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Background: Severity-based prehospital stroke triage protocols aim to identify patients with large vessel occlusion (LVO) acute ischemic strokes (AIS) who should be transported directly to comprehensive stroke centers (CSCs). Whether or not hemorrhagic stroke patients should be included in the stroke population targeted for direct routing to CSCs is unclear. We hypothesized that a majority of patients with hemorrhagic strokes who were initially transported to the ED of non-CSCs would be immediately transferred to CSCs for admission.Methods: We conducted a cross-sectional study of suspected stroke patients transported by our county’s EMS agency from December 2015 – October 2016. We categorized patient’s initial EMS destination facility as CSC or non-CSC, and determined if, after emergency department (ED) evaluation, patients were transferred to a CSC for admission. We determined acute stroke diagnoses from medical record review.Results: Among 2,402 EMS patients screened for stroke, 777 (32%) had a diagnosis consistent with acute stroke, of whom 10.9% (n=85) had an intracranial hemorrhage (ICH) and 2.1% (n=16) had a subarachnoid hemorrhage (SAH). Among all stroke patients, 51% (95% CI 48-55%) were initially transported to a non-CSC, including 42% (95% CI 32-54%) of all ICH and 38% (95% CI 15-65%) of all SAH patients. Among the ICH and SAH patients initially evaluated at a non-CSCs, 86% (95% CI 71-95%) were transferred to a CSC for admission. No SAH or ICH patients initially transported to a CSC were transferred to another facility for admission.Conclusions: In our metropolitan region, most hemorrhagic stroke patients initially transported by EMS to non-CSCs are transferred to CSCs for admission after their ED evaluation. These data suggest that when determining acceptable rates of over- and under-triage in severity-based stroke triage algorithms for EMS, hemorrhagic stroke patients should be included, along with LVO AIS patients, in the population considered appropriate for initial transport to a CSC.