Background: The activation of Emergency Department (ED) Code Stroke at our primary stroke center was not consistently meeting metric goals set by the hospital system for Door to Needle (DTN) time of <45 minutes. The process utilized Provider-only activation, with delays from limited providers and multiple relays of communication. Purpose: This practice change aimed to discover if nurse-activation of a Code Stroke in triage influenced the DTN metrics of: Door to Activation, Door to CT initiation, and DTN times. Methods: A collaborative approach was used to identify points of delay, develop innovative workflow, and education to the new process. A “Code Stroke Button” was added to the emergency call system terminal to minimize communication relays; pressing the button sends an alert directly to the Code Stroke response team. Education on the updated workflow was provided to the ED team by a multidisciplinary team (neurologist, ED provider, Nurse Educator and RN Stroke Coordinator). Training and education included: recognition of stroke symptoms, criteria for Code Stroke activation, and feedback. The Plan-Do-Check-Act framework was used to evaluate process performance monthly for 6 months and data was analyzed at one year post implementation. Results: By Quarter 4, six months from change, median times for all metrics saw meaningful reduction. Door to Activation time was reduced by 16 minutes and Door to CT initiation by 11 minutes. In thrombolytic cases, median DTN decreased by 12 minutes. At one year, the median DTN time improved by 20.8% (53 minutes to 42 minutes), meeting the DTN goal of <45 minutes. Concerns for overactivation were dispelled with data at one year showing 91.5% of nurse-activated Code Stroke met criteria. Conclusions: The activation of Code Stroke by nurses in triage led to a meaningful reduction in specific metrics. A collaborative approach was imperative to identify process issues and led our team to make innovative changes. Constructive feedback allowed staff to confidently put changes into practice. Sharing monthly data results with ED nurses, technicians, management, providers, Stroke Program management and neurologists allowed for evaluation of the changes to meet the DTN goals.
Crandell et al. (2026) studied this question.