Implementation of an emergency department based transient ischemic attack clinical pathway: a pilot study in knowledge translation.
OBJECTIVE
To assess the feasibility of implementing an emergency department (ED)-based transient ischemic attack (TIA) clinical pathway that uses computer-based clinical support, and to evaluate measures of quality, safety, and efficiency.


METHODS
This was a prospective cohort study of adult patients presenting to a community ED with symptoms consistent with acute TIA. Adherence to the clinical pathway served as a test of feasibility. Compliance with guideline recommendations for antithrombotic therapy and vascular imaging were used as process measures of quality. The 90-day risk of recurrent TIA, stroke, or death provided estimates of safety. Efficiency was assessed by measuring the rate of uneventful hospitalization, defined as a hospital admission that did not result in any major medical event or vascular intervention such as endarterectomy or stent placement.


RESULTS
Of the 75 subjects enrolled, physician adherence to the clinical pathway was 85.3%, and 35 patients (46.7%) were discharged home from the ED. Antithrombotic agents were prescribed to 68 (90.7%), and vascular imaging was performed in 70 (93.3%). The 90-day risk of recurrent TIA was seven out of 75 (9.3%; 95% confidence interval [CI] = 4.6% to 18.0%), one patient experienced stroke (1.3%; 95% CI = 0.2% to 7.2%), and three patients died (4.0%; 95% CI = 1.4% to 11.1%). Uneventful hospitalization occurred in 38 of 40 patients (95.0%).


CONCLUSIONS
Implementation of a clinical pathway for the evaluation and management of TIA using computer-based clinical support is feasible in a community ED setting. This pilot study in knowledge translation provides a design framework for further studies to assess the safety and efficiency of a structured ED-based TIA clinical pathway.
Brown
Michael D
MD
Grand Rapids MERC/Michigan State University Program in Emergency Medicine, Grand Rapids, MI, USA. brownm@msu.edu
Reeves
Mathew J
MJ
Glynn
Ted
T
Majid
Arshad
A
Kothari
Rashmi U
RU
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019091:Critical Pathways; D020000:Decision Support Systems, Clinical; D004059:Diffusion of Innovation; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005240:Feasibility Studies; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D002546:Ischemic Attack, Transient / Q000628:therapy*; D019359:Knowledge; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D012008:Recurrence; D020521:Stroke / Q000453:epidemiology / Q000517:prevention & control
D005343:Fibrinolytic Agents