The INSTINCT consult line received 113 calls between November 2007 and January 2009. Most calls (87.6%) were between 8 am and midnight. All sites were represented, however 71.6% of calls were received from facilities located in rural counties. Eighty-nine (78.8%) were unique calls related to tPA eligibility, and seventy-three (64.6%) were regarding patients within a 3-hour window. The most common questions on tPA treatment concerned historical factors such as use in mild/improving stroke (28), history of recent surgery (22), global eligibility (14), timing/onset (11), lab values (8), and other (8). The expert recommended tPA use in 29 cases (40%), provided other advice (such as re-evaluating time of onset) in 20 (27%) cases, and recommended against treatment in 24 (33%) cases. On-site administration of tPA occurred in 17, 5, and 0 cases, respectively, for each group of expert recommendations. No medical-legal issues have been reported. In conclusion, the effort required to provide expert stroke consultation via telephone by a comprehensive stroke center to this 12 hospital group was modest and provided clear benefits in promoting community use of tPA as well as enhancing adherence to treatment guidelines, particularly in rural areas. Further investigation is needed to determine issues involved when expert recommendations on treatment were not followed.