Safety and Feasibility of an Emergency Department-to-Outpatient Pathway for Patients With TIA and Nondisabling Stroke.

Background and Objectives

Evaluation of transient ischemic attack/nondisabling ischemic strokes (TIA/NDS) in the emergency department (ED) contributes to capacity issues and increasing health care expenditures, especially high-cost duplicative imaging.

Methods

As an institutional quality improvement project, we developed a novel pathway to evaluate patients with TIA/NDS in the ED using a core set of laboratory tests and CT-based neuroimaging. Patients identified as 'low risk' through a safety checklist were discharged and scheduled for prompt outpatient tests and stroke clinic follow-up. In this prespecified analysis designed to assess feasibility and safety, we abstracted data from patients consecutively enrolled in the first 6 months.

Results

We compared data from 106 patients with TIA/NDS enrolled in the new pathway from April through September 2020 (age 67.9 years, 45% female), against 55 unmatched historical controls with TIA encountered from April 2016 through March 2017 (age 68.3 years, 47% female). Both groups had similar median NIHSS scores (pathway and control 0) and ABCD

Discussion

Our TIA/NDS pathway, implemented during the initial outbreak of COVID-19, seems feasible and safe, with significant positive impact on ED throughput and ED-based high-cost duplicative imaging. The safety checklist and option of virtual telehealth follow-up are novel features. Broader adoption of such pathways has important implications for value-based health care.

Informations de copyright

© 2023 American Academy of Neurology.

Déclaration de conflit d'intérêts

The authors report no relevant disclosures. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.TAKE-HOME POINTS→ TIA/NDS require urgent evaluation, which can result in ED capacity issues and growing health care expenditures.→ We developed a pathway to accurately stratify patients with low-risk TIA/NDS presenting to the ED who could be discharged home with rapid outpatient follow-up using a set of standard clinical and imaging criteria.→ Feasibility was documented by the high rates of outpatient test completion, rapid outpatient follow-up, and low loss to follow-up rates. Safety was documented by low 90-day recurrent TIA/stroke rates and ED revisit/hospital admission rates.→ This pathway decreased ED LOS and high-cost duplicative imaging, which has the potential to reduce ED capacity and hospital expenditures.→ The safety checklist, utilization dashboard, and virtual telehealth follow-up are novel features.