A five-year comparative analysis of attending physician and non-attending initiated code stroke activations in a primary stroke center emergency department.

BACKGROUND: Rapid and accurate stroke triage is critical to optimizing outcomes for acute ischemic stroke. Code Stroke protocols rely on emergent neuroimaging to identify candidates for reperfusion therapy. While ER attending physicians traditionally initiate activations, non-attending providers, including nurse practitioners, physician assistants, residents, and nurses are increasingly responsible for activation decisions.

OBJECTIVE: To evaluate the diagnostic accuracy of Code Stroke activations stratified by initiating provider type, comparing radiologic yield of acute infarction, large-vessel occlusion, or other critical intracranial pathology.

METHODS: We retrospectively reviewed all Code Stroke activations at Monmouth Medical Center from July 1, 2020, through June 30, 2025. Code Stroke activations were categorized by provider type (ER Attending Physician vs. Non-attending, including, nurse practitioners, physician assistants, and nurses). Neuroimaging endpoints included acute infarct on diffusion-weighted MRI, large-vessel occlusion or high-grade stenosis on CTA, or other critical findings such as hemorrhage or mass lesions. Annual trends in activation volume, modality utilization, diagnostic yield, and stroke-related continuing education hours were analyzed.

RESULTS: Code Stroke activations increased significantly from 2020 to 2025, with diagnostic accuracy ranging from 25 to 35%. ER attending physician-initiated activations rose by 30% while maintaining stable accuracy. Non-attending activations more than doubled in 2025 and achieved a yield of 35.7%, surpassing the 29.7% accuracy of attending providers. Among the 734 patients who underwent MRI with diffusion-weighted imaging, 453 studies (62%) demonstrated no acute intracranial abnormality, while acute ischemic stroke was identified in 227 patients (31%), intracranial hemorrhage in 31 patients (4%), and other clinically significant findings-including tumor, metastases, or demyelinating disease-in 23 patients (3%). Concurrent increases in annual CEU hours across all groups correlated with shorter imaging times and improved non-attending diagnostic yield.

CONCLUSION: Non-attending providers now play a vital role in acute stroke triage and demonstrate diagnostic performance comparable to attendings. Structured education, including NIHSS certification and CEU requirements, was associated with incrementally improved accuracy and operational efficiency. These findings support integrating non-attending providers into Code Stroke pathways. Further multi-center validation is warranted.