Abstract WP320: Uncertainty: A Key Influence in the Decision to Admit Patients With Transient Ischemic Attack

Abstract

Introduction: Hospitalization of TIA patients has been shown to improve the timeliness and quality of TIA care yet admission rates for patients presenting with TIA vary considerably across centers. Methods: We sought to identify patient and system level factors linked to the decision to admit a patient with TIA. Trained interviewers conducted face-to-face semi-structured interviews with staff involved in TIA care at diverse Veterans Administration (VA) sites. All transcripts were de-identified and imported into a single NVivo10 project file for data coding and analysis. Results: 70 audiotaped interviews of multidisciplinary clinical staff took place at 14 Veterans Administration Medical Centers (VAMCs). We identified emergent themes and patterns in providers’ decision making. Uncertainty was a key theme in factors that staff reported as an influence in providers’ decisions to admit including: lack of guidance at sites without a facility TIA-specific policy, diagnostic uncertainty related to the TIA event (versus stroke or stroke mimic), general lack of confidence in the ability to complete a timely workup, and specific concerns about patients living a long distance from a VAMC or lacking a support system. Overall, the ABCD 2 score was reported by participants not as a rationale for decisions to admit, but rather for decisions not to admit. Other reported factors related to the decision not to admit included: longer period of time since symptom onset, lack of symptoms, confidence in the ability to get a timely workup as an outpatient, recent evaluation for a prior TIA or stroke event, close proximity of the patient’s residence to a VA facility, strong patient support at home, currently maximized medical management, and availability of observation beds. Conclusions: Issues related to uncertainty were reported as key factors in clinical decisions concerning admittance of patients presenting with TIA. Quality improvement interventions for TIA care may need to take into consideration how factors like uncertainty relate to the TIA admission decision-making process.