Introduction: Pediatric stroke is challenging to recognize due to variability in presentation resulting in delayed diagnosis and treatment with long-term consequences. To address this, a pediatric code stroke protocol was implemented in January 2022 at an academic tertiary care children’s hospital. The primary objective was to implement and routinely utilize a pediatric stroke pathway to identify 100% of true pediatric strokes—acknowledging that many activations would be negative—in order to expedite diagnosis, imaging, and treatment. Methods: A multidisciplinary team developed a standardized code stroke protocol outlining signs of pediatric stroke and steps for rapid evaluation and intervention. A paging system was established to alert key personnel for coordinated response and expedited imaging. Using the Model for Improvement, changes were made over time based on protocol performance. Enhancements included comprehensive provider education, a documentation template (including last known normal and NIH Stroke Scale), and chart reviews. In addition, as of 2025, stroke cases were able to be identified using neurology consult lists and discharge ICD-10 codes to evaluate missed opportunities for code stroke activation. Results: The median number of code stroke activations increased annually over the last three years, reaching a median of three per month in 2025. Nine out of 25 (36%) activations in 2025 resulted in confirmed strokes. Six of the 16 (37.5%) pediatric strokes identified in 2025 did not have a code stroke called. Missed cases occurred in all age groups. However, notably, none of the patients under 12 months of age had a code stroke called despite comprising 50% of the missed cases. Conclusions: The pediatric code stroke protocol has led to increased activation rates and improved stroke identification, with 20–30% of activations yielding true strokes. However, a significant proportion of strokes in 2025 lacked code stroke activation, leading to delayed diagnosis, especially among infants. Because the protocol is designed for liberal activation to minimize missed strokes, improving utilization remains critical. Ongoing efforts will focus on reducing time to imaging, increasing provider adherence, and ensuring sustainability through annual education, simulations, and continued pathway optimization.
Fleisher et al. (Sun,) studied this question.