Objective:

This study aimed to characterize stroke code activations in a tertiary non-acute care hospital without an emergency department by evaluating diagnostic yield, timing relative to last known well (LKWT), and the frequency and outcomes of acute interventions.

Background:

In-hospital stroke care is increasingly recognized as a major gap in acute systems of care. Stroke code activations within non-acute care settings such as inpatient wards remain under-studied, including the diagnostic yield of such activations, their timing within therapeutic windows and potential for acute intervention. There are fewer standardized pathways for rapid stroke triage, leading to inefficiencies in activation, diagnostic evaluation, and treatment delivery. 

Design/Methods:

A retrospective review was conducted of all acute stroke code activations at Keck Hospital of USC from October 2021 to December 2024. Data included presenting symptoms, neuroimaging, final adjudicated diagnosis, LKWT, and acute interventions were analyzed. Activations were categorized by LKWT-to-activation intervals: ≤4.5 hours, 4.5–24 hours, and >24 hours.

Results:

A total of 346 activations were identified. Final diagnoses included acute ischemic stroke (20.8%), hemorrhagic stroke (7.2%), TIA (4.6%), stroke recrudescence (2.2%), and stroke mimics (64.7%). Among 306 cases with documented LKWT, the mean LKWT-to-activation interval was 357 minutes (SD 528); 64% occurred within 4.5 hours and 95% within 24 hours. Despite early activation, treatment yield was low. Of activations ≤4.5 hours, most were stroke mimics, commonly encephalopathy/delirium (30.1%) and seizures (6.1%). Reperfusion therapies were infrequent (IV thrombolysis 1.7%, thrombectomy 2.9%). Peri-procedural strokes accounted for 37.5% of ischemic cases.

Conclusions:

Although most stroke code activations occurred within acute intervention windows, many early activations were driven by stroke mimics, yielding few treatments. These findings suggest that LKWT alone may be inadequate for guiding activations in non-acute care settings. Targeted triage strategies—such as tiered response models with early neurological screenings for mimic presentations—may improve diagnostic precision and stroke resource utilization in future studies.