An Emergency Department Diagnostic Protocol for Patients With Transient Ischemic Attack: A Randomized Controlled Trial

Study objective To determine whether transient ischemic attack patients treated with an accelerated diagnostic protocol in an emergency department (ED) observation unit will experience shorter lengths of stay, lower costs, and comparable clinical outcomes relative to patients with traditional inpatient admission. Methods A prospective randomized study of ED transient ischemic attack patients with a normal head computed tomography scan, ECG, and laboratory test results and no known embolic source. Patients were randomized to an inpatient bed or to accelerated diagnostic protocol care. Both groups had orders for serial clinical examinations, a neurology consultation, carotid Doppler tests, echocardiography, and cardiac monitoring. Accelerated diagnostic protocol patients with positive testing results were admitted. Study outcomes were length of stay, 90-day total direct cost, recidivism, and clinical outcome. Results One hundred forty-nine transient ischemic attack patients were randomized to the accelerated diagnostic protocol (75) or admission (74), with both groups similar in age, percentage of male patients, and stroke risk factors. Accelerated diagnostic protocol patient median length of stay was lower (25.6 hours [interquartile range 21.9 to 28.7 hours] versus 61.2 hours [interquartile range 41.6 to 92.2 hours]), and their 90-day costs were less ($890 [interquartile range $768 to 1,510] versus $1,547 [interquartile range $1,091 to 2,473]). Fifteen percent of accelerated diagnostic protocol patients were admitted, with all positive clinical outcomes occurring while patients were in the observation unit. More accelerated diagnostic protocol patients received carotid imaging (97% versus 91%) and in less time (median 13.0 hours versus 25.2 hours), and more received echocardiography (97% versus 73%) in less time (median 19.1 versus 43.0 hours). Both groups had comparable rates of related return visits (12% each), subsequent strokes (3 versus 2), and major clinical event (4 each). Conclusion A diagnostic protocol for transient ischemic attack using an accelerated diagnostic protocol is more efficient and less costly than traditional inpatient admission and demonstrated clinical outcomes comparable to those of traditional inpatient admission.