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According to The Journal of Emergency Medical Services (EMS) the goal of stroke care is to minimize brain injury and maximize recovery. The stroke chain of survival links actions taken by patients, family, EMS and healthcare providers. Recent innovations in stroke treatment require accurate identification and appropriate triage to the appropriate treatment facility. Evidence in the literature demonstrates variability with EMS correct identification of stroke patients between 30% and 80%. Our 164 bed primary stroke center in rural Pennsylvania has been active in providing stroke education on an annual basis to emergency medical services within a two county radius. As part of our ongoing process improvement we wanted to evaluate the emergency medical technicians and paramedics knowledge of stroke signs and symptoms, their understanding of the evaluation, treatment and triage of stroke patients. A standard questionnaire with 14 variables was developed using the American Heart and Stroke Association prehospital guidelines. The questionnaire included 16 stroke and non stroke symptoms, identifying transport to primary verses comprehensive stroke centers and initial evaluation. A sample population of 90 emergency medical service staff were asked to complete the questionnaire with 28 (31%) responses received. All participants indicated they were confident to recognize stroke signs and symptoms but 6 of the non stroke items were chosen as stroke symptoms. All participants indicated they were confident in the initial evaluation of a stroke patient but 14 (50%) appropriately identified airway, breathing, circulation as the first evaluation. Evaluating triage knowledge, 26 (93%) stated confidence in decision to transport to a primary stroke center and 22 (79%) to a comprehensive stroke center, however, appropriate decision to transport to a primary stroke center was identified correctly by 46% a comprehensive stroke center 66%. In conclusion, results from this study suggest that in this rural setting, barriers exist in prehospital recognition and evaluation of the stroke patient for which proper education may be remediable. Our goal is to use this information to revise our current EMS stroke education program and enhance prehospital assessment and triage.