BI stratified severity groups. Wilcoxon Rank Sum test measured differences in total PSC score (range 0-9) across mRS and BI severity groups. Results: 103 patients responded positively to one or more PSC items. The cognition item had the highest frequency, 51 (23.9%) of positive responses followed by the mood item, 33 (15.49). The median (range) BI was 100 (10-100) and mRS was 1 (0-5). Patients were distributed across the two BI and mRS severity groups: BI-S (more severe) 0-89 (n=26) and BI-L (less severe) 90-100 (n=187); mRS-S (more severe) 3-5 (n=31) and mRS-L (less severe) 0-2 (n=159). There were significant differences in total PSC scores across both mRS (p=<0.0001) and BI (p=.002) severity groups. There were significant differences in the mood (p=<0.0001), cognition (p=0.004), and life after stroke (p=0.014) items across the mRS severity groups. Patients in the more severe mRS group had higher proportion of positive responses on the mood, cognition and life after stroke items. Conclusion: The PSC identified a substantial proportion of unmet needs in both low severity and high severity stroke patients. The highest frequency related to cognitive function and mood/mental health - often overlooked if not probed for. Our results suggest the importance of cognitive and mental health assessment/referral, especially for high severity stroke patients.

Background: Emergency department (ED) nurses play a vital role in initiating the appropriate care of stroke patients. Nurses must demonstrate a proficient skill level in order to partner with the health care team to ensure the delivery of quality stroke care. Education is a key component to attaining and maintaining proficiency and comfort in these skills. Telestroke partnerships provide a unique opportunity to improve the knowledge and skill level of nurses in community hospital emergency departments. Purpose: The purpose of this study is to measure the impact on nursing knowledge and practice through the establishment of a telestroke partnership between a Comprehensive Stroke Center and community partner hospitals. Methods: After a literature review, a questionnaire was developed and evaluated by the nursing research council. The proposed research was approved by our Institutional Review Board (IRB). Prior to any education related to stroke care and telestroke technology, the ED nurses in our partner hospitals completed the questionnaire measuring their knowledge and comfort level in caring for acute stroke patients. Education related to stroke identification, assessment, tPA administration, and advanced interventions was provided via small group lecture by the telestroke coordinator. A follow up questionnaire was completed at 3 month post education and implementation. Results: As a result of the education and support provided through the telestroke partnership, the community hospital ED nurses’ scores demonstrated an increased level of comfort and knowledge related to the care of an acute stroke patient. Conclusions: Stroke care and patient outcomes are directly impacted by the level of nursing knowledge and practice at the bedside. Telestroke partnerships between comprehensive centers and community hospitals strengthen the nursing practice levels in the community hospital setting.

Background: The Post Stroke Checklist (PSC) is an easily administered, recently developed clinical tool to identify unmet needs in stroke patients. The relative value of the PSC compared to other outcome measures has yet to be determined. Method: We evaluated 126 ischemic stroke patients (median age 68, range 31-97) 30 days following discharge in the outpatient clinic of our Comprehensive Stroke Center. Items were originally scored by a nurse and reviewed with a stroke physician. The PSC was administered to all patients as well as the Barthel Index (BI) and modified Rankin Scale (mRS). We stratified each scale according to severity and identified actionable PSC items in each severity group. Using Fisher’s Exact Test we searched for correlation between the total number of PSC items scored positively and the total score of other outcome measures. We also looked for correlations between individual PSC items and other outcome scores. Results: The median (range) BI was 100 (10-100) and mRS was 1 (0-4). We stratified each outcome measure into 2 groups: BI-S (more severe) 0-89 (n=23) and BI-L (less severe) 90-100 (n=103); mRS-S (more severe) 3-5 (n=23) and mRS-L (less severe) 0-2 (n=103). 79 patients responded positively to one or more items in the PSC. There was no difference in total positive scores for any of the stratified groups, mRS (p=0.69) and BI (p=0.28). The frequency of positive responses for individual patients ranged from 1 to 6. The most common items identified are listed in the table below. No significant differences were noted. Conclusion: The PSC is simple to administer and was well accepted by clinicians and patients. Depression/Anxiety, Cognitive Dysfunction, Instrumental ADL’s, and New Onset Pain are not included in the BI and mRS but are easily identified using the PSC. Our results suggest that the PSC provides important information about these unmet needs in stroke patients independent of stroke severity.