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Background and Purpose— We quantified population access to endovascular-capable centers, timing, and rates of thrombectomy in Los Angeles County before and after implementing 2-tiered routing in a regional stroke system of care. Methods— In 2018, the Los Angeles County Emergency Medical Services Agency implemented transport of patients with suspected large vessel occlusions identified by Los Angeles Motor Scale ≥4 directly to designated endovascular-capable centers. We calculated population access to a designated endovascular-capable center within 30 minutes comparing 2016, before 2-tiered system planning began, to 2018 after implementation. We analyzed data from stroke centers in the region from 1 year before and after implementation to delineate changes in rates and speed of administration of tPA (tissue-type plasminogen activator) and thrombectomy and frequency of interfacility transfer. Results— With implementation of the 2-tier system, certified endovascular-capable hospitals increased from 4 to 19 centers, and within 30-minute access to endovascular care for the public in Los Angeles County, from 40% in 2016 to 93% in 2018. Comparing Emergency Medical Services–transported stroke patients in the first post-implementation year (N=3303) with those transported in the last pre-implementation year (N=3008), age, sex, and presenting deficit severity were similar. The frequency of thrombolytic therapy increased from 23.8% to 26.9% (odds ratio, 1.2 [95% CI, 1.05–1.3];P =0.006), and median first medical contact by paramedic-to-needle time decreased by 3 minutes ([95% CI, 0–5]P =0.03). The frequency of thrombectomy increased from 6.8% to 15.1% (odds ratio, 2.4 [95% CI, 2.0–2.9];P &lt;0.0001), although first medical contact-to-puncture time did not change significantly, median decrease of 8 minutes ([95% CI, −4 to 20]P =0.2). The frequency of interfacility transfers declined from 3.2% to 1.0% (odds ratio, 0.3 [95% CI, 0.2–0.5];P &lt;0.0001).Conclusions— After implementation of 2-tiered stroke routing in the most populous US county, thrombectomy access increased to 93% of the population, and the frequency of thrombectomy more than doubled, whereas interfacility transfers declined.

Increased Access to and Use of Endovascular Therapy Following Implementation of a 2-Tiered Regional Stroke System