Abstract W P301: A Neurology/Emergency Medicine Co-Management Protocol for the Observation Management of Transient Ischemic Attack
Background: TIAs are potentially unstable conditions that frequently precede acute ischemic stroke (IS). An evaluation for thromboembolic source and risk is indicated; unfortunately, diagnostic resources for this work up are not immediately available in the Emergency Department (ED). In response to logistic difficulties arranging timely outpatient workup as well as inappropriately long lengths of stay (LOS) on the inpatient Neurology service, we developed a co-management protocol in the ED-based Clinical Decision Unit (CDU). We aimed to evaluate the quality of this model in terms of efficiency and prevention of stroke at 30 days.
Methods: Eligible patients were those with resolved or minimal symptoms, hemodynamic stability, and no known source of emboli (artificial valve, endocarditis, or atrial fibrillation requiring anticoagulation). The protocol consisted of ongoing ED management with Neurology consultation and determination of the diagnostic evaluation, which could include MRI, cardiac echo, and carotid ultrasound/transcranial Doppler. Patients with IS on MRI or carotid stenosis were admitted; the remainder discharged on antiplatelet medication and Neurology follow-up. Using a retrospective case control design, we reviewed records of consecutive patients managed in the CDU TIA protocol in the first 6 months of 2014. Controls consisted of 100 TIA patients (discharged without confirmed CVA) managed on the Neurology service prior to the implementation of the CDU TIA protocol. Outcomes included LOS and 30 day readmission rate for acute IS.
Results: There were 127 CDU patients and 100 controls in the sample. After CDU evaluation, 31 patients required further inpatient admission (24%, 95%CI 17-33%) due to demonstration of acute IS or severe carotid stenosis. The average CDU LOS was 12.2 (SD 6.9) hours compared with 42 (SD 35.3) hours in the historical controls (p<0.001 per t-test for unequal variances). No patients discharged from the CDU TIA protocol returned within 30 days with IS (0%, 97.5%CI 0-2.9%).
Conclusion: An ED/Neurology co-managed CDU-based observation protocol for patients with TIA greatly reduced LOS and variability, with no detected rate of IS readmissions within 30 days of discharge.
Author Disclosures: S. Ritter: None. S. Baghshomali: None. C. Bushnell: Research Grant; Significant; World Federation of Neurology support for the International Maternal Newborn Stroke Registry. D. Cline: None. A. Guzik: None. P. Reynolds: None. B. Hiestand: None.
- © 2015 by American Heart Association, Inc.