Acute ischemic stroke (AIS) is one of the major causes of fatality and persistent disability globally, representing about 85% of total stroke cases.1,2 Sudden occlusion of a cerebral artery, leading to interruption of cerebral blood flow and rapid neuronal injury resulted in this disease.3Approximately 1.9 million neurons are lost every minute during untreated cerebral ischemia, which emphasize the critical importance of rapid diagnosis and treatment4,5 As a result, the concept of "time is brain" has become the cornerstone of modern acute stroke management.6

Intravenous fibrinolytic therapy using genetically engineered tissue plasminogen activator (IV- fibrinolytic agent, alteplase) continues to be the standard treatment for suitable patients arriving no later than 4.5 hours of onset of symptoms.7,8,9 Numerous clinical trials have demonstrated that earlier administration of thrombolytic therapy significantly improves neurological recovery, reduces long-term disability, and enhances functional independence.6 Global guidelines from the American cardiovascular and stroke guidelines and the European stroke guidelines suggest door-to-treatment time of less than one hour, with comprehensive stroke centers increasingly aiming for initiation of therapy during 45 minutes or fewer.8,9

In spite of these recommendations, achieving the target DTN time remains challenging in many healthcare settings, especially within low- and middle-income settings. Delays commonly arise at multiple stages of emergency department care, including delayed patient recognition, prolonged triage, incomplete pre-hospital communication, slow neuroimaging, laboratory processing delays, delayed neurological consultation, and inefficient coordination among emergency physicians, neurologists, radiologists, nurses, and laboratory personnel. Administrative procedures and lack of standardized treatment pathways further contribute to prolonged treatment times, reducing the proportion of patients who receive timely thrombolysis and adversely affecting clinical outcomes.

Many hospitals have introduced stroke pathways or fast-track systems to streamline emergency stroke care. These protocols typically incorporate emergency medical services (EMS) pre-notification, immediate stroke code activation, rapid triage, direct transfer to computed tomography (CT), parallel laboratory testing, predefined treatment algorithms, and multidisciplinary team coordination. Previous studies have shown that such workflow optimization strategies can substantially reduce DTN time without requiring additional infrastructure or financial resources. However, the effectiveness of these interventions varies across institutions because emergency department organization, staffing, available resources, and patient flow differ considerably between healthcare settings.

Although stroke care services in Pakistan have better in recent ages, organized stroke pathways are not yet widely established. Thus, there is limited local evidence identifying the emergency department factors associated with delayed thrombolysis or assessing the effectiveness of multidisciplinary fast-track protocols in reducing treatment delays. Recognizing these barriers is important for developing practical, locally adaptable interventions that can improve the efficiency of acute stroke care while maximizing the benefits of intravenous thrombolysis.

Hence, the existing study aimed to identify modifiable emergency department barriers contributing to prolonged door-to-treatment time in individuals with acute ischemic stroke and to evaluate the effectiveness of a multidisciplinary Stroke Fast-Track Protocol in reducing treatment delays and improving functional outcomes. We assumed that implementation of a structured, multidisciplinary workflow would meaningfully decrease DTN time, increase the proportion of patients getting thrombolysis within the recommended one-hour target, and increase clinical outcomes without increasing treatment-related complications.