title: Impact of an emergency department observation unit transient ischemic attack protocol on length of stay and cost.
abstract: This study examined the impact of an emergency department (ED) observation unit's accelerated diagnostic protocol (ADP) on hospital length of stay (LOS), cost of care, and clinical outcome of patients who had sustained a transient ischemic attack (TIA). All patients with TIA presenting to the ED over a 18-consecutive month period were eligible for the study. During the initial 11 months of the study (pre-ADP period), all patients were admitted to the neurology service. Over the subsequent 7 months (post-ADP period), patients were either managed using the ADP or were admitted based on ADP exclusion criteria or at a physician's discretion. All patients had orders for serial clinical examinations, neurologic evaluation, cardiac monitoring, vascular imaging of the brain and neck, and echocardiography. A total of 142 patients were included in the study (mean age, 67.9 ± 13.9 years; 61% female; mean ABCD(2) score, 4.3 ± 1.4). In the post-ADP period, 68% of the patients were managed using the ADP. Of these patients, 79% were discharged with a median LOS of 25.5 hours (ED + observation unit). Compared with the pre-ADP patients, the post-ADP patients (ADP and non-ADP) had a 20.8-hour shorter median LOS (95% confidence interval, 16.3-25.1 hours; P < .01) than pre-ADP patients and lower median associated costs (cost difference, $1643; 95% confidence interval, $1047-$2238). The stroke rate at 90 days was low in both groups (pre-ADP, 0%; post-ADP, 1.2%). Our findings indicate that introduction of an ED observation unit ADP for patients with TIA at a primary stroke center is associated with a significantly shorter LOS and lower costs compared with inpatient admission, with comparable clinical outcomes.
authors.affiliation: Department of Neurology, Emory University, Atlanta, Georgia 30322, USA. fnahab@emory.edu
authors.forename: Fadi
authors.initials: F
authors.lastname: Nahab
authors.forename: George
authors.initials: G
authors.lastname: Leach
authors.forename: Carlene
authors.initials: C
authors.lastname: Kingston
authors.forename: Osman
authors.initials: O
authors.lastname: Mir
authors.forename: Jerome
authors.initials: J
authors.lastname: Abramson
authors.forename: Sarah
authors.initials: S
authors.lastname: Hilton
authors.forename: Matthew
authors.initials: M
authors.lastname: Keadey
authors.forename: Bryce
authors.initials: B
authors.lastname: Gartland
authors.forename: Michael
authors.initials: M
authors.lastname: Ross
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001774:Blood Chemical Analysis / Q000191:economics; D002985:Clinical Protocols; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003952:Diagnostic Imaging / Q000191:economics; D004636:Emergency Service, Hospital / Q000191:economics*; D005260:Female; D006334:Heart Function Tests / Q000191:economics; D017721:Hospital Costs; D006801:Humans; D002546:Ischemic Attack, Transient / Q000175:diagnosis* / Q000191:economics* / Q000628:therapy; D007902:Length of Stay / Q000191:economics*; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination / Q000191:economics; D010343:Patient Admission / Q000191:economics; D011237:Predictive Value of Tests; D011379:Prognosis; D012008:Recurrence; D012017:Referral and Consultation / Q000191:economics; D012189:Retrospective Studies; D020521:Stroke / Q000175:diagnosis / Q000191:economics / Q000628:therapy; D013997:Time Factors