Stroke and emergency department re-presentation after outpatient TIA management: An interrupted time series study



      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.


      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.


      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.


      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.


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        • Fonseca AC
        • Merwick A
        • Dennis M
        • et al.
        European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack.
        Eur Stroke J. Jun 2021; 6: CLXIII-CLXXXVI
        • Easton JD
        • Saver JL
        • Albers GW
        • et al.
        Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease.
        Stroke. Jun 2009; 40: 2276-2293
      1. Stroke Foundation. Clinical Guidelines for Stroke Management. Updated 2/12/2021. Accessed 15/12/2021, 2021.

        • Sanders LM
        • Srikanth VK
        • Jolley DJ
        • et al.
        Monash transient ischemic attack triaging treatment: safety of a transient ischemic attack mechanism-based outpatient model of care.
        Stroke. Nov 2012; 43: 2936-2941
        • Ranta A
        • Barber PA.
        Transient ischemic attack service provision: A review of available service models.
        Neurology. Mar 8 2016; 86: 947-953
      2. Stroke Foundation. National Stroke Audit – Acute Services Report. Accessed 5/04/2022,

        • Johnston SC
        • Rothwell PM
        • Nguyen-Huynh MN
        • et al.
        Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack.
        The Lancet. 2007; 369: 283-292
        • Blythe R
        • Kularatna S
        • White N
        • et al.
        Fits, faints, falls and funny turns: cost and capacity savings in Queensland from the accelerated transient attack pathway initiative (ATAP).
        Age Ageing. 2019; 48 (Sep 1): 745-750
        • Sundararajan V
        • Henderson T
        • Perry C
        • Muggivan A
        • Quan H
        • Ghali WA.
        New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality.
        J Clin Epidemiol. 2004; 57 (Dec): 1288-1294
        • Australian Institute of Health and Welfare
        Data tables: Health expenditure Australia 2017-18 supplementary tables.
        Australian Government, 2020 (Accessed 06/08/2020)
        • Penfold RB
        • Zhang F.
        Use of interrupted time series analysis in evaluating health care quality improvements.
        Acad Pediatr. 2013; 13 (Nov-Dec): S38-S44
        • Linden A.
        A Comprehensive set of Postestimation Measures to Enrich Interrupted Time-series Analysis.
        Stata J. 2017; 17: 73-88
        • Cheong E
        • Toner P
        • Dowie G
        • Jannes J
        • Kleinig T.
        Evaluation of a CTA-Triage Based Transient Ischemic Attack Service: A Retrospective Single Center Cohort Study.
        J Stroke Cerebrovasc Dis. 2018; 27 (Dec): 3436-3442
        • Chang BP
        • Rostanski S
        • Willey J
        • et al.
        Safety and Feasibility of a Rapid Outpatient Management Strategy for Transient Ischemic Attack and Minor Stroke: The Rapid Access Vascular Evaluation-Neurology (RAVEN) Approach.
        Ann Emerg Med. 2019; 74 (Oct): 562-571
        • Lim A
        • Singhal S
        • Lavallee P
        • et al.
        An International Report on the Adaptations of Rapid Transient Ischaemic Attack Pathways During the COVID-19 Pandemic.
        J Stroke Cerebrovasc Dis. 2020; 29 (Nov)105228