Our study was conducted among one of the largest clinical cohorts of HIV-infected patients in the United States. Given the current movement towards health care reform, it is important to investigate survival patterns of HIV-infected individuals within a health plan with characteristics similar to those plans that may result from health reform. In summary, higher mortality occurred among HIV infected patients diagnosed with psychiatric and SU disorders for whom access to medical services and ability to pay for care are not significant factors. In this analysis we did not observe significant differences in cause of death by psychiatric disorder status. The occurrence of higher mortality among these dual diagnosed patients receiving HIV/AIDS care may indicate that even when psychiatric treatment and SU treatment is available but not accessed, HIV-infected patients with psychiatric and co-occurring substance problems remain vulnerable to less than optimal health outcomes. Our study findings suggest that screening for psychiatric disorder and for SU problems at the initiation of HIV/AIDS treatment and providing psychiatric and SU disorder treatment may prove beneficial and extend life for these heavily burdened patients.Transient ischemic attack affects 0.3% of the United States population annually and is associated with high risk for stroke or cerebrovascular accident.The risk of subsequent ischemic stroke is up to 5% in the first 48 hours, and up to 12% within the first 30 days.Data has shown that urgent workup and treatment can minimize this risk.Therefore,indoor plant table the early stages of TIA represent a tremendous opportunity for stroke prevention.
Many TIA patients present to, or are referred to, the emergency department , and for many healthcare systems the ED represents both the point of first healthcare contact and location for initial workup. However, it is unclear if the emergent workup is best performed in the ED, inpatient unit, or on an outpatient basis.Some healthcare systems have developed rapid TIA outpatient clinics,but these are not widely available in the U.S. As a result, many patients in U.S. systems receive inpatient hospitalization, and recent study results point to a significant increase in admit rates for TIA.In our hospital we noted substantial variability in workup, both in types of testing and in ED and in-patient length of stay. In addition, it appeared that there were opportunities to streamline care and improve our ability to risk-stratify patients. Therefore, to optimize quality and efficiency, in 2012 we developed a protocol-based pathway for acute TIA management. This pathway was based upon existing guidelines including those from the American Heart Association20. These highlighted the value of clinical information in risk stratification; brain imaging , and cerebrovascular imaging. In particular, they included recommendations regarding the use of the ABCD2 score for risk stratification; therefore, these were included in our pathway. Finally, other studies had suggested that an ED observation unit may provide an optimized pathway for TIA evaluation, and so we incorporated its use for selected patients.While less common in other countries, EDOUs are increasingly used in the U.S. for patients who require more than a brief ED stay but less than 24 hours of observation or urgent diagnostics.Our EDOU was managed by a nurse practitioner who was empowered to guide patients who would likely require more than 24 hours for their workup, based on availability of hospital resources at the time. In this analysis, we evaluated whether we could use this pathway to provide consistent streamlined care with shorter LOS without increasing 90-day stroke risk.
Patients with suspected TIA were eligible if they presented to our ED and if clinical providers determined that a TIA workup was necessary. To capture all eligible patients, we used a number of overlapping methods.We included patients if clinical providers evaluated and worked up the patient for TIA. For patients with multiple visits, we collected data on the first visit only, and recorded the following visits as adverse events if within the given time frame of data collection.We performed a structured chart review, collecting data on patient demographics, imaging, workup, ED LOS, and hospital LOS. Two physicians abstracted data. Demographics collected included age, sex, presenting features, and past medical history. We calculated the primary outcome LOS, based on times of registration and transfer – all abstracted electronically; therefore, no inter-rater agreement was calculated. Imaging data included all brain and vascular imaging. Data were collected on workup including any echocardiography or Holter monitoring. We captured final diagnoses of the clinical providers.In addition, the physician reviewer independently determined a likely final diagnosis. To evaluate outcome and adverse events, we reviewed the electronic record for followup outpatient visits and inpatient visits, up to 90 days after initial presentation. This electronic record review included data from our hospital as well as six other local hospitals covered by the same IRB.Our search strategy yielded 3,388 visits, of which 989 were overlapping. After removing these and repeat visits, 2,399 unique visits remained, of which 1,043 occurred during the time period of analysis. After chart review, 280 patients were found to have presented with transient neurologic symptoms that received evaluation for TIA; 130 patients were worked up for TIA before and 150 after protocol implementation. Table 1 shows the demographics of these two cohorts.
