Since the advent of imaging studies such as magnetic resonance imaging (MRI), the role of electroencephalograms (EEGs) has diminished. Simultaneously, computerized scanning and miniaturization of the EEG and its components have allowed us to obtain lengthier recordings in an ambulatory setting. We report on 261 ambulatory electroencephalograms performed consecutively in the two year period of 2011 and 2012 in a busy neurology and neuropsychiatry practice with predominantly geriatric patient population. 23% of these patients had abnormal AEEGs demonstrating clear-cut epileptogenic discharges. The role of these findings in clinical practice, especially in geriatric and psychiatric populations is discussed.
OBJECTIVES/SPECIFIC AIMS: Current practice frequently dictates hospitalization for TIA and minor stroke (TIAMS) in order to obtain comprehensive evaluation of stroke risk factors and mechanism. Inpatient hospitalization is often done to expedite workup and to coordinate care although may be associated with nosocomial risks and increased healthcare cost. However, a subset of these patients who do not have debilitating deficits may not require inpatient hospitalization. We conducted a pilot study to assess the feasibility of conducting rapid outpatient stroke evaluations in low risk patients with TIAMS without disabling deficits. METHODS/STUDY POPULATION: The rapid access clinic was initiated at a single-site urban tertiary care facility for outpatient evaluation of TIAMS within 24 hours of emergency department (ED) evaluation. Patients were selected using a decision tool identifying presumed low-risk TIAMS seen in the ED. Criteria included medical (e.g., no disabling deficit, no thrombolytic agent given, negative CT for hemorrhagic stroke) as well as social criteria (e.g., patient ability to follow-up as an outpatient). We evaluated rates of noncompliance with post-ED follow-up, need for hospitalization from clinic, and 90 day stroke and health outcome data. RESULTS/ANTICIPATED RESULTS: Between December 2016 and December 2017 a total of 93 TIAMS patients seen in the ED were recommended for the rapid access clinic utilizing the decision tool. Of these patients, 94.5% (86) were evaluated within 24 hours of ED discharge. Only 2 patients (2.4%) who received outpatient evaluation required hospitalization; 61 (71.8%) patients had TIAMS on final evaluation in clinic. DISCUSSION/SIGNIFICANCE OF IMPACT: Our pilot data suggests that for a subset of patients, rapid outpatient evaluation may be a feasible and safe strategy for TIAMS management. Future work exploring such strategies may help improve TIAMS outcomes and reduce ED crowding and unnecessary hospital admissions.
Introduction:
Patients presenting to emergency departments (ED) with TIA and minor strokes (TIAMS) are often admitted for expedited evaluation, though outpatient care models have been proposed. We piloted a rapid outpatient evaluation protocol for patients presenting with TIAMS within 24 hours of ED discharge. We hypothesized that this approach would reduce hospital costs and length of stay (LOS).
Methods:
This analysis looked at patients presenting to our institution’s ED with TIAMS (NIHSS
<
5) in calendar year 2017. We compared hospitalization LOS, costs and expected revenues between admitted patients and those referred for rapid outpatient evaluation. Patients eligible for outpatient evaluation were without disabling deficits, recurrent symptoms, new-onset atrial fibrillation, prior carotid imaging with >50% stenosis, and not receiving thrombolysis. Disabling deficits were defined as new gait impairments, significant motor weakness, hemianopia, dysphagia or severe aphasia. Cost data was obtained from our finance department and expected revenue was estimated using Medicare reimbursement data, assuming Medicare-Fee for Service as the primary payer for all patients.
Results:
We identified 92 patients referred to our rapid outpatient clinic and 90 admitted patients (mean NIHSS 0.8 vs 1.8 respectively). In comparison to patients who were admitted, patients referred to outpatient evaluation had shorter hospital stays, lower total hospitalization costs, and decreased net-losses after accounting for expected revenue (Table). Only one patient in the outpatient cohort was readmitted for further management. Overall, the one-year pilot cohort averted approximately 138 bed-days and $950,000 in hospitalization costs.
Conclusions:
For patients who presented to our ED with TIAMS without disabling deficits, rapid outpatient evaluation reduced hospital LOS and total costs. Further research is needed to incorporate costs to payers and patients.
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