Multidisciplinary Inpatient Code Stroke Protocol

Protocol Overview

Your hospital must implement a rapid-response inpatient code stroke system modeled after cardiac arrest protocols, with immediate activation leading to evaluation within 10 minutes and brain imaging within 25 minutes, followed by either IV alteplase administration or immediate transfer to the thrombectomy center 15 minutes away. 1, 2

1. Activation and Recognition

Who Can Activate

Any hospital staff member (nurses, physicians, respiratory therapists, physical therapists, etc.) who observes new neurological symptoms in a hospitalized patient 1
Use a single access number connected to all stroke team members' pagers for immediate activation 3

Recognition Criteria - Liberal Approach

Any focal neurological deficit: face drooping, arm/leg weakness, speech difficulty, visual changes, ataxia, sensory loss 1, 2
Altered mental status alone warrants activation, though this has lower stroke yield (48% are mimics in hospitalized patients vs. 10% in ED patients) 4
Do NOT delay activation for unclear symptoms - adopt a liberal threshold given that hospitalized patients have worse outcomes than ED patients 1, 4

High-Risk Patient Populations Requiring Enhanced Surveillance

Cardiac surgery patients 1
Patients with atrial fibrillation 1
Post-catheterization patients 1
Patients on anticoagulation 1
Perform serial neurological assessments in these populations 1

2. Immediate Response Team Composition

Core Team Members (Respond Within 4-5 Minutes)

Stroke neurologist or physician with stroke expertise (in-person or via telemedicine) 1, 3
Stroke-trained nurse 1
CT technologist (pre-notified to prepare scanner) 2
Pharmacy (to prepare alteplase if indicated) 2
Neurosurgery (on standby for hemorrhagic complications) 1

Extended Team (Notified Simultaneously)

Thrombectomy center (15 minutes away) - activate their team immediately upon code stroke activation 1
Interfacility transport service (ambulance or helicopter) - activate in parallel with code stroke 1
Interventional neuroradiologist at thrombectomy center 1, 5

3. Time-Critical Assessment Protocol

First 10 Minutes: Simultaneous Actions

Bedside Assessment 2

NIHSS score by stroke team member 5, 2
Last known normal time - document exact time patient was last at neurological baseline 2
ABCDE assessment: Airway (intubate only if compromised), Breathing (O2 only if sat <94%), Circulation (obtain IV access), Disability (NIHSS), Exposure 2
Blood pressure measurement - must be <185/110 mmHg for alteplase eligibility 2
Point-of-care glucose 2

Laboratory Orders (Do NOT Wait for Results Before Imaging) 2

CBC with platelets (must be >100,000 for alteplase) 2
PT/INR, aPTT 2
Basic metabolic panel 2
Troponin 2

Contraindication Screening for Alteplase 2

Recent surgery (<14 days) 2
Active bleeding 2
Recent stroke or head trauma (<3 months) 2
History of intracranial hemorrhage 2

Minutes 10-25: Emergency Imaging

Non-Contrast CT Head 2

Target: imaging completed within 25 minutes of code stroke activation 2
Purpose: Exclude hemorrhage, identify early ischemic changes, rule out stroke mimics 2
Interpretation within 45 minutes of arrival 2

CT Angiography (CTA) Head and Neck 6

Perform immediately after non-contrast CT without waiting for laboratory results 2, 6
Purpose: Identify large vessel occlusion (LVO) - internal carotid artery, M1, M2, basilar artery 6
Critical for transfer decision: LVO presence mandates immediate transfer to thrombectomy center 1, 5

4. Treatment Decision Algorithm

Decision Point 1: Hemorrhage Present?