To determine whether our intervention was associated with any changes in processes of care, we examined admission patterns, workup,hydroponic vertical farming and outcomes. We found that patients admitted to ED observation increased from 27% to 72%. This was associated with a decrease in inpatient admissions from 62% to 24%. Median total hospital LOS also decreased from 29.4 hours to 23.1 hours. To examine whether there was a change in type of patients chosen for TIA workup , we examined the frequency with which final diagnosis was in fact TIA. We found that the distribution of final diagnosis was quite similar with 45% TIA diagnosis before and 41% after. Of those ultimately found not to have a TIA, similar frequencies of alternative diagnoses were found. We noted that the majority of patients, both pre and post intervention, received brain imaging and vascular imaging. For brain imaging, 52% of patients received both head computed tomography and brain magnetic resonance imaging , while only 4% received both CT angiography and MR angiography. As our observation protocol included preferential use of MRI over CT, we examined whether head CT use changed. Use of head CT decreased from 68% to 58% and from 32% to 22% for neck CTA. Yield of various modalities is shown in Table 3. Significant findings on head CT were typically findings suggestive of recent infarction. Significant findings on CTA and MRA were typically findings of vascular stenosis or occlusions. To examine whether our intervention, and its associated shorter LOS, led to higher risk of adverse outcomes, we evaluated risk of TIA or stroke within 90 days of presentation. Table 4 shows that short-term stroke and recurrent TIA rates were approximately 3% both pre and post intervention. Overall we found that implementation of a TIA clinical pathway, incorporating the use of an ED observation unit for selected patients, shortened hospital LOS, and we found no evidence for increased risk of followup stroke. After this study was completed, the American College of Emergency Physicians published guidelines for TIA management.These guidelines suggested not using the ABCD2 score to determine which patients could be discharged from the ED before a complete workup, instead highlighting the value of urgent imaging. As the American Heart Association suggests, there is substantial value in using a tissue-based definition of TIA rather than time based, a definition requiring brain imaging to evaluate for signs of areas of infarct.In addition, many authors have found that clinical prediction scores that do not use imaging do not appear adequately sensitive to safely guide which patients can be discharged prior to urgent evaluation.We note that we did not use the ABCD2 or another clinical score to discharge patients prior to urgent workup. Instead, our clinical pathway used this score to stratify which patients could receive their workup in an EDOU rather than as an inpatient. In fact, the ACEP guidelines included many elements that we had already included, such as “when feasible, physicians should obtain MRI with diffusion-weighted imaging to identify patients at high short-term risk for stroke;” “When feasible, physicians should obtain cervical vascular imaging to identify patients at high short-term risk for stroke;” and “a rapid ED-based diagnostic protocol may be used to evaluate patients at short-term risk for stroke,”As a result, our clinical pathway, although designed before these guidelines were published, remains concordant with them and remains in place today.
It is also concordant with many suggested pathways in the literature.Many centers have studied the optimal location for TIA workup. These have included outpatient TIA clinics where assessment, workup, diagnosis and treatment can be efficiently performed. These may reduce unnecessary or avoidable hospital admissions.14, 27 Such clinics may be less common in the U.S. than in countries with single-payer healthcare systems. Others have studied the use of EDOUs, typically structured as an ED or inpatient unit but designed for patients who need more than an initial ED workup, but less than 24 hours of observation or evaluation. These can be lower cost than an inpatient admission, and are increasing in popularity in the U.S.Some have found that these EDOUs can minimize inpatient admission for lower risk TIA patients in a safe manner.Our results are consistent with these findings. It appears that urgent workup of low- and intermediate-risk patients can be safely performed in an EDOU, reserving high acuity, in-hospital beds for just the highest risk patients or those with clinically significant findings on workup. Such efforts successfully reduced not just hospital admissions, but total hospital LOS for all patients, while ensuring all necessary workup was performed in the acute setting. One common limitation in TIA studies is that they often include only those patients with final diagnosis of TIA. However, many patients present with symptoms concerning for TIA, who are later determined to have an alternate diagnosis. The strength of this study is that we included all patients for whom ED providers suspected TIA. However, as a result only about half of patients finally did have TIA, similar to other findings.One interesting finding was that while use of head CT was reduced, approximately half of patients still received one. Many patients received brain imaging with both CT and MRI, which may expose patients to avoidable radiation risk, as CT did not appear to offer additional information beyond what MRI could provide. It may be that providers wished to obtain head CT to screen for an emergent process before initiating the observation protocol and awaiting MRI. The decision of whether to triage an injured patient to a trauma center can be difficult, and most emergency medical system agencies rely on standardized decision making systems.However, multiple studies have demonstrated that vital signs are limited in this role.Field measurement of serum lactate concentration could be of potential benefit in accurately identifying patients with more severe injury and need for resuscitative care. Lactic acid is a byproduct of anaerobic metabolism and is a marker of inadequate tissue oxygenation or shock. Technological advancements have led to the development of rapid, portable, lactate assays, permitting lactate measurement in the prehospital and early clinical setting. Previous studies have demonstrated that elevated prehospital and emergency department lactate levels are predictive of poor outcomes in several populations: septic patients, cardiac arrest patients, and general medical patients.Prehospital lactate has also been validated in two populations of patients selected for severe injury: those transported by helicopter and those with prehospital hypotension.However, the prognostic utility of a prehospital lactate level has not been studied systematically in a population of normotensive trauma patients encountered by ground advanced life support crews. Of particular interest is the question of whether the test can risk-stratify normotensive trauma patients and retain specificity for the need for RC when applied to a much broader population with a lower overall prevalence of severe injury than those previously studied. We sought to determine the test characteristics of prehospital lactate levels for predicting need for resuscitative care among a broad population of normotensive trauma patients being transported by ground ALS units.This study was approved by the University of Washington Institutional Review Board.