Cost and Resource Implications of Pseudo-stroke Code Activations: An Audit from a Tertiary Care Centre in South India

Background: Stroke code pathways expedite reperfusion therapy, but 20%–40% of activations are later identified as stroke mimics. While clinically necessary, these pseudo-activations incur significant costs and resource use, particularly in out-of-pocket payment models. Aim: To analyse cost, efficiency, and resource utilisation of stroke code activations at a tertiary hospital in South India, focusing on pseudo-activations. Methods: Retrospective audit of 44 consecutive stroke code activations (January-June 2025). Data sources included emergency logs, imaging timestamps, treatment records and discharge summaries. Stroke mimics were evaluated for timelines and hospital costs using 2025 institutional tariffs. Activation efficiency was assessed using the Number needed to activate (NNA) and therapeutic yield by number needed to treat (NNT) from published trials. Results: Of 44 activations, 25 (56.8%) were true strokes, 13 (29.5%) were mimics, five were transient ischaemic attacks (TIAs), and one had atrial fibrillation without stroke. Eleven patients were thrombolysis-eligible; five received therapy (mean door-to-needle 113 min). NNAs came to around two activations per true stroke, around four per thrombolysis-eligible patient and around nine per treated patient. Direct per-activation costs were ₹47,000–₹69,000 ($538–$790). Typical mimic workups (imaging, labs, short-stay bed) accounted for ₹3.96–₹7.32 lakh ($4,536–$8,385; 26%–40% of total ₹14.1–₹17.5 lakh/$16,151–$20,046). Each activation diverted 4–6 hours of staff/scanner resources. Based on trial NNTs, five treated patients may have yielded around one additional independent outcome. Conclusion: Nearly one-third of stroke code activations were mimics, generating substantial cost and operational burden. Structured triage, staff education and tiered activation protocols may improve efficiency without compromising safety.