The emergency department transient ischemic attack accelerated diagnostic protocol (TIA ADP) study

Abstract

Study objectives: It is important to determine whether an accelerated diagnostic protocol (ADP) for transient ischemic attack (TIA) is economically or clinically beneficial. This is a preliminary report of a prospective study of a TIA ADP. The primary objective of this study is to determine whether emergency department (ED) TIA patients who are treated using an ADP will demonstrate a decrease in their index visit length of stay and cost, with comparable diagnostic and 90-day clinical outcomes relative to TIA patients randomized to traditional inpatient care. Methods: This prospective randomized study was conducted in the ED and ED observation unit of a high-volume university-affiliated suburban teaching hospital with an annual census of 113,105. Initial ED screening included a medical history, physical examination, ECG, and head computed tomographic imaging. Patients were then randomized to either an inpatient bed or ED observation unit for carotid imaging, cardiac monitoring, 2-dimensional echocardiogram, and serial neurologic examinations. Patients were discharged home if testing results were negative or when clinically stable. Hospital length of stay and total direct cost were compared, and clinical outcomes were compared initially and at 90 days. Results: During 8 months, 64 patients were randomized. There were small differences between inpatient and ED observation unit groups in terms of age (68.6 versus 71.1 years, respectively), percentage of male patients (52% versus 49%), the number of TIA stroke risk factors (2.82 versus 2.45), and TIA cardiac risk factors (1.04 versus 1.21). However, there were larger differences between groups in length of stay (2.61 versus 2.27 days) and total direct cost ($1,562 versus $1,103). Of ED observation unit patients, 74.4% had negative ADP results and were discharged in less time (0.91 days) and at lower costs ($955). Each group had 3 patients who were found to have had a stroke. One patient in the ED observation unit group received a carotid endarterectomy. Conclusion: These preliminary results suggest that an ADP for TIA may decrease length of stay and costs for selected patients.