Department of Neurology, Emory University, Atlanta, Georgia 30322, USA.
J Stroke Cerebrovasc Dis. 2012 Nov;21(8):673-8. doi: 10.1016/j.jstrokecerebrovasdis.2011.02.017. Epub 2011 Apr 9.
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.
这项研究考察了急诊科（ED）观察单元加速诊断方案（ADP）对短暂性脑缺血发作（TIA）患者的住院时间（LOS）、医疗费用和临床结果的影响。在连续 18 个月的时间里，所有到急诊科就诊的 TIA 患者都符合研究条件。在研究的前 11 个月（ADP 前），所有患者都被收入神经内科。在随后的 7 个月（ADP 后），患者要么根据 ADP 进行管理，要么根据 ADP 排除标准或医生的判断入院。所有患者都接受了连续的临床检查、神经评估、心脏监测、脑和颈部血管成像以及超声心动图检查。共有 142 名患者纳入研究（平均年龄 67.9 ± 13.9 岁；61%为女性；平均 ABCD(2)评分 4.3 ± 1.4）。在 ADP 后期间，68%的患者接受了 ADP 管理。在这些患者中，79%的患者在 ED+观察单元的中位 LOS 为 25.5 小时出院。与 ADP 前患者相比，ADP 后患者（ADP 和非 ADP）的中位 LOS 缩短了 20.8 小时（95%置信区间，16.3-25.1 小时；P<.01），中位相关费用也降低了（费用差异为 1643 美元；95%置信区间，1047-2238 美元）。两组患者 90 天的卒中发生率均较低（ADP 前，0%；ADP 后，1.2%）。我们的研究结果表明，在初级卒中中心，为 TIA 患者引入 ED 观察单元 ADP 与住院治疗相比，LOS 显著缩短，成本降低，且临床结果相当。
