Skip to main content
SpringerLink
Log in

Multidisciplinary quality improvement initiative to optimize acute neurovascular imaging for transient ischemic attack or minor stroke

  • Quality Improvement and Patient Safety (QIPS)
  • Published:
Canadian Journal of Emergency Medicine Aims and scope Submit manuscript

Abstract

Background

Neurovascular imaging for patients with high-risk transient ischemic attack (TIA) or minor stroke in the emergency department (ED) with computed tomography angiography (CTA) of the head and neck is the guideline-recommended standard of care, but it is underutilized in routine practice. We conducted a quality initiative to improve adherence to guidelines.

Methods

Between January 2017 and March 2019, we implemented a decision support tool integrated into the electronic ordering system to guide ED physicians to order a CTA on patients with high-risk TIA or minor stroke defined as ongoing neurological deficits in the ED or resolved motor or speech deficits in the preceding 48 h. Data were collected retrospectively pre-intervention and prospectively post-intervention. We used an interrupted time-series analysis for the before–after comparison of the use of CTA among patients who met criteria (main process measure) and those who did not meet criteria (balancing measure).

Results

Among 861 patients with TIA or minor stroke, the proportion of patients with high-risk events imaged with a CTA in the ED increased from 12.0% pre-intervention to 77.0% post-intervention and this shift was sustained over 11 months. CTA use in those without high-risk events increased to a lesser extent (15.3% versus 42.9%). The interrupted time-series analysis showed a step change immediately post-intervention where the increase in CTA use in patients with high-risk events was 51.7% higher than its use in those without high-risk events (p < 0.001). Compared to pre-intervention, the median ED length of stay increased by 2 h and neurology consultation in the ED was more frequent (5.8% versus 19.5%) post-intervention.

Conclusion

We provide a detailed framework that improved adherence to acute imaging guidelines for patients with TIA or minor stroke and anticipate that our approach could improve acute imaging for such patients in most EDs.

Résumé

Contexte

L'imagerie neurovasculaire pour les patients présentant un risque élevé d'accident ischémique transitoire (AIT) ou d'accident vasculaire cérébral mineur aux services d'urgence, avec une angiographie par tomodensitométrie (CTA) de la tête et du cou, est la norme de soins recommandée par les directives, mais elle est sous-utilisée dans la pratique courante. Nous avons mené une initiative de qualité pour améliorer le respect des lignes directrices.

Méthodes

Entre janvier 2017 et mars 2019, nous avons mis en place un outil d'aide à la décision intégré au système de commande électronique pour guider les médecins du service d'urgence à prescrire un CTA sur des patients atteints d'un AIT à haut risque ou d'un AVC mineur défini comme des déficits neurologiques en cours au service des urgences ou une résolution de la motricité ou des troubles de la parole dans les 48 heures précédentes. Les données ont été recueillies rétrospectivement avant l'intervention et prospectivement après l'intervention. Nous avons utilisé une analyse de séries chronologiques interrompues pour la comparaison avant-après de l'utilisation du CTA chez les patients qui répondaient aux critères (mesure principale du processus) et ceux qui ne répondaient pas aux critères (mesure d'équilibrage).

Résultats

Parmi les 861 patients atteints d'un AIT ou d'un AVC mineur, la proportion de patients présentant des événements à haut risque imagés avec un CTA au service d'urgence est passé de 12,0 % avant l'intervention à 77,0 % après l'intervention et ce changement s'est maintenu pendant 11 mois. L'utilisation de CTA chez les personnes sans événements à haut risque a augmenté dans une moindre mesure (15,3 % contre 42,9 %). L'analyse des séries chronologiques interrompues a montré un changement d'étape immédiatement après l'intervention où l'augmentation de l'utilisation du CTA chez les patients présentant des événements à haut risque était 51,7 % plus élevée que son utilisation chez ceux sans événements à haut risque (p < 0,001). Par rapport à la pré-intervention, la durée médiane du séjour au SU a augmenté de deux heures et les consultations de neurologie au SU étaient plus fréquentes (5,8 % contre 19,5 %) après l'intervention.

Conclusion

Nous fournissons un cadre détaillé qui a amélioré le respect des lignes directrices en matière d'imagerie aiguë pour les patients souffrant d'AIT ou d'AVC mineur et nous prévoyons que notre approche pourrait améliorer l'imagerie aiguë pour ces patients dans la plupart des urgences.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Code availability

Not applicable.

