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Cost Effective Strategies:

1. Use some form of risk stratification. The short-term risk of stroke after TIA is much higher than previously recognized. If you are not admitting all your TIA patients, then it is cost effective to admit those who are at highest risk. There are at least 3 specific risk stratification
tools (California rule, ABCD rule, ABCD2 rule) that are all easy to use in the ED and seem to be indicative of stroke outcome.

2. Perform carotid ultrasound in the ED on your TIA patients. Finding the underlying vascular cause of a TIA is an important step in fixing that underlying lesion. Carotid ultrasound is quick and very sensitive to high grade stenosis. It is much cheaper than CT or MR angiography and does not expose the patient to radiation or iodinated dye. Patients with high grade stenosis benefit from rapid revascularization.

3. Give all TIA patients aspirin (or some other AHA-recommended antiplatelet medication). You wouldn’t think of not giving aspirin to an active chest pain patient, and the same applies to TIA patients. Unless there is a specific and absolute contraindication, all TIA patients should receive an antiplatelet medication. Aspirin is the cheapest and reduces stroke by approximately 20% to 25% over placebo.

4. Arrange for your TIA patients to have immediate evaluations. It’s become very clear in recent years that rapid evaluation of TIA patients can decrease the high early stroke rate. Studies suggest that ED-based observation units can be implemented with similarly good results.

Case Study:
Nearing the end of your day shift in a community hospital emergency department (ED), a 71-year-old male is brought in by his wife who says that while signing the receipt for their meal, her husband suddenly had difficulty writing, dropped his pen from his right hand, had a right facial droop, and had “garbled” speech. The patient’s wife says the symptoms resolved completely after approximately 10 minutes. Now, approximately 60 minutes later in the ED, the patient appears well, has normal vital signs, and a normal neurologic examination. He says he feels fine and wants to go home. The patient’s wife says that although her husband has a history of high blood pressure, he has always been otherwise healthy, but she is very concerned about him. She has never seen him like that before and asks what needs to be done for her husband after almost having a stroke.

Case Study Conclusion:
Your 71-year-old male patient with a history of hyper¬tension presented to the ED with 10 minutes of right arm weakness, right facial droop, and garbled speech. It was clear to you that he was at high risk of having as stroke within the 48 hours following presentation. When applying the clinical prediction rules, his score was 5, which placed him in the high/intermediate risk group. This indicated that his risk of stroke within the next 2 days was approximately 5% and would rise to nearly 10% by 7 days from presentation. Thus, this patient highly benefited from immediate evaluation and intervention in your hospital.

Purchase the individual issue for pitfalls to avoid, cost-effective tips, and much more