Abstract
Objectives
To assess the effects of a non-admitted management pathway following emergency department
(ED) presentation with suspected TIA on: 90-day stroke and ED re-presentations, overnight
admission, length of stay (LOS) and costs.
Methods
We implemented a management pathway across an Australian regional health service (4
hospitals; 2 rural, 10,000 km2) including ED protocols followed by urgent outpatient review or telemedicine consultation
to one rural hospital. Interrupted time series analysis was conducted on linked hospital
administrative datasets for all ED TIA diagnoses 5 years before and 2 years after
intervention (2015). We assessed whether pathway introduction was associated with
immediate change (level) or subsequent rate of change (slope) in outcomes.
Results
There were 2031 presentations: 1,467 before, 564 after implementation. Against background
declining trends, overnight admissions decreased by 12.4% (95%CI 5.0, 19.7) and total
LOS decreased 6 hours (95%CI 1.5, 10.4). Hospital costs reduced by AUD683 per patient
with implementation. Outpatient review occurred for 36% at median 5 days (IQR 3, 9),
including 19/87 (22%) telemedicine reviews. Pathway adherence was incomplete: 29%
had no specialist review. Recurrent stroke increased by 1.3/100 presentations (95%CI
0.6, 2.1) with implementation, then returned to baseline of 0.9/100. ED re-presentations
rose at a significant rate after implementation (extra 1.69/100 patients re-presenting/quarter;
95%CI 0.8, 2.6) reaching 32/100.
Conclusions
An ED TIA management pathway designed to avoid hospital admission resulted in decreased
hospital use and costs; but an initial increase in recurrent stroke and sustained
rise in ED re-presentation, possibly related to delayed and incomplete follow-up.
Keywords
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Article info
Publication history
Published online: November 22, 2022
Accepted:
November 15,
2022
Received in revised form:
October 24,
2022
Received:
June 3,
2022
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106900
Copyright
© 2022 Elsevier Inc. All rights reserved.