References

  1. Reeves M, Khoury J, Alwell K, Moomaw C, Flaherty M, Woo D, et al. Distribution of National Institutes of Health stroke scale in the Cincinnati/Northern Kentucky Stroke Study. Stroke J Cereb Circ. 2013;44(11):3211–3.

    Article  Google Scholar 

  2. Smith EE, Fonarow GC, Reeves MJ, Cox M, Olson DM, Hernandez AF, et al. Outcomes in mild or rapidly improving stroke not treated with intravenous recombinant tissue-type plasminogen activator: findings from Get With The Guidelines-Stroke. Stroke J Cereb Circ. 2011;42(11):3110–5.

    Article  CAS  Google Scholar 

  3. Coutts SB, Modi J, Patel SK, Aram H, Demchuk AM, Goyal M, et al. What causes disability after transient ischemic attack and minor stroke?: Results from the CT and MRI in the Triage of TIA and minor Cerebrovascular Events to Identify High Risk Patients (CATCH) Study. Stroke J Cereb Circ. 2012;43(11):3018–22.

    Article  Google Scholar 

  4. Wasserman J, Perry J, Dowlatshahi D, Stotts G, Stiell I, Sutherland J, et al. Stratified, urgent care for transient ischemic attack results in low stroke rates. Stroke J Cereb Circ. 2010;41(11):2601–5.

    Article  Google Scholar 

  5. Graham BR, Menon BK, Coutts SB, Goyal M, Demchuk AM. Computed tomographic angiography in stroke and high-risk transient ischemic attack: Do not leave the emergency department without it! Int J Stroke. 2018;13(7):673–86.

    Article  Google Scholar 

  6. Yu AY, Hill MD, Coutts SB. Should minor stroke patients be thrombolyzed? A focused review and future directions. Int J Stroke. 2015;10(3):292–7.

    Article  Google Scholar 

  7. Wein T, Lindsay MP, Cote R, Foley N, Berlingieri J, Bhogal S, et al. Canadian stroke best practice recommendations: Secondary prevention of stroke, sixth edition practice guidelines, update 2017. Int J Stroke. 2017:1747493017743062.

  8. Ranta A, Barber PA. Transient ischemic attack service provision: a review of available service models. Neurology. 2016;86(10):947–53.

    Article  Google Scholar 

  9. Kapral MK, Hall R, Fang J, Austin PC, Silver FL, Gladstone DJ, et al. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology. 2016;86(17):1582–9.

    Article  Google Scholar 

  10. Timpone VM, Jensen A, Poisson SN, Trivedi PS. Compliance with imaging guidelines for workup of transient ischemic attack: evidence from the nationwide emergency department sample. Stroke. 2020;51(8):2563–7.

    Article  Google Scholar 

  11. Wintermark M, Sanelli PC, Albers GW, Bello JA, Derdeyn CP, Hetts SW, et al. Imaging recommendations for acute stroke and transient ischemic attack patients: a joint statement by the American Society of Neuroradiology, the American College of Radiology and the Society of NeuroInterventional Surgery. J Am College Radiol. 2013;10(11):828–32.

    Article  Google Scholar 

  12. Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann E, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke; a journal of cerebral circulation. 2009;40(6):2276–93.

  13. Bhayana R, Wang CD, Menezes RJ, Bartlett ES, Choi J. Optimising after-hours workflow of computed tomography orders in the emergency department. BMJ open quality. 2020;9(3).

  14. Perla RJ, Provost LP, Murray SK. The run chart: a simple analytical tool for learning from variation in healthcare processes. BMJ Qual Saf. 2011;20(1):46–51.

    Article  Google Scholar 

  15. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2014;23(4):290–8.

    Article  Google Scholar 

  16. Kokotailo RA, Hill MD. Coding of stroke and stroke risk factors using international classification of diseases, revisions 9 and 10. Stroke J Cereb Circ. 2005;36(8):1776–81.

    Article  Google Scholar 

  17. Linden A. Using group-based trajectory modelling to enhance causal inference in interrupted time series analysis. J Eval Clin Pract. 2018;24(3):502–7.

    Article  Google Scholar 

  18. Leong M, Stang JM, McGuire N, Lang E, Coutts SB, Patocka C. Regional variation in transient ischemic attack and minor stroke in alberta emergency departments. Stroke. 2020;51(6):1820–4.

    Article  Google Scholar 

  19. Ranta A, Dovey S, Weatherall M, O’Dea D, Gommans J, Tilyard M. Cluster randomized controlled trial of TIA electronic decision support in primary care. Neurology. 2015;84(15):1545–51.

