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

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

Alexis Roy, MD, MSc https://orcid.org/0000-0001-7406-307X, Anirudh Sreekrishnan, MD https://orcid.org/0000-0001-7251-7189, Erica Camargo Faye, MD, MSc https://orcid.org/0000-0002-3722-6463, Scott Silverman, MD https://orcid.org/0000-0002-0149-7632, Kori S. Zachrison, MD, MSc https://orcid.org/0000-0001-8160-3257, Andrea M. Harriott, MD, PhD https://orcid.org/0000-0003-0417-7586, Marcelo Matiello, MD, MSc https://orcid.org/0000-0001-9753-8816, Giovanna S. Manzano, MD https://orcid.org/0000-0002-9991-9222, Mrinalini Prasanna, MD, Simona Nedelcu, MD, PhD https://orcid.org/0000-0001-5473-1368, and Aneesh B. Singhal, MDAuthors Info & Affiliations

December 2023 issue

13 (6)

https://doi.org/10.1212/CPJ.0000000000200209

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Abstract

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 ABCD² scores (pathway and control 3). Pathway-enrolled patients had a 44% decrease in mean ED length of stay (pathway 13.7 hours, control 24.4 hours, p < 0.001) and decreased utilization of ED MRI-based imaging (pathway 63%, control 91%, p < 0.001) and duplicative ED CT plus MRI-based brain and/or vascular imaging (pathway 35%, control 53%, p = 0.04). Among pathway-enrolled patients, 89% were evaluated in our stroke clinic within a median of 5 business days; only 5.5% were lost to follow-up. Both groups had similar 90-day rates of ED revisits (pathway 21%, control 18%, p = 0.84) and recurrent TIA/ischemic stroke (pathway 1%, control 2%, p = 1.0). Recurrent ischemic events among pathway-enrolled patients were attributed to errors in following the safety checklist before discharge.

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.

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