Acute code stroke activations seen in the emergency department: how often are we missing the mark?

Background: A code stroke activation involves mobilization of finite health care resources. We evaluated the proportion of activations that were non-compliant with code stroke criteria, and the acute treatments and healthcare use after these activations in two urban comprehensive stroke centres.

Methods: We conducted a multicentre health records review of adult patients seen in the context of code stroke activations in the emergency departments (ED) at two comprehensive stroke centres in Toronto, Canada, between January 1 and December 31, 2022. Code strokes activated in the field by paramedics, or by physicians or nurses in the ED were included. The primary outcome was the proportion of non-compliant activations, defined as an activation that did not meet institutional criteria. Secondary outcomes were receipt of thrombolysis or thrombectomy in code stroke activations that were non-compliant vs. compliant.

Results: A total of 1028 code strokes were included, of which 768 (74.7%) were paramedic-initiated. Overall, 314 (30.5%) were non-compliant: 19.6% paramedic-initiated and 70.7% ED-staff initiated. Incorrect determination of the last seen normal time was the most common cause of non-compliant activations. Although a small number of patients received reperfusion therapy despite non-compliant activation (n = 26, 8.2%), most of these patients were less likely to receive these treatments or be admitted to a stroke unit compared to patients with compliant activations.

Conclusion: One in three code stroke activations were non-compliant to activation criteria. Quality improvement strategies such as increasing adherence to code stroke protocols by simplifying the protocol, use of simulation exercises, and involving stroke team for borderline cases could help reduce non-compliant activation and conserve healthcare resources.