Rapid diagnosis of mini-strokes saves time and money – with no harm to patientsAs many as 300,000 Americans per year are diagnosed with Transient Ischemic Attack (TIA, or "mini-stroke"). One of the difficulties with such patients is that by the time they reach the emergency room, their symptoms may have disappeared. Over 10% of these patients will suffer a stroke within 90 days, with 64% of those strokes being disabling, and 5% will experience a major cardiac event. Traditionally, these patients are admitted for a series of diagnostic tests over several days.
In a paper presented at the 2006 Society for Academic Emergency Medicine Annual Meeting, May 18-21, 2006 in San Francisco, researchers from William Beaumont Hospital and Wayne State University described a rapid protocol to evaluate TIA patients.
While there is consensus for rapid CT brain imaging, there is not agreement about the timing of other tests, such as carotid imaging. There is some interest in the use of an Accelerated Diagnostic Protocol (ADP), coupled with an Emergency Department Observational Unit, to avoid the average 3-day stay for admitted patients. This protocol may lower costs and reduce hospital stays, but questions remain about the outcomes and overall quality of care that such patients receive.
To address these and other questions, a controlled trial was conducted at Beaumont Hospital, Royal Oak, Michigan. After an initial evaluation and diagnosis of TIA, 149 patients were randomly assigned to the ADP group or to an inpatient hospital bed. All patients received the same 4 diagnostic tests (Carotid imaging, echocardiogram, cardiac monitoring, and serial clinical evaluation) but those in the ADP group received those tests more rapidly.
The median length of stay for the ADP group was 25 hours vs. 61 hours for the admitted patients, and their 90-day costs were $890 vs. $1547. Approximately 15% of the ADP patients were admitted and their length of stay averaged 100 hours with costs of $2737. While these cost savings are substantial, this protocol did not harm patients.
Both study groups had a 12% chance of having a return visit for a related problem. Although more ADP patients were found to have stroke during their initial visit (7 vs. 4), a comparable number developed a subsequent stroke (3 vs. 2) or other major clinical event (4 each). In summary, using an accelerated diagnostic protocol in an emergency observation unit is more efficient, less costly, resulted in shorter hospitals stays and had comparable clinical outcomes compared to traditional inpatient admission. Michael Ross, MD, says, "I think the protocol offers a win-win-win situation. The patient has a shorter stay, the hospital keeps more beds open, and the doctor gets answers more quickly."
The presentation is "An Emergency Department Diagnostic Protocol for Patients with Transient Ischemic Attack: A Randomized Controlled Trial." The authors are Michael A. Ross MD, Scott Compton PhD, Philip Kilanowski MD, Patrick Medado BS, and Brian O'Neil MD. This paper will be presented at the 2006 SAEM Annual Meeting, May 18-21, 2006, San Francisco, CA on Thursday, May 18, in the Plenary Session beginning at 8:00 AM in Salon 9 of the San Francisco Marriott. Abstracts of the papers presented are published in the May issue of the official journal of the SAEM, Academic Emergency Medicine.
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