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Stroke Code Missed Activations by Emergency Medical Services: Identifying Gaps and Opportunities for Improvement
Andrés Girona San Miguel1, Sílvia Solà2, Martha Elena Vargas1
1Functional Unit of Cerebrovascular Disorders, Neurology Department, Hospital Clínic de Barcelona, Barcelona, Spain.
Prehospital Emergency Care
|December 1, 2025
Summary
Emergency Medical Services (EMS) missed opportunities to activate stroke codes (SC) for eligible patients, causing treatment delays. Improving EMS recognition of diverse stroke symptoms is crucial for better patient outcomes.
Area of Science:
- Neurology
- Emergency Medicine
- Public Health
Background:
- Delays in hospital management due to missed stroke code activations by Emergency Medical Services (EMS) negatively impact acute stroke treatment and patient outcomes.
- This study addresses the gap in understanding the characteristics and frequency of patients eligible for stroke code activation who were not identified by EMS.
Purpose of the Study:
- To analyze the proportion and characteristics of stroke patients eligible for stroke code activation but not activated by EMS.
- To identify factors contributing to missed stroke code activations in a contemporary cohort.
Main Methods:
- Retrospective cohort analysis of prehospital stroke patients from the Catalan Stroke Code registry (2016-2022).
- Classification of patients based on EMS activation of stroke code.
- Analysis of demographic characteristics, comorbidities, clinical details, and treatment timelines.
Main Results:
- Out of 34,331 subjects, 28,221 were transported by EMS, with 81% having stroke codes activated.
- Patients without stroke code activation had lower NIH Stroke Scale scores and longer symptom onset intervals.
- While 28% of non-activated patients received reperfusion therapy, it was significantly delayed compared to the activated group.
Conclusions:
- EMS accurately identifies most acute neurological patients requiring stroke code activation.
- A significant proportion of eligible patients are missed, leading to critical treatment delays.
- Enhancing EMS's ability to recognize the clinical heterogeneity of stroke presentations is vital for timely stroke code activation and improved patient outcomes.
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