Adherence to institutional stroke alert criteria in an academic adult emergency department population.

Background: Timely recognition of acute ischemic stroke (AIS) is essential to identify patients who may be eligible for acute intervention. Protocols to streamline systems-based care, such as "stroke alerts" in the emergency department (ED) can safely reduce time-to-care while enhancing safety. However, clinician adherence to stroke alert criteria is poorly described. We sought to describe the adherence and secondarily the detection rate of stroke alerts initiated by both pre-hospital and ED providers in adult patients with neurologic symptoms concerning for AIS.

Methods: We conducted a retrospective, observational, quality improvement study at a single, quaternary care academic ED in Nashville, Tennessee. We identified adult patients presenting with acute neurological deficits concerning for AIS who received a stroke alert consultation between 2018 and 2024. The primary outcome was the adherence to institutional stroke alert protocols informed by evidence-based stroke criteria. Secondary outcomes included stroke detection, imaging utilization, and treatment interventions.

Results: There were 861 adult stroke alert consultations during the study period that met inclusion criteria; the median age (interquartile range [IQR]) was 62.8 (50.4, 73.0) years, 450 (52.3 %) were female, and 174 (20.2 %) were Black race. Overall, 560 (65.0 %) stroke alerts met institutional activation criteria, and of these, 153 (27.3 %) had either an ischemic or hemorrhagic stroke, and 90 (16.1 %) received either a thrombolytic medication or cerebral angiography. Of the 301 (35.0 %) stroke alert activations not meeting institutional eligibility criteria, 74 (24.6 %) of these had either an ischemic or hemorrhagic stroke, and 10 (3.3 %) received thrombolytic medication or cerebral angiography.

Conclusion: Nearly two-thirds of ED-initiated stroke alert consultations met institutional criteria. Non-adherent stroke alerts were frequently outside the time window for activation. Continued education directed toward clinical providers may enhance adherence, resource utilization, and patient outcomes for patients with suspected strokes.