Lessons Learnt in Implementation of ABCD Score in an Emergency Department
To the Editor:
Sciolla et al’s article1 regarding the prospective validation of the ABCD score is relative to our results. Our group recently reported our own data, which also found the ABCD score highly predictive of stroke (ABCD score of 5 to 6 predicting 4/4 strokes at 7 days and 6/7 at 90 days) and prompted the creation of a transient ischemic attack (TIA) pathway.2 We would like to take this opportunity to share some of the difficulties we encountered with its use in our Emergency Department (ED).
The TIA pathway stratifies the emergency management of suspected TIA patients based on their ABCD score. Education sessions were provided to ED medical staff and an evaluation audit was conducted of 87 confirmed TIA patients admitted September 2005 through March 2006.
Use of the TIA pathway was found in only 20 (23%) patient records. When compared to previous data (2004, n=102), there was no statistically significant change to the overall numbers of neurology consultations (44% versus 45%), patients admitted (46% versus 55%), use of discharge antithrombotics (90% versus 90%), inpatient carotid doppler (42% versus 33%), or discharge neurology appointments (33% versus 33%). There was, however, an increase in the number of inpatient CT scans (79% versus 93%, P=0.007).
The uptake of the ABCD score is fraught with the same difficulties as introducing any protocols in the ED. We found the ED staff turnover and lack of involvement of nursing staff in initial education sessions to be significant. Based on this experience, we recommend continuous upfront education of all medical and nursing ED staff and regular reminders to use the pathway by neurology staff called to consult on TIA patients. The two published ABCD scores3,4 are highly predictive of stroke, but their use is limited without uptake by “front-line” clinicians.
Sciolla R, Melis F. Rapid identification of high-risk transient ischemic attacks: prospective validation of the ABCD score. Stroke. 2008; 39: 297–302.
Bray JE, Coughlan K, Bladin C. Can the ABCD Score be dichotomised to identify high-risk patients with transient ischaemic attack in the emergency department? Emerg Med J. 2007; 24: 92–95.