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Retrospective evaluation of a clinical decision support tool for effective computed tomography angiography utilization in urgent brain imaging of suspected TIA/minor stroke in the emergency department

  • Maximilian B. Bibok (a1), Kristine Votova (a1) (a2), Robert F. Balshaw (a3), Melanie Penn (a1), Mary L. Lesperance (a4), Devin R. Harris (a5), Colin Sedgwick (a6), Madeline Nealis (a1), Brian Farrell (a7), John R. Mathieson (a8) and Andrew M. Penn (a9)...

Abstract

Objectives

The Canadian Stroke Best Practice Recommendations suggests that patients suspected of transient ischemic attack (TIA)/minor stroke receive urgent brain imaging, preferably computed tomography angiography (CTA). Yet, high requisition rates for non-cerebrovascular patients overburden limited radiological resources, putting patients at risk. We hypothesize that our clinical decision support tool (CDST) developed for risk stratification of TIA in the emergency department (ED), and which incorporates Canadian guidelines, could improve CTA utilization.

Methods

Retrospective study design with clinical information gathered from ED patient referrals to an outpatient TIA unit in Victoria, BC, from 2015-2016. Actual CTA orders by ED and TIA unit staff were compared to hypothetical CTA ordering if our CDST had been used in the ED upon patient arrival.

Results

For 1,679 referrals, clinicians ordered 954 CTAs. Our CDST would have ordered a total of 977 CTAs for these patients. Overall, this would have increased the number of imaged-TIA patients by 89 (10.1%) while imaging 98 (16.1%) fewer non-cerebrovascular patients over the 2-year period. Our CDST would have ordered CTA for 18 (78.3%) of the recurrent stroke patients in the sample.

Conclusions

Our CDST could enhance CTA utilization in the ED for suspected TIA patients, and facilitate guideline-based stroke care. Use of our CDST would increase the number of TIA patients receiving CTA before ED discharge (rather than later at TIA units) and reduce the burden of imaging stroke mimics in radiological departments.

Objectifs

D’après les lignes directrices canadiennes sur les pratiques exemplaires en matière de prise en charge des accidents vasculaires cérébraux (AVC), il est recommandé de pratiquer d’urgence, dans les cas présumés d’accident ischémique transitoire (AIT) ou d’AVC léger, un examen par imagerie cérébrale, de préférence une angiographie par tomodensitométrie (TDM). Toutefois, le nombre élevé de demandes d’examen chez les patients exempts de lésions vasculaires cérébrales exerce une pression à la hausse sur les ressources disponibles en radiologie, d’où une augmentation du risque chez les patients concernés. Aussi l’étude visait-elle à vérifier si l’outil d’aide à la décision clinique (OADC) que l’équipe a élaboré pour l’évaluation du risque d’AIT au service des urgences (SU) et qui tient compte des lignes directrices en vigueur au Canada aurait permis une utilisation plus rationnelle de l’angiographie par TDM.

Méthode

Il s’agit d’une étude rétrospective reposant sur la collecte de renseignements cliniques, tirés de demandes d’examens faites par des SU à un service de consultations externes spécialisé dans le traitement des AIT, à Victoria, en Colombie-Britannique, de 2015 à 2016. Ont été comparés le nombre réel de demandes d’angiographie par TDM faites par le personnel de SU et du service spécialisé dans le traitement des AIT, et le nombre hypothétique de demandes d’angiographie par TDM si l’OADC avait été utilisé au SU, à l’arrivée des patients.

Résultats

Sur 1679 demandes de consultation, il y a eu 954 demandes d’angiographie par TDM faites par des cliniciens. Si l’OADC avait été appliqué, le nombre total d’angiographies par TDM se serait élevé à 977 chez les patients concernés, ce qui se serait traduit, dans l’ensemble, par une augmentation de 89 (10,1 %) demandes d’examens par imagerie chez les patients ayant subi un AIT et une diminution de 98 (16,1 %) chez les patients exempts de lésions vasculaires cérébrales, sur la période de 2 ans. Ainsi, l’OADC aurait permis de faire une demande d’angiographie par TDM chez 18 (78,3 %) des patients ayant subi une récidive d’AVC, dans l’échantillon étudié.

Conclusion

L’application de l’OADC permettrait une utilisation plus rationnelle de l’angiographie par TDM, au SU, chez les patients atteints d’un AIT présumé, et faciliterait la prestation de soins fondés sur les lignes directrices dans les cas d’AVC. Ce faisant, il y aurait une augmentation du nombre d’angiographies par TDM pratiquées chez les patients souffrant d’un AIT avant le congé du SU (plutôt qu’après, dans les services de traitement des AIT) ainsi qu’une réduction du fardeau imposé par les affections simulant un AVC, quant au nombre d’examens par imagerie, sur les services de radiologie.

Copyright

Corresponding author

Correspondence to: Dr. Maximilian B. Bibok, Department of Research and Capacity Building, Island Health Authority, 1952 Bay Street, Victoria, BC V8R 1J8; Email: Maximilian.Bibok@viha.ca

References

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Retrospective evaluation of a clinical decision support tool for effective computed tomography angiography utilization in urgent brain imaging of suspected TIA/minor stroke in the emergency department

  • Maximilian B. Bibok (a1), Kristine Votova (a1) (a2), Robert F. Balshaw (a3), Melanie Penn (a1), Mary L. Lesperance (a4), Devin R. Harris (a5), Colin Sedgwick (a6), Madeline Nealis (a1), Brian Farrell (a7), John R. Mathieson (a8) and Andrew M. Penn (a9)...

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