Code Stroke

The ED attending or EM-3 resident will call a Code Stroke from the dashboard for:

  1. Patients who present with NIHSS ≥ 1 within 6 hours of symptom onset

  2. Patients who present with NIHSS ≥ 6 within 24 hours of symptom onset

For a patient suspected to have a large cortical or basilar stroke, order a CTA head/neck as well as a CT perfusion with the CT, as the patient may be a candidate for endovascular treatment.

Notes:

1. Use these criteria even if the patient does not meet criteria for IV tPA use; the DPH collects data and we are measured on patients who are discharged with a stroke or TIA, not just the ones to whom we give tPA.

2. As a general rule, a Code Stroke should be activated when a patient (who otherwise meets the above criteria) has the abrupt onset of focal neurological deficits. Some of these patients will end up with a final diagnosis of seizure, migraine, tumor or other, but the decision must be made in the first minutes.

3. Nursing must notify the EM attending immediately from triage for a possible TIA or stroke patient. A trigger does not necessarily need to be called but the attending must be notified immediately so that a Code stroke can be activated as rapidly as possible.

5. EVERY MINUTE counts

  • Nurses - alert the EM-3 or attending

  • Emergency physicians - order the CT and labs as soon as you activate the code

  • Neurology and EM must work together to accomplish actual time savings.

6. The state is measuring various intervals (recommended time window)

  • Registration to code stroke activation (15 minutes)

  • Door to CT (25 minutes)

  • Labs ordered to labs resulted (45 minutes)

  • Door to tPA (60 minutes)

Right now, these are just DPH and Get With the Guidelines measures but they may become a pay-for-performance metrics in the future.