Stroke is the foremost cause of death and disability and persons presenting with stroke-like symptoms must be treated as a potential stroke [1], [2]. The terms stroke code, code stroke, and stroke alert, are interchangeable and are used to describe patients who present to the emergency department (ED) with a suspected acute stroke. Hospitals are notified in advance by emergency medical services (EMS) of an incoming patient with a potential acute stroke to try and reduce evaluation and treatment times, improving treatment rates [3], [4]. Patients admitted under a stroke code include both those patients who are ultimately diagnosed with stroke (true-stroke) and patients who present with a stroke mimic (mimics). A stroke mimic refers to any non-stroke condition that presents with focal neurological deficits, raising concern for a potential stroke.

EMS stroke prenotification (EMS-SP) differs from routine stroke code in the sense that the hospital is specifically notified a potential stroke patient is incoming [5], [6]. An EMS-SP that includes patient’s information and initial clinical assessment is key to reducing door-to-needle time, improving clinical outcomes, and has been linked to faster treatment [7], [8], [9], [10], [11], [12]. In the ED every patient who arrives as a stroke code is treated as a true stroke unless and until they are determined to not have a stroke. Therefore, in this analysis we include stroke mimic patients and true-stroke patients. A multicenter analysis using Get With-The-Guidelines® (GWTG) data reported improved prenotification rates, but highlighted disparities based on patient characteristics [3], [13]. However, the specific predictor variables influencing EMS prenotification remain unclear.

We currently lack comprehensive data on what determines EMS prenotification for patients at high risk of receiving a stroke code. Prioritizing early prenotification has a major impact on mortality and disability [14]. The Face Arm Speech Time (FAST),[15], [16] FASTER (Face, Arm, Speech, Time, Emergency Response),[17] and the Recognition of Stroke in the Emergency Room (ROSIER) [18] scale have been designed for use by EMS or ED staff, respectively, who are the usual first point of contact for these patients [19], [20]. Despite their utility, these tools are not infallible, with both false negatives and false positives occurring. EMS prenotification times are further influenced by factors such as EMS utilization, residence, insurance type, socioeconomic status, and language barriers.

Stroke remains a leading cause of long-term disability and mortality worldwide, demanding time-sensitive interventions to improve neurological outcomes [21], [22], [23], [24]. The purpose of this study is to assess the specific predictor variables influencing EMS prenotification and secondarily evaluate whether EMS-SP rates differ between true stroke and stroke mimic patients. This analysis includes all patients admitted as a stroke code to the ED and examines key predictor variables associated with prenotification.