YES - Hemorrhagic Stroke 1

Immediate transfer to thrombectomy center (which functions as your comprehensive stroke center) 1
Rationale: Both SAH and ICH require neurosurgical capability for life-saving interventions (EVD placement, decompressive craniectomy, aneurysm securing) 1
Do NOT transfer to non-neurosurgical hospitals - this is "devastating" per AHA guidelines 1
High-volume centers (>35 SAH cases/year, high ICH volume) have reduced mortality 1

NO - Proceed to Ischemic Stroke Pathway

Decision Point 2: Large Vessel Occlusion (LVO) Present on CTA?

YES - LVO Identified 1, 5

Immediate Actions (Parallel Processing):

Administer IV alteplase 0.9 mg/kg (max 90 mg) if within 4.5 hours of last known normal AND no contraindications 2, 6
- Do NOT delay alteplase waiting for transfer - "drip-and-ship" approach 5, 6, 7
- Target door-to-needle time: <60 minutes (ideally <45 minutes) 2
Simultaneously activate transfer to thrombectomy center 1, 5
- Call thrombectomy center stroke team - they should meet patient at arrival 5
- Activate neuro-interventional team at receiving center 5
- Activate transport (ground ambulance given 15-minute proximity) 1
Minimize door-in-door-out (DIDO) time 1
- Target DIDO: <30 minutes for patients requiring transfer 1
- Every 30-minute delay decreases good functional outcome by 8-14% 5, 6

Transfer Criteria:

NIHSS ≥6 (87% sensitivity for LVO) 5, 6
Any confirmed LVO on CTA (ICA, M1, M2, basilar) 6
Time window: Up to 24 hours from last known normal with appropriate imaging selection 6

NO - No LVO Identified

Decision Point 3: Alteplase Eligible?

YES - Administer Alteplase 2

Dose: 0.9 mg/kg IV (maximum 90 mg) - 10% bolus, 90% infusion over 60 minutes 2
Time window: Within 4.5 hours of last known normal 2
Blood pressure: Must be <185/110 mmHg 2
Monitor: NIHSS every 15 minutes × 2 hours, then every 30 minutes × 6 hours, then hourly × 16 hours 2
Keep NPO until swallow screen completed 2
Admit to stroke unit or ICU for monitoring 1

NO - Alteplase Contraindicated or Outside Window

Standard Stroke Care: 6

Aspirin 160-325 mg within 48 hours of symptom onset 6
Blood pressure management: Avoid antihypertensives unless SBP >220 or DBP >120 mmHg 6
VTE prophylaxis: Prophylactic-dose LMWH or intermittent pneumatic compression within 24 hours 6
Early rehabilitation: Begin within 24 hours if no contraindications 6
Admit to stroke unit with interdisciplinary team 1

5. Transfer Protocol to Thrombectomy Center

Pre-Transfer Checklist

Alteplase infusing (if eligible) - continue during transport 5, 7
Blood pressure controlled to <185/110 mmHg 2
Airway secured if needed 2
IV access maintained 2
All imaging transferred electronically to receiving center 1

Communication Requirements

Direct physician-to-physician handoff to thrombectomy center stroke team 1
Provide: Last known normal time, NIHSS score, alteplase administration time, blood pressure, contraindications, imaging findings 1, 2
Receiving team preparation: Angiography suite ready, interventionalist scrubbed, standardized tray prepared 5, 6

Transport Mode

Ground ambulance (given 15-minute proximity) 1
Paramedic or critical care transport with stroke training 1
Continuous monitoring during transport 1

Target Metrics

DIDO time <30 minutes 1
Total time from symptom onset to groin puncture: Minimize every minute 5, 6
Door-to-groin-puncture at thrombectomy center: As short as possible 5

6. Special Considerations for Hospitalized Patients

Common Pitfalls to Avoid

Recognition Delays 1, 4

Altered mental status alone accounts for 48% of in-hospital code strokes but has 63% mimic rate 4
Develop standardized assessment protocol for altered mental status to improve efficacy 4
Non-focal symptoms (confusion, decreased responsiveness) are common but delay recognition 1

