To assess utilization of BEFAST in the emergency department (ED) of a rural hospital after inclusion in the acute stroke protocol.

There are known regional disparities in treatment rates with thrombolysis and thrombectomy for acute ischemic stroke. BEFAST has been implemented in acute stroke protocols to aid in recognition of signs of stroke, but its utility in a rural ED is not well known. In February 2022 the acute stroke protocol was updated to include the BEFAST screening tool.

A retrospective chart review was conducted on all patients with an ED diagnosis of stroke, dizziness, vertigo, imbalance, lightheadedness or visual disturbance for six months before and after BEFAST stroke protocol implementation.  Primary outcomes included appropriateness of tool utilization and subsequent activation of the acute stroke order set.  Secondary outcomes were treatment with tenecteplase and thrombectomy, door to needle time, and door to transfer time. Pre- and post-implementation cohorts were compared.

In the pre- and post-implementation cohorts there were 151 and 210 patients for whom a BEFAST was appropriate.  BEFAST was utilized in 54% (n=81) in the pre-implementation cohort and 77% (n=161) in the post-implementation cohort (p<0.01). The acute stroke order set was activated by the ED in 37% (n=30) pre-implementation and 47% (n=76) post- implementation (p<0.01). Five patients were treated with tenecteplase, thrombectomy or both in the pre-implementation cohort and 5 post-implementation. Median time door to needle was 44 minutes pre-implementation and 58.5 minutes post-implementation. Median door to transfer times were 214 minutes and 141 minutes respectively.

Although BEFAST can be successfully utilized in the rural hospital emergency department, utilization does not always result in activation of the acute stroke order set.  Reasons for failure to activate the acute stroke order set in the rural ED need to be elucidated.