Examine stroke code activation accuracy during emergency triage in patients presenting with dizziness or visual changes and describe a needs assessment of stroke identification performance.

A resource intensive process (“stroke code”) summons healthcare stakeholders to urgently evaluate patients presenting with stroke-like symptoms (i.e., dizziness, visual changes). Incorporating “timing”, “triggers”, and “associated symptoms” may more reliably identify stroke than the traditional symptom-quality paradigm.

Retrospective analysis of triage workflow during stroke code activation for patients presenting with dizziness or vision changes. We examined stroke code identification accuracy and cancellation rates. We performed a needs assessment to identify gaps in triage knowledge and interest in performance improvement curricula.

657 stroke codes were activated over a 12-month period, and 10% were cancelled—a rate that doubled to 20% the subsequent 6-months. "Dizziness” and "vision changes” represented 16% of cancellations the initial year and rose to 41% over the following 6-months. Despite cancellations, stroke identification accuracy worsened from 40% to 30% over the 18-month period. Of 50 consecutive stroke code cancellations, “triggers” were documented in only 7.69% and 2.71%, “timing of symptoms” in only 61.5% and 57% during the initial and subsequent year, respectively. No missed strokes were identified in the cancellations. An ophthalmologic, “other” neurologic, and medical condition were the cause of presenting symptoms in 21%, 43%, and 34%, respectively. The needs assessment from 34 of 100 triage nurses demonstrated that 74% felt confident in identifying stroke, but only 25% felt similarly when patients presented with dizziness or visual changes.

Stroke code activation occurs commonly in patients presenting with dizziness and visual disturbances and cancellation rates are high. Valuable neurological history and examination elements such as “timing” and “triggers” are seldom obtained, and stroke identification rates are low. A tailored curriculum germane to emergency triage may improve gaps in stroke assessment, knowledge and performance.