The Stroke Code was introduced in Catalonia, covering the whole region in 2006. Currently, there are six comprehensive stroke centers that can provide intravascular neurosurgical treatment 24 hours a day, for seven days a week, and eight primary stroke centers that can give intravenous treatment and have a stroke unit. In addition, since 2013, 12 local centers have been set up that can give thrombolysis using a Telestroke system connected to an expert neurologists via video conferencing facilities. The Stroke Code is activated around 5,000 times per year, which corresponds to some 10 to 15 activations per day for the whole of Catalonia. The criteria for activation of a Stroke Coding Catalonia are neurological symptoms suggestive of stroke according to the rapid. Two, a patient with no previous functional dependence, according to RANCOM, less than eight hours since onset including patients with unknown time of onset or wakeup stroke and no age limit. Rapid is a simple tool that allows identification of patients with focal neurologic signs suggestive of stroke. If one of the rapid symptoms is present, the Stroke Codes should be activated. The rapid acronym stands for [inaudible]. Translated in English, this means smile, lift your arms, speak, stroke, and quickly. The RANCOM tool allows simple assessment of the patient's previous functional status. The letters RANCOM stand for RAN, for Rankin, a scale used to assess patients functional status and COM, for comorbidity. You should ask if prior to the stroke, the patient could mobilize without help even if this was with a stick or a wheelchair. If he could shower and go to the bathroom without help. If you could get dressed without help. If the answer is yes to all three questions, the Stroke Codes should be activated. When we look at the final diagnosis of patients in Catalonia for whom the Stroke Code was activated, most are ischemic strokes. Twenty percent are hemorrhagic strokes and the minority are transient ischemic attacks. It should be noted that 50 percent of cases that involve Stroke Code activation are mimic stroke. In these cases, after performing a full neurological assessment and investigations, a non stroke diagnosis is established. The most common diagnosis being seizures, non-organic or functional impairment, migraine with aura and metabolic abnormalities such as hypoglycaemia. The Stroke Code system, the cell progressively increase access to specialized care and reprofusion treatment in patients with stroke. All cases of Stroke Code activation are registered in mandatory population-based registry, Seagat registry managed by Catalonia cerebrovascular disease program which allows monitoring of the number of patients treated and their clinical outcome. In Catalonia, the number of patients who benefits from reprofusion treatment has increased in recent years, reaching a current level of more than 1,600 patients per year, which represents 20 percent of all patients with stroke. In addition, metrics show that times are in general very short with an overall time from onset of symptoms to treatment of about 120 minutes, from rival that's hospital to intravenous TPA treatment, door-to-needle of 38 minutes and endovascular treatment of 68 minutes. The data from Catalonia show good outcomes with half the patients who receive reprofusion treatment being independent in basic activities of daily life at three months and the mortality and hemorrhagic complication rates in line with the average. Finally, it is important to remember that the Stroke Code systems were first introduced to allow intravenous thrombolysis to be given as early as possible. However, in light of recent evidence on the benefits of intravascular treatment in patients with large vessel occlusion, the Stroke Code systems must be reorganized and we must establish pre-hospital circuits that allow definitive treatment, arterial regularization to be given as early as possible. One of the questions currently being investigated is, where should the EMS transfer patients with large vessel occlusions? One option is to transfer them to the closest local center where the patient can receive early intravenous treatment and then later transfer them to endovascular center if necessary, known as the drip and ship route. Another option is transfer the patient directly to a center that can offer endovascular treatment, a mothership. Establishing the most appropriate method for identifying patients who are candidates for endovascular treatment in the pre-hospital setting and the model that provides the righteous benefits are the issues that are currently being investigated. In summary, the Catalonia and model is an example of a regional model which includes different levels of health care and require significant coordination between the emergency medical services and the receiving stroke centers. Stroke Code protocols should be adapted to the needs of each region. But there are some common key points for their success. A single protocol that all staff are aware of, coordination between EMS and the receiving stroke centers, training for healthcare professionals, recording an analysis of outcomes and motivated professionals.
