In lower-middle-income countries (LMIC) like Pakistan, implementing evidence-based acute stroke care in areas with limited healthcare resources is challenging. Recent data suggest that including trained nurse practitioners in acute stroke teams results in improved intravenous thrombolysis rates and enhanced patient outcomes.

We conducted a retrospective per-post study comparing stroke metrics before and after the introduction of the SNAP program and the e-ambulance service. Pre-implementation data consisted of acute stroke cases managed till March 2025, while post-implementation data spanned five months following the introduction of these initiatives. Primary outcomes included the total number of intravenous tissue-plasminogen activator (tPA) injections given and the number of thrombectomies performed. We also measured the mean time from ER to angio-suite.

From July 2024 till the implementation of the SNAP program in March 2025, 56 tPA were administered, with a monthly average of around 6 injections. From April 2025 to August 2025, the monthly average increased significantly from 6 to 10, with an overall number of 50 injections administered during these 5 months. During pre-implementation period, a total of eight thrombectomies were performed over 13 months. The number increased to 16 in five months after these measures were introduced. Post-implementation, mean triage to CT scan, triage to stroke bay arrival, and triage to tPA time were 36, 54, and 85 min, respectively. With introduction of an e-ambulance, mean ER-to-angio time reduced from 45 min to 12 min (range 10-15).

This experience from an LMIC highlights the importance of having stroke-trained nurses in ER. Acute stroke metrics improved significantly with the introduction of trained nursing staff under the SNAP program. The e-Ambulance service improved the transit time markedly from ER to the angio-suite.