Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department

Carpenter, Christopher R.; Wright, Brian J.; Brown, Michael D.; Byyny, Richard L.; Diercks, Deborah B.; Gemme, Seth R.; Gerardo, Charles J.; Godwin, Steven A.; Hahn, Sigrid A.; Hatten, Benjamin W.; Haukoos, Jason S.; Ingalsbe, Graham S.; Kaji, Amy H.; Kwok, Heemun; Lo, Bruce M.; Mace, Sharon E.; Nazarian, Devorah J.; Proehl, Jean A.; Promes, Susan B.; Shah, Kaushal; Shih, Richard D.; Silvers, Scott M.; Smith, Michael D.; Thiessen, Molly E.W.; Tomaszewski, Christian; Valente, Jonathan H.; Wall, Stephen P.; Wolf, Stephen J.; Cantrill, Stephen V.; O’Connor, Robert E.; Whitson, Rhonda R.; Mitchell, Mary Anne

doi:10.1016/j.annemergmed.2016.06.048

Cited by 25 publications

(17 citation statements)

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“…After this study was completed, the American College of Emergency Physicians (ACEP) published guidelines for TIA management. 25 These guidelines suggested not using the ABCD2 score to determine which patients could be discharged from the ED before a complete workup, instead highlighting the value of urgent imaging. As the American Heart Association suggests, there is substantial value in using a tissue-based definition of TIA rather than time-based, a definition requiring brain imaging to evaluate for signs of areas of infarct.…”

Section: Discussionmentioning

confidence: 99%

“…Instead, our clinical pathway used this score to stratify which patients could receive their workup in an EDOU rather than as an inpatient. In fact, the ACEP guidelines included many elements that we had already included, such as “when feasible, physicians should obtain MRI with diffusion-weighted imaging (DWI) to identify patients at high short-term risk for stroke;” “When feasible, physicians should obtain cervical vascular imaging to identify patients at high short-term risk for stroke;” and “a rapid ED-based diagnostic protocol may be used to evaluate patients at short-term risk for stroke,” 25 As a result, our clinical pathway, although designed before these guidelines were published, remains concordant with them and remains in place today. It is also concordant with many suggested pathways in the literature.…”

Section: Discussionmentioning

confidence: 99%

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Implementation of a Rapid, Protocol-based TIA Management Pathway

Järhult¹,

Howell²,

Barnaure-Nachbar³

et al. 2018

WestJEM

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IntroductionOur goal was to assess whether use of a standardized clinical protocol improves efficiency for patients who present to the emergency department (ED) with symptoms of transient ischemic attack (TIA).MethodsWe performed a structured, retrospective, cohort study at a large, urban, tertiary care academic center. In July 2012 this hospital implemented a standardized protocol for patients with suspected TIA. The protocol selected high-risk patients for admission and low/intermediate-risk patients to an ED observation unit for workup. Recommended workup included brain imaging, vascular imaging, cardiac monitoring, and observation. Patients were included if clinical providers determined the need for workup for TIA. We included consecutive patients presenting during a six-month period prior to protocol implementation, and those presenting between 6–12 months after implementation. Outcomes included ED length of stay (LOS), hospital LOS, use of neuroimaging, and 90-day risk of stroke or TIA.ResultsFrom 01/2012 to 06/2012, 130 patients were evaluated for TIA symptoms in the ED, and from 01/2013 to 06/2013, 150 patients. The final diagnosis was TIA or stroke in 45% before vs. 41% after (p=0.18). Following the intervention, the inpatient admission rate decreased from 62% to 24% (p<0.001), median ED LOS decreased by 1.2 hours (5.7 to 4.9 hours, p=0.027), and median total hospital LOS from 29.4 hours to 23.1 hours (p=0.019). The proportion of patients receiving head computed tomography (CT) went from 68% to 58% (p=0.087); brain magnetic resonance (MR) imaging from 83% to 88%, (p=0.44) neck CT angiography from 32% to 22% (p=0.039); and neck MR angiography from 61% to 72% (p=0.046). Ninety-day stroke or recurrent TIA among those with final diagnosis of TIA was 3% for both periods.ConclusionImplementation of a TIA protocol significantly reduced ED LOS and total hospital LOS.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Implementation of a Rapid, Protocol-based TIA Management Pathway

Järhult¹,

Howell²,

Barnaure-Nachbar³

et al. 2018

WestJEM

View full text Add to dashboard Cite

show abstract

“…Finally, to our knowledge, this is the first study of ischemic stroke care in an EDOU in any setting. While patients with transient ischemic attacks are routinely cared for in EDOUs in high-resource settings [ 39 , 40 ], to our knowledge, stroke patients are usually admitted. While the available treatments differ between regions, future studies should examine if a subset of stroke patients could be cared for in high-resource setting EDOUs.…”

Section: Discussionmentioning

confidence: 99%

Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti

Rouhani

Marsh

Rimpel³

et al. 2020

African Journal of Emergency Medicine

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Introduction In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti. Methods We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency. Results Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023). Conclusion Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.

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“…Experience in an OU allows extended care of patients at intermediate risk and teaches evidence‐based risk stratification that impacts disposition decisions. Patients of intermediate risk for certain common conditions such as chest pain, heart failure, syncope, and transient ischemic attack are appropriate for an OU with the added benefits of a shorter length of stay and being less costly compared to admission to an inpatient unit . As health care systems strain to reduce costs, the threshold for inpatient admission gets higher and the number of patients placed in an OU will continue to increase.…”

Section: Implications Of Om In Em Education and Trainingmentioning

confidence: 99%

The Case for Observation Medicine Education and Training in Emergency Medicine

Pena

Wheatley

Suri

et al. 2019

AEM Education and Training

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Background: Many hospitals have or will be opening an observation unit (OU), the majority managed by the emergency department (ED). Graduating emergency medicine (EM) residents will be expected to have the knowledge and skills necessary to appropriately identify and manage patients in this setting. Our objective is to examine the current state of observation medicine (OM) education and prevalence in EM training. Methods:In a follow-up to the 2019 Society for Academic Emergency Medicine (SAEM) OM Interest Group meeting, we convened an expert panel of OM physicians who are members of both the SAEM OM Interest Group and the American College of Emergency Physicians Section of OM. The panel of six emergency physicians representing geographic diversity was formed. A structured literature review was performed yielding 16 educational publications and sources pertaining to OM education and training across all specialties.Report on the Existing Literature: Only a small number of EM residencies have a required or elective OM rotation in an OU. An OM rotation in a protocol-driven ED OU gives residents experience managing patients in this setting and improves skills integral to EM and part of the EM milestones and Accreditation Council for Graduate Medical Education (ACGME) core competencies: reassessment, disposition decision making, risk stratification, team management, and practicing cost-appropriate care. Even without a formal rotation, multiple OM educational resources can be incorporated into EM resident education and didactics. Education research opportunity exists. Conclusions: This panel believes that OM is an important component of EM that should be incorporated into EMresidency as the knowledge and skills learned such as risk stratification, disposition decision making, and team management augment those needed for the practice of EM. There is a distinct opportunity for EM educators to better equip their trainees for a career in EM by including OM education and experience in EM residency training.From the

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Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department

Cited by 25 publications

References 69 publications

Implementation of a Rapid, Protocol-based TIA Management Pathway

Implementation of a Rapid, Protocol-based TIA Management Pathway

Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti

The Case for Observation Medicine Education and Training in Emergency Medicine

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