Stroke Code Missed Activations by Emergency Medical Services: Identifying Gaps and Opportunities for Improvement

Abstract

Objectives: Delays in hospital management resulting from the failure of emergency medical services (EMS) to activate the stroke code (SC) diminish the probability of receiving acute stroke treatment, adversely affecting patient outcomes. This study aims to analyze the proportion and characteristics of patients eligible for SC not activated by EMS, within a contemporary cohort.

Methods: A retrospective cohort analysis was conducted on prehospital stroke patients from the Catalan SC registry from 2016 to June 2022, who were transported by ambulance. Patients were classified according to whether EMS activated SC or not. Baseline demographic characteristics, comorbidities, clinical episode details, and treatment timelines were analyzed.

Results: Among 34,331 subjects, 28,221 (82%) were transported by EMS, with SC activation occurring in 22,968 (81%) cases. Patients for whom SC was not activated presented with lower National Institutes of Health Stroke Scale scores and longer intervals from symptom onset. Large vessel occlusions were more frequent in EMS-activated patients (24% vs. 18%). The non-EMS-activated cohort exhibited a higher prevalence of posterior circulation occlusions. Despite the absence of initial SC activation, 28% of these patients ultimately received reperfusion therapy, albeit with significant delays compared to the EMS-activated group.

Conclusions: Most acute neurological patients who qualify for SC activation are accurately identified by EMS. However, a substantial proportion of patients are missed, leading to treatment delays. Enhancing the capacity of EMS to recognize the clinical heterogeneity of stroke presentations is essential for prompt SC activation and optimizing patient outcomes.