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Background: Immediately after a stroke, the time it takes to reach a designated stroke center can determine the patient’s chances of recovery or permanent disability. In pre-hospital care, the first level of care occurs when 911 is called, second when the paramedics arrive and triage, and third, transport to the nearest primary stroke center (PSC). When emergency medical dispatchers (EMD) initially recognize stroke they provide critical stroke triage codes guiding the paramedic’s decision in appropriate hospital choice, saving time and improving patient recovery. This study assessed EMD and paramedic stroke recognition and performance in an urban area.Hypothesis: EMD recognition of stroke would provide paramedics adequate codes for correct recognition and influence transports to area primary stroke centers (PSCs).Methods: All emergency medical service (EMS) transports in an urban county area (392,664 population) during 2014 were retrospectively analyzed. The transports encompassed True/Negatives, False/Positives, False/Negatives and True/Positives for data on the number and percentages of EMS correctly identified stroke ground transport 911 calls. Dispatch impressions of calls were compared to paramedic decisions and confirmed by hospital ICD-9-CM billing codes 430-438. Transports to area PSC and non-PSC hospitals were determined.Results: Over 12 months, in N=40,171 total transports, EMDs impression of strokes were n=942 with 51.3% confirmed as strokes by paramedics. The other 47.6% of calls reported as strokes by EMDs were coded by paramedics as syncope/fainting, altered level of consciousness, abdominal pain, diabetic, behavioral, cardiac rhythm disturbance and seizures. Paramedic reported strokes were coded by dispatchers as 52.0% strokes/CVA or as headaches, sick person, unconscious/fainting, fall victim, chest pain, convulsions/seizures and breathing problems. Significantly more stroke-related deliveries were made to PSCs (55%, p<0.001) than other area facilities. Hospital confirmation by discharge data services of paramedic coded strokes provided a true positive predictive value of 44.8% and sensitivity of 25%.Conclusion: EMS dispatch and paramedic services could benefit from stroke recognition education.