What is the recommended code‑stroke protocol for an adult inpatient presenting with an acute ischemic stroke, including target times from code‑stroke activation to neuroimaging, intravenous alteplase administration, and endovascular thrombectomy?

Code Stroke Protocol for Hospitalized Patients: Goal Time Parameters

Hospital inpatients who develop acute stroke symptoms must be treated with the same urgency as emergency department patients, with a target door-to-needle time of less than 60 minutes in 90% of cases and a median door-to-needle time of 30 minutes for IV alteplase. 1

Immediate Code Stroke Activation

When an inpatient develops sudden neurological symptoms, activate the code stroke protocol immediately—do not delay for "routine" floor assessment. 1

• Hospital inpatients presenting with sudden onset of new stroke symptoms should be rapidly evaluated by a specialist stroke team and provided with access to appropriate acute stroke treatments including thrombolysis and endovascular thrombectomy 1
• Once stroke occurs in an existing inpatient, all acute stroke management protocols apply identically to these patients as they would for emergency department arrivals 1

Target Time Intervals from Code Stroke Activation

Door-to-Imaging Time

• Obtain non-contrast CT of the head within 15-20 minutes of code stroke activation 2, 3
• Non-contrast CT is mandatory to exclude intracranial hemorrhage before any reperfusion therapy 2
• For patients potentially eligible for mechanical thrombectomy, perform CT angiography from aortic arch to vertex immediately after non-contrast CT 2

Door-to-Needle Time (Alteplase Administration)

• Target door-to-needle time: <60 minutes in 90% of treated patients 1
• Median door-to-needle time goal: 30 minutes 1
• Treatment should be initiated as soon as possible after CT scan completion 1
• Implementation of structured code stroke protocols has been shown to reduce median door-to-needle time from 57 minutes to 33 minutes 3

Component Time Intervals to Monitor

Research demonstrates that successful code stroke protocols reduce these specific intervals 3:

• Door-to-triage time: should be immediate for inpatients (nurse recognition and activation)
• Triage-to-physician evaluation: <10 minutes
• Physician evaluation-to-CT time: <15 minutes
• CT-to-needle time: <15 minutes

Door-to-Groin Puncture Time (Endovascular Thrombectomy)

• For patients eligible for mechanical thrombectomy, achieve groin puncture within 90 minutes of code stroke activation 2
• Do not wait for a response to alteplase before proceeding to angiography; coordinate thrombolysis and thrombectomy in parallel 2

Critical Protocol Elements for Inpatients

Rapid Neuroimaging Access

• All patients with disabling acute ischemic stroke within 24 hours of symptom onset or last known well should be rapidly screened clinically and with neurovascular imaging 1
• Blood glucose measurement is the only laboratory test that must be completed before administering alteplase—do not delay imaging for other laboratory results 2

Specialist Team Mobilization

• All patients with disabling acute ischemic stroke who can be treated within indicated time windows must be screened without delay by a physician with stroke expertise (either on-site or by telemedicine/telestroke consultation) 1
• When it is unclear whether a patient should be treated with alteplase, urgently consult with a stroke specialist within the institution or through telestroke services 1

Blood Pressure Management Timeline

• Lower systolic/diastolic BP to <185/110 mmHg before starting alteplase 2
• Maintain BP <180/105 mmHg for the first 24 hours after alteplase infusion 2
• Use titratable IV agents (labetalol or nicardipine) for rapid BP control 2

Alteplase Administration Protocol

Dosing

• Alteplase dose: 0.9 mg/kg (maximum 90 mg total) 1, 2
• Give 10% (0.09 mg/kg) as IV bolus over 1 minute 1, 2
• Infuse remaining 90% (0.81 mg/kg) over 60 minutes 1, 2

Critical pitfall: The dosing of alteplase for stroke is NOT the same as the dosing protocol for myocardial infarction 1

Time Windows for Inpatients

• 0-3 hours from symptom onset: all eligible patients should receive alteplase (Class I, Level A evidence) 2
• 3-4.5 hours from symptom onset: eligible patients should receive alteplase with specific exclusions (age >80 years, diabetes + prior stroke, NIHSS >25, or oral anticoagulants) 2
• 4.5-9 hours: alteplase may be given when advanced perfusion imaging shows favorable core-penumbra mismatch 2

Post-Alteplase Monitoring

• Monitor neurologic status every 15 minutes during infusion, then hourly for the next 6 hours 2
• Avoid all antithrombotic agents (aspirin, heparin, anticoagulants) for the first 24 hours after alteplase 2
• Obtain emergent repeat CT if the patient develops neurological deterioration, severe headache, or hypertensive spikes 2

Common Pitfalls to Avoid in Inpatient Code Strokes

• Never delay alteplase for "complete" laboratory results—only bedside glucose is required before treatment 2
• Do not assume inpatient strokes are "less urgent"—time-to-treatment goals are identical to emergency department presentations 1
• Do not withhold code stroke activation because the patient is already hospitalized—every minute of delay costs 1.9 million brain cells 1
• Do not delay imaging to obtain IV access or complete nursing documentation—imaging and treatment preparation should occur simultaneously 3

Quality Metrics to Track

• Percentage of inpatient code strokes with door-to-needle time <60 minutes (target: ≥90%) 1
• Median door-to-needle time for inpatient strokes (target: ≤30 minutes) 1
• Door-to-imaging time (target: <20 minutes) 3
• Rate of IV alteplase usage among eligible inpatient strokes 4