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Introduction: As a Comprehensive Stroke Center and a hub for telestroke stroke alert process is continual effort. Collaborating with spoke Stroke Coordinators is imperative to improving overall stroke alert process. A goal of national guidelines is to achieve a door to needle for administration of intravenous tissue-type plasminogen activator (tPA) of less than 60 minutes. A point of contention in the stroke alert process is the debate between Registered Nurse mixing versus pharmacy mixing of tPA. The question remains contentious in our telestroke community hospitals and therefore was analyzed.Methods: The telestroke network consists of 14 community hospitals of various bed sizes and stroke volume. Seven of the spokes use an Emergency Room nurse to mix tPA and the remaining seven use their pharmacy. Using data generated over 4 years from the telemedicine provider, the door to needle was assessed and compared. In addition, door to telestroke consultant decision to administer tPA was also analyzed. The average, minimum, maximum and median time in minutes was calculated for the door to needle and door to decision time points.Results: The average time for door to needle when nurses mix is 83 minutes versus an average door to needle time when pharmacy mixes is 93 minutes (p = 0.0398). The median time for nursing mixing is 81 minutes and pharmacy mixing is 89 minutes. The average door to consultant decision to administer tPA when nurses mix is 19 minutes compared to an average door to consultant decision to administer tPA when pharmacy mixes is 20 minutes (p = 0.5593). The fastest door to tPA administration is a spoke with a pharmacy mixing the drug at 23 minutes.Conclusion: The analysis of the telestroke network door to needle and door to consultant decision did not conclusively add evidence to a benefit of either the Emergency Room nurse or a Pharmacist mixing tPA. An effective and efficient stroke alert process demands a coordinated effort by all individuals. Not one role in the process makes the target achievable. Whether the Pharmacist or the bedside nurse prepares the drug, what makes it possible to achieve the target is the collaboration and understanding of everyone’s role.