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Introduction: With 18 University Hospitals at 12 locations, UH Case Medical Center is second in the University HealthSystem Consortium ranking for patient transfers at 24% of total volume. In 2009, the University Hospitals System Stroke Program developed a Clinical Practice Guideline (UHSSP-CPG) with the goal of providing the same, high quality stroke care throughout the health system that included a triage and transfer algorithm.Methods: From 2011-2q2016 (annualized), 5666 hospital discharges from MS-DRGs 61-66 representing medical management of cerebral infarction (CI) and intracerebral hemorrhage (ICH) were analyzed from 6 UH Legacy hospitals- UH-Case CSC, 4 PSCs and 2 Stroke Ready Facilities (SRF). Advanced expertise (AE) was developed at 2 PSCs for medical management of CI (2014) and low risk ICH (2015, 2016).Results: From 2011 to 2016, total stroke discharges increased across the UHSSP by 22%; total CI by 14%; and total ICH by 68%. Total IV-tPA cases increased by 174%, representing an increase in IV-tPA utilization from 6% to 15% of total CI. At UH-Case CSC, total stroke discharges increased by 15%, especially for ICH which increased by 63%. At the PSC-AE hospitals, total stroke discharges increased by 133%; IV-tPA Drip and Keep by 1300%; and total ICH by 700%. Total stroke discharges decreased by 28% at the other PSC hospitals.Conclusions: Implementation of the UHSSP-CPG triage and transfer algorithm resulted in an increase in total stroke volume across the health system but shifted more patients with lower risk ischemic and hemorrhagic stroke to PSC within their community. This strategy promotes enhanced access of more complex stroke patients to UH-Case CSC. As hospitals continue to coalesce into systems, robust triage and transfer algorithms will play an increasingly important role in systems stroke care.