Urumov, Andrej

Introduction: Previous studies have established the safety and economic benefits of outpatient Transient Ischemic Attack (TIA) management, highlighting reduced expenses for outpatient evaluation. This context underscores the potential advantages of refined outpatient TIA management, a focus of our study, through the implementation of a novel expedited outpatient TIA workflow and assessment of its economic, administrative and clinical impact. Methods: We implemented a novel TIA pathway including streamlined assessments by emergency department (ED) physicians, a structured expedited set of diagnostic tests and outpatient follow-up with vascular neurologists within 48-72 hours of ED presentation. We conducted a retrospective cost-efficacy analysis, contrasting two phases: pre-implementation (standard ED-to-hospital admission TIA workflow from May 1, 2020 - December 31, 2020) and post-implementation (ED-to- outpatient TIA workflow from May 1, 2021 - December 31, 2021). We also compared the clinical outcomes of patients with a final diagnosis of TIA or minor ischemic stroke syndrome from the implementation cohort (May 2021-May 2022) with those from an ABCD2-matched inpatient TIA cohort evaluated in the pre-implementation period (2017-2021). Results: The newly implemented outpatient TIA workflow resulted in a 7% decrease in admissions to hospital observation status, 14.8% reduction in hospital admissions, whereas ED discharge rates rose by 20.4%. Within 8 months, these changes equated to 21 fewer hospitalizations or admissions, reducing costs by approximately $103,320 (Figure1). Laboratories, diagnostic imaging, and neurology evaluations were completed faster in the inpatient pathway. Both pathways had similar vascular risk factors and outcomes regarding final diagnosis, - diagnostic testing achieved, preventative treatments prescribed, stroke/TIA recurrences, re-admissions, TIA-related morbidity and mortality, and related ED return visits (Table 1). Conclusion: The deployment of an optimized outpatient TIA management workflow at Mayo Clinic Arizona had demonstrated improved administrative and cost efficiency, with similar clinical outcomes as inpatient TIA pathway. This investigation corroborates the efficacy of workflow enhancements in outpatient TIA settings and suggests a scalable model for analogous strategies in other medical centers.

Introduction Transient Ischemic Attack (TIA) evaluation requires urgent etiology identification and targeted stroke prevention, traditionally performed via hospital admission. The literature suggests that outpatient evaluation may be safe and cost‐effective. Hence, we implemented an expedited outpatient pathway (OP) for patients presenting to our institution’s Emergency Department (ED) with TIA. To further guide future practice, we compared clinical features and outcomes between expedited OP and our well‐established inpatient pathway (IP). Methods We implemented an algorithm of direct communication between ED providers and Vascular Neurologists for all TIA patients. Certain screening studies (head CT, CT angiogram, basic laboratories) and acute therapies were implemented in the ED, whereas others (brain MRI, echocardiogram, etc) and Vascular Neurology consultations were expedited outpatient within 48–72 hours.We included all patients that underwent OP evaluation from May 2021‐May 2022. Further, we extracted patients with a final diagnosis of TIA and compared them with IP TIA patients hospitalized (2017‐2021), matched by age, gender, and clinical severity (ABCD2). Descriptive statistics were used to summarize patient demographics, clinical data, treatments, and 3‐month outcomes. Continuous variables were summarized with mean and standard deviations while categorical variables were shown as counts and percentages. Chi‐square test was used for categorical variables and Mann‐Whitney U test was used to compare continuous variables. P‐values < 0.05 were considered statistically significant and all tests were two‐sided. Statistical Analysis was completed in R 4.0.3. Results Of 43 patients who underwent expedited OP TIA workup, TIA or minor stroke was diagnosed in 21/43 (48.9%). 18 TIAs underwent comparative analyses. Mean symptom duration was longer in the IP (2.06 hours) than OP (0.99 hours), p = 0.370%. TIA was more likely to be diagnosed in the OP 14/18 (78%) versus IP 12/18 (67%), (p = 0.423). OP had more transesophageal echocardiograms (17% vs 5%, p = 0.630) and longer duration of ambulatory cardiac monitoring (mean 574.3 vs 381.7 hours, p = 0.100). IP patients were more likely to get started on anticoagulation compared to OP (38% vs 11%, p = 0.258) and high‐intensity statin (38% vs 17%, p = 0.260). All laboratories, echocardiograms and brain MR imaging were performed significantly sooner for the IP (p< 0.05 for all). IP had higher rate of return ED visits (22%) and readmissions at 3 months (11%), whereas OP had none. OP had no deaths or recurrent strokes, whereas 11% and 5.6% respectively were noted in the IP at 3 months (p = 0.310, p = 0.310). Conclusions Our study shows that routine IP evaluation for patients presenting with TIA in the ED may not offer diagnostic superiority nor lead to improvement of short‐term clinical outcomes, as compared to the expedited OP evaluation. Careful evaluation of TIA patients in the ED followed by expedited OP evaluation might be a plausible approach to help lower costs and avoid hospitalization without compromising the safety of these patients.

Case Presentation: A 37-year-old man with severe obstructive sleep apnea presented to the emergency department with burning pain, redness and swelling in his hands and feet, worsening for several weeks. Pertinent laboratory studies revealed polycythemia. Discussion: Erythromelalgia is a clinical diagnosis characterized by painful burning, erythema, warmth, and edema usually involving the distal extremities. Therapeutic goals are focused on symptom reduction, while also managing the underlying condition in cases of secondary erythromelalgia. Pharmacological and non-pharmacological therapies have proven to be of limited success.