Cross-sectional analysis of emergency department neurology access and 30-day stroke mortality in community hospitals

INTRODUCTION: Access to neurology expertise during emergency department (ED) stroke care may influence treatment timeliness and outcomes, yet specialist availability varies widely across U.S. community hospitals. While telestroke has expanded access, its impact on patient outcomes in community EDs remains unclear. METHODS: We performed a cross-sectional analysis of 52 community EDs participating in the American College of Emergency Physicians Emergency Quality Network Stroke Collaborative (2022-2024), linked to Centers for Medicare & Medicaid Services risk-standardized 30-day stroke mortality data. Neurologist availability during ED stroke codes was categorized as in-person, telestroke, or phone-only involvement. Linear regression assessed association between neurologist access and hospital-level mortality, adjusting for ED stroke volume, rurality, stroke registry participation, and disposition practices after thrombolysis. RESULTS: Neurologists were available in-person at 48.1% of EDs, via telestroke at 38.5%, and by phone or not at all at 13.5%. Mean 30-day stroke mortality was 13.1% for in-person access, 14.0% for telestroke, and 15.2% for phone-only involvement. Compared with in-person access, EDs with phone-only neurology had significantly higher mortality (adjusted difference +1.7%, 95% CI 0.32-3.08; p = 0.02), whereas telestroke was not significantly different. Rural EDs also had higher mortality (+2.8%, 95% CI 0.89-4.65; p = 0.006). Other hospital characteristics were not associated with mortality. CONCLUSIONS: Limited neurologist access to phone-only during ED stroke codes is associated with higher 30-day mortality, but telestroke availability did not show significantly different outcomes compared to in-person neurology, supporting the role of telestroke in improving access and mitigating disparities in resource-limited settings.