Confounding Factors 1

Sedation: Use short-acting sedatives, hold at regular intervals for neurological assessment 1
Intubation: Limits examination but should not delay imaging 1
Coexisting medical conditions: Sepsis, metabolic derangements can mimic stroke 1

System Delays 1, 4, 8

In-hospital strokes have worse outcomes than ED strokes (longer length of stay, higher disability, higher mortality) 8
Median time to imaging: 69 minutes pre-protocol vs. 37 minutes post-protocol implementation 8
Lower treatment rates: 26.8% of hospitalized patients receive acute treatment vs. 51.4% of ED patients 4

Quality Improvement Strategies

Education 1

Periodic training for all hospital staff on stroke signs and symptoms 1
Case simulation exercises 1
Targeted education for high-risk units (cardiac surgery, cardiology, ICU) 1

Process Optimization 1, 8

Checklists for stroke alert process 1
Dedicated stroke order sets 1
Rapid transportation protocol to CT scanner 1
Real-time feedback to stakeholders 1
Lean methodologies to standardize protocol and optimize skill-task alignment 8

7. Quality Metrics and Monitoring

Time Metrics (Track and Report Monthly)

Code stroke activation to physician evaluation: Target <5 minutes 3
Code stroke activation to CT completion: Target <25 minutes 2, 8
Door-to-needle time (for alteplase): Target <60 minutes, ideally <45 minutes 2
Door-in-door-out time (for transfers): Target <30 minutes 1
Symptom onset to groin puncture (for thrombectomy patients): Minimize every minute 5, 6

Process Metrics

Percentage of true strokes among code stroke activations 4
Percentage receiving alteplase among eligible patients 4
Percentage transferred for thrombectomy among LVO patients 1
Percentage with NIHSS documented 2
Percentage with last known normal time documented 2

Outcome Metrics

Symptomatic hemorrhage rate: Expected 3-6% 7
In-hospital mortality 7
Discharge disposition (home, acute rehab, skilled nursing facility) 7
Modified Rankin Scale at discharge 7

Benchmarking

Compare in-hospital vs. ED stroke metrics to identify gaps 4
Participate in national stroke quality improvement program (e.g., Get With The Guidelines-Stroke) 1
Review cases monthly with multidisciplinary team 1

8. Protocol Implementation Steps

Phase 1: Infrastructure Development

Establish formal partnership with thrombectomy center 15 minutes away 1
Create single access number for stroke team activation 3
Develop written protocols defining processes and responsibilities 1
Establish 24/7 stroke team availability (in-person or telemedicine) 1
Create stroke order sets in electronic medical record 1

Phase 2: Team Training

Train all hospital staff on stroke recognition and activation process 1
Conduct simulation exercises with code stroke team 1
Establish communication protocols with thrombectomy center 1
Train transport teams on stroke patient management 1

Phase 3: Quality Monitoring

Track all metrics listed above 1
Monthly case review with multidisciplinary team 1
Identify barriers and implement solutions 1
Provide real-time feedback to all stakeholders 1
Continuous protocol refinement based on data 1, 8

9. Critical Success Factors

Speed is paramount: Every 30-minute delay reduces good functional outcome by 8-14% 5, 6

Parallel processing: Activate thrombectomy center and transport simultaneously with in-hospital evaluation 1, 5

Liberal activation threshold: Better to over-activate than miss strokes, especially given worse outcomes in hospitalized patients 1, 4

Drip-and-ship approach: Administer alteplase at your hospital, then transfer - do NOT delay alteplase waiting for transfer 5, 6, 7

Minimize DIDO time: Target <30 minutes from arrival at your hospital to departure for thrombectomy center 1

Continuous quality improvement: Track metrics, review cases, identify barriers, implement solutions 1, 8

Can you create a multidisciplinary inpatient code‑stroke protocol for hospitalized patients at a hospital without on‑site thrombectomy but with a thrombectomy center within a 15‑minute drive?

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