Kapoor Arunima, Verma Aikta, Kim Isabelle J, Kujbid Nastasia, Si Kevin, Casaubon Leanne K, Kapral Moira K, Fang Jiming, Symons Sean, Swartz Richard H, Yu Amy Y X
Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada.
Department of Medicine (Emergency Medicine), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
CJEM. 2021 Nov;23(6):820-827. doi: 10.1007/s43678-021-00180-1. Epub 2021 Sep 13.
Neurovascular imaging for patients with high-risk transient ischemic attack (TIA) or minor stroke in the emergency department (ED) with computed tomography angiography (CTA) of the head and neck is the guideline-recommended standard of care, but it is underutilized in routine practice. We conducted a quality initiative to improve adherence to guidelines.
Between January 2017 and March 2019, we implemented a decision support tool integrated into the electronic ordering system to guide ED physicians to order a CTA on patients with high-risk TIA or minor stroke defined as ongoing neurological deficits in the ED or resolved motor or speech deficits in the preceding 48 h. Data were collected retrospectively pre-intervention and prospectively post-intervention. We used an interrupted time-series analysis for the before-after comparison of the use of CTA among patients who met criteria (main process measure) and those who did not meet criteria (balancing measure).
Among 861 patients with TIA or minor stroke, the proportion of patients with high-risk events imaged with a CTA in the ED increased from 12.0% pre-intervention to 77.0% post-intervention and this shift was sustained over 11 months. CTA use in those without high-risk events increased to a lesser extent (15.3% versus 42.9%). The interrupted time-series analysis showed a step change immediately post-intervention where the increase in CTA use in patients with high-risk events was 51.7% higher than its use in those without high-risk events (p < 0.001). Compared to pre-intervention, the median ED length of stay increased by 2 h and neurology consultation in the ED was more frequent (5.8% versus 19.5%) post-intervention.
We provide a detailed framework that improved adherence to acute imaging guidelines for patients with TIA or minor stroke and anticipate that our approach could improve acute imaging for such patients in most EDs.
对于急诊科（ED）中具有高危短暂性脑缺血发作（TIA）或轻度卒中的患者，采用头颈部计算机断层血管造影（CTA）进行神经血管成像检查是指南推荐的标准治疗方法，但在常规实践中该方法未得到充分利用。我们开展了一项质量改进计划以提高对指南的遵循情况。
在2017年1月至2019年3月期间，我们实施了一种集成到电子医嘱系统中的决策支持工具，以指导急诊科医生对高危TIA或轻度卒中患者开具CTA检查医嘱，高危TIA或轻度卒中的定义为在急诊科存在持续的神经功能缺损或在之前48小时内已缓解的运动或言语功能缺损。在干预前进行回顾性数据收集，在干预后进行前瞻性数据收集。我们使用中断时间序列分析对符合标准的患者（主要过程指标）和不符合标准的患者（平衡指标）中CTA的使用情况进行前后比较。
在861例TIA或轻度卒中患者中，急诊科对高危事件患者进行CTA成像检查的比例从干预前的12.0%增至干预后的77.0%，且这一变化在11个月内持续存在。对无高危事件患者的CTA使用量也有一定程度增加（从15.3%增至42.9%）。中断时间序列分析显示，干预后立即出现了阶跃变化，高危事件患者的CTA使用量增加幅度比无高危事件患者高51.7%（p < 0.001）。与干预前相比，急诊科的中位住院时间增加了2小时，且干预后急诊科的神经科会诊更频繁（从5.8%增至19.5%）。
我们提供了一个详细的框架，该框架提高了对TIA或轻度卒中患者急性成像指南的遵循情况，并预计我们的方法可改善大多数急诊科对此类患者的急性成像检查。
