Q. If a patient enters Emergency Department with symptoms of stroke with onset more than three hours, or even three or four days prior to ED visit, do the CT and labs need to be performed within the 45 minute timeframe required in the standard?

A. The Joint Commission expectation is as follows: “80% of acute stroke patients have a diagnostic brain image (head CT) completed (and results reported to or reviewed by a member of the stroke team) within 45 minutes of it being ordered, when clinically indicated (in acute hemorrhagic or ischemic stroke resuscitation candidates).”  Once a patient is determined not to be an IV thrombolytic therapy or an acute resuscitation candidate, the expedited CT and labs are not required.  Acute resuscitation or treatment may include use of MERCI retrieval device for ischemic stroke, reversible of coagulopathy, surgical intervention, or blood pressure management as evidenced-based approved modalities for hemorrhagic stroke.

If in the judgment of the treating physician(s) it is determined that an expedited CT is not required, the rationale for this decision should be documented in the medical record, and the team should proceed accordingly.  However, in the event of unknown time of symptom onset, the recommendation would be to treat the patient as a candidate for IV thrombolytic therapy until time of symptom onset is known.