Risk of emergency department re-presentation following introduction of ambulant care for suspected TIA

Abstract

Background and Aims: Urgent ambulant care is recommended following suspected TIA, but unintended consequences including ED re-presentations are poorly investigated. We aimed to assess the effects of an ambulatory care pathway following emergency department (ED) TIA presentation on 90-day stroke and ED re-presentations. Methods: Hospital administrative datasets were linked across the Sunshine Coast Health Service (Queensland, Australia. 4 hospitals [2 rural], 10,000 km2), 5 years before (control) and 2 years after (intervention) a censored six-month implementation phase (2015). Interrupted time series analysis was used to assess the effects on outcomes. Results: Included were 2020 presentations with an ED TIA diagnosis (1476 control, 564 intervention). In the control phase 58% were admitted. In the intervention phase, 71% were either admitted (35%) or received ambulant review (36%, at median 5days; IQR 3, 9). Initially 21% of patients re-presented within 90 days. An increasing trend in re-presentation became significant in the intervention phase with 1.5 more patients re-presenting/100/quarter than control phase (95%CI 0.8, 2.6); reaching 32% at study end. One third of re-presentations were stroke/TIA related in both study periods; occurring earlier in the intervention (2days IQR 1, 2) than control period (5days IQR 1, 5). Recurrent stroke declined non-significantly from 0.9/100 presentations in control period, rose by 1.3/100 (95%CI 0.6, 2.1) in the first intervention quarter, then declined to 0.9/100 by study end. Conclusions: Increased ED representation may be an unintended consequence of ambulant care models. Ensuring complete and early follow up is essential in providing safe and effective ambulant TIA care.