In both scenarios, the focus was to identify potential IV tPA candidates and initiate infusion as soon as possible. If no hemorrhage was seen, an update page was sent out based on NIHSS (NIHSS 6 also included the interventional team). A stroke alert page was triggered if the symptom onset was within 8 hours of last known normal and the stroke team went to the identified location, where the National Institute of Health Stroke Scale (NIHSS) was performed and the patient underwent a noncontrast head computed tomography scan (HCT). According to the old algorithm, a patient with acute, nontraumatic focal neurologic deficit concerning for ischemic stroke was identified in the ED or as an inpatient. Prior to May 2012, a previous stroke algorithm was in effect. The Vanderbilt University Medical Center (VUMC) Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine revised an existing protocol for the preparation, response, and treatment of ischemic stroke patients. While these studies provide insight into developing a stroke algorithm, we hope to describe our institutional experience, focusing on the process involved. In this regard, several studies have explored ways to expedite acute stroke care and improve triage times. The paradigm, “ Time is brain” – that every passing minute reduces the chance of neurological recovery and worsens prognosis – continues to thrust efforts to reduce time to symptom recognition, patient transport, and neurological evaluation and intervention. The Center for Disease Control and Prevention (CDC) reported that approximately 22% of US counties did not have a hospital, 31% did not have a hospital emergency department (ED), and approximately 77% lacked hospitals with neurological services. A major contributor to the inequity in stroke mortality rates across Tennessee is timely access to care, typically only available at major urban hospitals. Located in the stroke belt, ischemic stroke mortality rates in Tennessee are some of the highest in the country, where 58–125 per 100,000 individuals died from ischemic stroke versus approximately 42 per 100,000 individuals nationally during 2008–2010. Stroke costs are upwards of $41 billion annually due to medical expenses and work-hours lost. Ischemic stroke is one of the leading causes of morbidity and mortality in the United States (US) resulting in approximately 795,000 first-time or recurrent strokes each year, of which 130,000 result in death.
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