Emergency physicians’ management of transient ischemic attack and desired sensitivity of a clinical decision rule for stroke in three countries

Abstract

Four to 10% of patients with transient ischemic attack (TIA) suffer a stroke or die within 7 days. Our objectives were to determine (1) current practice for investigating and treating emergency department (ED) patients with TIA, (2) willingness to use a clinical decision rule to identify patients at high risk of impending stroke or death, and (3) the required sensitivity of this rule. We administered a mail survey to a random sample of members of three national emergency physician associations in Australia, Canada, and the United States using a modified Dillman technique. A prenotification letter and up to three surveys were sent. A total of 801 responses (53.7%) from 1,493 surveys were received; 53.6% (95% CI 47.5-59.7) of emergency physicians reported routinely admitting TIA patients, ranging from 6.6% in Canada to 56.7% in the United States, and 9.9% of emergency physicians have a stroke prevention clinic, with 4.7% estimating that patients are seen within 7 days. A sensitive clinical decision rule for TIA patients would be used by 96.3% (95% CI 93.9-98.7) of emergency physicians. The median required sensitivity of this rule for stroke or death within 7 days was 97%. Almost half of all TIA patients are managed as outpatients, which is neither expedited nor in a dedicated stroke clinic. Emergency physicians indicate a willingness to use a highly sensitive clinical decision rule to triage TIA patients.