6-24 Hr ACT-FAST Protocol

6-24H Protocol - Initiative to "Call More, Activate Less" and Do ACT-FAST*
*this includes "Assess at the Door"

The ED physician group will “call more and activate less”.
Of course, if you review the form and the patient meets criteria, just activate a code stroke.
If they clearly do not meet criteria, then don’t activate, no need for a call.
It is only if you are on the fence and are considering erring on the side of activating a code stroke, we are requesting you call the staff stroke neurologist on call to discuss. They can be reached by paging, or locating can transfer you directly to their cell phone.
This should be a staff to staff discussion. After the discussion, they will either advise:
1) activate a code stroke
2) do not activate a code stroke (and proceed with typical ED triage/assessment).

The stroke physician will not request that we order any expedited imaging, as we recognize that is not always reliable. For several practical reasons (including there is no MRN during this discussion), the stroke neurologists are not able to document their own note in Sunnycare, but the ED physician Assess form is scanned into Sovera and becomes part of the chart. ED physicians should be documenting the discussion on this Assess form (+/- on Sunnycare later), and the stroke physicians expect their names to be mentioned in this note for medicolegal reasons.


Edge cases: 

The Stroke team was able to identify 5 of the 6 cases of treatment (TNK or EVT) in patients who didn’t meet criteria, and the big theme was significant neurologic deficit. This suggests that the ones to really consider calling are the patients with severe neurologic deficits but for some reason don’t officially meet criteria. In more detail:
-No clear last seen normal time so initially no code stroke, but patient developed worsening aphasia in waiting room and so then code stroke activated
-Severe neurological symptoms, but had relative contraindications (due to baseline functional status)
-Several episodes over 6-24h isolated aphasia (and also mild/mod arm weakness, but not drop to bed)
-Severe leg weakness but not arm
-Did not meet code stroke criteria as mild symptoms (NIHSS=2), however they happened to meet criteria for a clinical trial which included TNK.

Please note that for referring hospitals - they are obligated to perform a CTA during daytime hours to confirm or refute the presence of a large-vessel occlusion. After hours, a plain CT head is required to rule out a bleed or low ASPECTS.