Impact of Nurse-Initiated Stroke Alerts on Door-to-Needle Times for Thrombolysis at a Rural Emergency Department

While prior studies from academic centers suggest nurse-initiated stroke alerts can reduce treatment delays, there is limited evidence from rural hospital settings. We evaluated door-to-needle (DTN) times for thrombolysis before and after the implementation of nurse stroke alert activation in a rural emergency department.

This retrospective, observational before-and-after analysis was conducted at a rural Texas community ED with 15,000 annual visits. All patients with stroke alert designation from 5/2000 to 5/2025 were included in the study group. In January 2024, as part of a hospital QI initiative, triage nurses were designated to call “stroke alert” for patients with neurological symptoms meeting standardized criteria. Data was collected by trained data abstractors for the purpose of QI, and, then, study authors conducted a secondary analysis. The primary outcome was DTN time for patients before and after the commencement of the QI protocol, analyzed by t-tests.

A total of 1,042 patients who had stroke alerts initiated were included; mean age 63+/-16 years, 53% female, 561 in the post-intervention period. Among these, 56 patients received intravenous thrombolysis (pre: n=36; post: n=20). Mean DTN time was significantly shorter in the post-intervention group (57+/-29 vs. 37+/- min; p=0.01). Arrival-to-consult time decreased from 28+/-52 to 12+/-29 minutes (p<0.001), and arrival-to-video consult time from 32+/-52 to 16+/-29 minutes (p<0.001). Other intervals, including consult-to-needle and video-to-needle, showed non-significant trends favoring the intervention group. Among all stroke alerts not treated with thrombolysis, common final ICD-10 diagnoses included dizziness (19.2%), paresthesia (16.7%), and TIA (15.7%). 17.7% had a final diagnosis of AIS/CVA but did not receive thrombolysis.

At a rural community ED, implementation of nurse-initiated stroke alerts was associated with reduced DTN times and earlier consult activation for thrombolysis. These findings add to the growing body of evidence supporting nurse-led stroke activation protocols and suggest potential benefits in resource-limited rural settings, though further validation is warranted.