Abstract TP027: Neurology Resident Autonomy in Acute Stroke Management

Background: The standard of care for acute stroke management includes the use of thrombolytics. In most academic centers, attending physicians typically oversee thrombolytic decisions to minimize complications—especially symptomatic intracerebral hemorrhage (sICH)—and to address medicolegal concerns. This study aims to demonstrate that granting resident autonomy over thrombolytic decisions does not increase the rate sICH nor significantly prolong door-to-needle (DTN) times compared to national benchmarks. Empowering residents to lead acute stroke management prepares graduates to confidently administer thrombolytics in their future practice. Methods: This is a retrospective chart review of patients 18 years or older who received thrombolytics for acute stroke by a resident’s decision-making process without attending oversight between July 2022 to June 2025. Thrombectomy cases were excluded as these are always overseen by attendings. sICH and DTN averages were calculated over the 3 academic years and compared to national averages using Get with the Guidelines (GWTG) database. A post graduate survey assessing comfortability with thrombolytic decisions was sent to graduates and elicited 35 responses. Results: A total of 117 thrombolytic cases were reviewed. Of these 50 were managed without attending/fellow oversight, and 19 met the criteria for inclusion in the GWTG database; the remainder met GWTG exclusion criteria. Over a three-year period, our rate of sICH remained 0.0%, compared to the national average of roughly 4% per year. DTN times were also comparable, with 80–100% of cases meeting the GWTG DTN goal of <60 minutes and 60–80% achieving the <45-minute goal. Post-graduate surveys (n=35) showed that 88.6% of graduates felt comfortable/very comfortable discussing thrombolytics. Additionally, 97.2% agreed/strongly agreed that their education adequately prepared them for independent thrombolytic decision-making. Only one-third of respondents pursued stroke/NCC fellowships. Conclusions: Resident driven decisions to give thrombolytics did not result in increased sICH rates or prolonged DTN compared to national averages. This demonstrates that resident autonomy can be safe and effective. Prioritizing resident autonomy during training is associated with greater confidence and competence reported by attendings post-graduation, independent of subspecialty training, as demonstrated by self-reflective surveys.