1.                  Initial team assignment.  Day or night, all stroke alerts will be discussed with the stroke fellow on call as is standard practice.  At the conclusion of the stroke alert process (ideally within 30 min of the initial call), the stroke fellow will determine if the diagnosis is likely stroke/TIA (or the primary evaluation is for stroke/TIA), or not, and then explicitly triage the patient to either the stroke or general consult service.  The residents and APPs will add that patient to the designated list. For all non-stroke alerts, the residents and APPs will discuss with the senior resident on call as is standard practice and the senior resident will triage that patient to the appropriate list.

2.                  Communication. 

a.          Each morning, the attendings should review the patients placed on their lists overnight. If either attending has issues with the patients assigned to their list, there should be a brief morning phone call or text prior to rounds between the general consult attending and stroke consult attending to make adjustments as needed. This should be based on information available at that time, which could include new information (history, imaging, etc.) after initial assignment.

b.          During the day, if a stroke alert is being triaged to the general service for an obvious non-vascular diagnosis, the stroke consult attending should text the general consult attending to staff. If a stroke alert is being assigned to the general service during the day for an uncertain etiology or nuanced presentation, the stroke consult attending must call to discuss with the general consult attending.

3.                  Post-initial consult adjustment.  It is very clear that the initial diagnosis of stroke/TIA or not is based on limited information and is imperfect, and 10-20% of patients may be subsequently be found to have been mismatched (i.e. a stroke patient on general consult service or non-stroke patients on stroke service).  In many cases, those patients can continue to be managed by the receiving team despite the mismatch. The general consult team can also discuss with the remote stroke support (RSS) attending in the morning.  However, if either attending feels that a mismatched patient should be followed instead by the other team, they must call and discuss a transition in care with the other attending. If an attending remains uncomfortable after this discussion, this should be brought to us to address.

4.                  If volume becomes challenging on either side, the attendings will communicate by phone in real time to flex accordingly with a focus on helping each other and providing optimal patient care.