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Background and purpose: The study aimed to assess the efficiency (percent treated) of existing in-hospital stroke alert activation criteria and to improve these criteria.Methods: 209 patient records from in-hospital stroke alerts at an academic medical center between January 2015 and December 2016 were reviewed retrospectively. Patients were sorted into five categories by final diagnosis: cerebral ischemia, cerebral hemorrhage, seizure, delirium or toxic/metabolic encephalopathy, and other. Acute treatment result of any in-hospital stroke was recorded. The study team determined adherence to the institution’s existing in-hospital stroke alert activation criteria. To improve efficiency a new set of in-hospital stroke alert activation criteria called “S3TOP for Stroke” was then developed. The checklist for “S3TOP for Stroke” guides hospital staff to assess the following items: symptoms, sedation, sugar, time, oxygenation and pulse. The checklist was then retrospectively applied to the 209 records.Results: Of 209 patients who received in-hospital stroke alerts according to existing activation criteria: 192 (91.9%) met existing criteria, and 14 (6.7%) received acute stroke treatment. Applying the “S3TOP for Stroke” checklist to the study group excluded 56 of these and included all 14 (14/153 =9.2%) who received acute stroke treatment.Conclusions: This study found good adherence with poor efficiency for existing institutional stroke alert activation criteria. Retrospectively, the “S3TOP for Stroke” checklist improved efficiency. Prospective testing of this algorithm is underway.