Implementation of an Emergency Department–based Transient Ischemic Attack Clinical Pathway: A Pilot Study in Knowledge Translation

Abstract

Objectives: To assess the feasibility of implementing an emergency department (ED)-based transient ischemic attack (TIA) clinical pathway that uses computer-based clinical support, and to evaluate measures of quality, safety, and efficiency.Methods: This was a prospective cohort study of adult patients presenting to a community ED with symptoms consistent with acute TIA. Adherence to the clinical pathway served as a test of feasibility. Compliance with guideline recommendations for antithrombotic therapy and vascular imaging were used as process measures of quality. The 90-day risk of recurrent TIA, stroke, or death provided estimates of safety. Efficiency was assessed by measuring the rate of uneventful hospitalization, defined as a hospital admission that did not result in any major medical event or vascular intervention such as endarterectomy or stent placement.Results: Of the 75 subjects enrolled, physician adherence to the clinical pathway was 85.3%, and 35 patients (46.7%) were discharged home from the ED. Antithrombotic agents were prescribed to 68 (90.7%), and vascular imaging was performed in 70 (93.3%). The 90-day risk of recurrent TIA was seven out of 75 (9.3%; 95% confidence interval [CI] = 4.6% to 18.0%), one patient experienced stroke (1.3%; 95% CI = 0.2% to 7.2%), and three patients died (4.0%; 95% CI = 1.4% to 11.1%). Uneventful hospitalization occurred in 38 of 40 patients (95.0%).Conclusions: Implementation of a clinical pathway for the evaluation and management of TIA using computer-based clinical support is feasible in a community ED setting. This pilot study in knowledge translation provides a design framework for further studies to assess the safety and efficiency of a structured ED-based TIA clinical pathway.

The Role of Decision Support System (DSS) in Prevention of Cardiovascular Disease: A Systematic Review and Meta-Analysis

“…Five studies were conducted in the USA [14], [15], [16], [17], [18], two in UK [19], [20], one in Israel [21], one in Australia [22], and one in Canada [23]. Five papers reported outcomes on blood pressure management [14], [15], [16], [19], [23], one on heart failure [22], two on Transient Ischemic Attack (TIA) or stroke [17], [20] and two on coronary heart disease [18], [21] ( table 1 ). Seven papers were randomized trials and the remaining three [17], [18], [22], were cohort studies.…”

“…Five papers reported outcomes on blood pressure management [14], [15], [16], [19], [23], one on heart failure [22], two on Transient Ischemic Attack (TIA) or stroke [17], [20] and two on coronary heart disease [18], [21] ( table 1 ). Seven papers were randomized trials and the remaining three [17], [18], [22], were cohort studies. Eight of the papers had a computerised decision support system (CDSS), one had a telephone linked IT supported program [23] and the remaining one [22] had written guideline reminders to physicians coupled with education to the pharmacists.…”

“…In addition, three papers had support systems for the nurses [21], [22], [23] and two had interventions which also involved the pharmacists [22], [23]. Three were conducted in inpatient settings [17], [20], [22]. Nine papers clearly mentioned the source for the clinical knowledge in the decision support systems (except Rinfret, 2009 [23]).…”

Rapid assessment of transient ischaemic attack in a hospital with no on-call neurologist

“…This number is similar to results from other published series, although methodological differences, and probably the idiosyncrasies of each hospital as well, have resulted in a range of 17.3% and 65%. 8,11,12,17,18 The main purpose of all rapid action protocols for TIA is to minimise the recurrence rate. In fact, recurrence rates after TIA have been dropping gradually over the past 10 years.…”

Evaluación rápida del ataque isquémico transitorio en un hospital sin guardias de neurología

“…La atención rápida al AIT permite reducir significativamente el número de ingresos hospitalarios. En nuestra serie, se decidió el ingreso en un 28,7%, cifras similares a las publicadas hasta ahora en otras series, aunque la diversidad de metodología y probablemente las peculiaridades de cada centro hace que las cifras oscilen entre el 17,3 y el 65% 8,11,12,17,18 . Evaluación rápida del ataque isquémico transitorio en un hospital sin guardias de neurología 5…”