Background:
About one in four ischemic strokes are preceded by a TIA; 43% of TIAs occur within one week before stroke. Patients with a TIA require urgent assessment, risk stratification, and preventative treatment, but often cannot access a Stroke Prevention Clinic in a timely fashion. Therefore, these patients are often admitted to hospital for evaluation but it is unclear if inpatient evaluation is optimal or specifically necessary for this patient population.
Methods:
We developed a novel high-risk TIA and Minor Stroke (TAMS) day-unit to provide rapid access to patient assessment, investigations, initiation of prevention strategies, and stroke prevention education. The TAMS Unit patient assessments were based on a collaborative model led by stroke Nurse Practitioners and an attending stroke Neurologist. All patients had cerebrovascular imaging (CT angiography, MR angiography, or carotid Doppler if there were exclusions to CT or MR angiography), and as appropriate, echocardiography and Holter monitoring initiated at the TAMS Unit visit. We evaluated the feasibility of this novel care model. Outcomes including time to assessment, investigations, and treatment for high-risk TIA/stroke etiologies and stroke risk factors, as well as return emergency department visits or readmissions within 30 days were assessed.
Results:
Between Sept. 6, 2011 and Aug. 8, 2012, 142 patients were seen in the TAMS Unit. Median time from emergency department visit to TAMS Unit assessment was 1 day. The final diagnosis was TIA in 41% of patients and minor stroke (NIHSS < 4) in 27.5% of patients. Atrial fibrillation was diagnosed in 8 (5.6%) patients; anticoagulation was initiated promptly upon diagnosis. High-grade carotid stenosis was diagnosed in 4 (2.8%) patients and these patients were referred for urgent endarterectomy. There were 12 (8.5%) patients that had a return visit to the emergency department within 30 days; 2 (1.4%) with stroke, 8 (5.6%) with recurrent TIA or fluctuating symptoms, and 2 (1.4%) with other diagnoses.
Conclusion:
Our novel TAMS Unit is a feasible care model that provides rapid access to assessment and treatment of high-risk TIA and minor stroke patients, and is another level of care between hospital admission and the outpatient Stroke Prevention Clinic.
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