    Article  Google Scholar 

  20. Rowe BH, McRae A, Rosychuk RJ. Temporal trends in emergency department volumes and crowding metrics in a western Canadian province: a population-based, administrative data study. BMC Health Serv Res. 2020;20(1):356.

    Article  Google Scholar 

  21. Perry JJ, Sivilotti MLA, Émond M, Stiell IG, Stotts G, Lee J, et al. Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study. BMJ. 2021;372:n49.

  22. Preston H, Swan I, Davies L, Dummer S, Aravindan V, Beh YY, et al. Improving VTE risk assessment and prophylaxis prescribing rate in medical patients: integrating risk assessment tool into the workflow. BMJ open quality. 2020;9(2).

  23. Becker BA, Yeich T, Jaffe JT, Sun S, Chen Y, Rebert T, et al. Impact of creatinine screening on contrast-induced nephropathy following computerized tomography for stroke. Am J Emerg Med. 2020.

  24. Hopyan JJ, Gladstone DJ, Mallia G, Schiff J, Fox AJ, Symons SP, et al. Renal safety of CT angiography and perfusion imaging in the emergency evaluation of acute stroke. Am J Neuroradiol. 2008;29(10):1826–30.

    Article  CAS  Google Scholar 

  25. Rothwell PM, Giles MF, Chandratheva A, Marquardt L, Geraghty O, Redgrave JN, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet. 2007;370(9596):1432–42.

    Article  Google Scholar 

  26. Lavallee PC, Meseguer E, Abboud H, Cabrejo L, Olivot JM, Simon O, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol. 2007;6(11):953–60.

    Article  CAS  Google Scholar 

  27. Duncan PW, Bushnell CD, Rosamond WD, Jones Berkeley SB, Gesell SB, D’Agostino RB Jr, et al. The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial. BMC Neurol. 2017;17(1):133.

    Article  Google Scholar 

  28. Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ. Carotid Endarterectomy Trialists C. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet. 2004;363(9413):915–24.

    Article  CAS  Google Scholar 

  29. Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011;365(11):993–1003.

    Article  CAS  Google Scholar 

  30. Coutts SB, Dubuc V, Mandzia J, Kenney C, Demchuk AM, Smith EE, et al. Tenecteplase-tissue-type plasminogen activator evaluation for minor ischemic stroke with proven occlusion. Stroke. 2015;46(3):769–74.

    Article  CAS  Google Scholar 

  31. Seners P, Ben Hassen W, Lapergue B, Arquizan C, Heldner MR, Henon H, et al. Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone. JAMA Neurol. 2021.

Download references

Acknowledgements

This study was supported by ICES, formally Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and/or information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed in the material are those of the author(s), and not necessarily those of CIHI.

Funding

This study is funded by a grant from the Academic Health Sciences Centres of Ontario Alternative Funding Plan Innovation Fund. AYXY is supported by a New Investigator Award and the HJ Barnett Award from Heart and Stroke. RHS is supported by a clinician-scientist phase II award from the Heart and Stroke Foundation of Canada. MKK is supported by a mid-career investigator award from the Heart and Stroke Foundation of Canada and holds the Lillian Love Chair in Women’s Health at the University Health Network.

Author information

Authors and Affiliations

  1. Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada

    Arunima Kapoor, Isabelle J. Kim, Nastasia Kujbid, Kevin Si, Sean Symons, Richard H. Swartz & Amy Y. X. Yu

  2. Department of Medicine (Emergency Medicine), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Aikta Verma

  3. Department of Medicine (Neurology), University of Toronto, Toronto Western Hospital, Toronto, ON, Canada

    Leanne K. Casaubon

  4. Department of Medicine (General Internal Medicine), University of Toronto, Toronto General Hospital, Toronto, ON, Canada

    Moira K. Kapral

  5. Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Sean Symons

  6. ICES, Toronto, ON, Canada

    Moira K. Kapral, Jiming Fang, Richard H. Swartz & Amy Y. X. Yu

  7. Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Richard H. Swartz & Amy Y. X. Yu

Authors
  1. Arunima Kapoor
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Aikta Verma
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Isabelle J. Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Nastasia Kujbid
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kevin Si
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Leanne K. Casaubon
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Moira K. Kapral
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jiming Fang
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Sean Symons
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Richard H. Swartz
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Amy Y. X. Yu
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

AK: study design, data collection, analysis, drafting manuscript, AV: study design, data collection, analysis, drafting manuscript, IJK: data collection, reviewing 3 manuscript, NK: data collection, reviewing manuscript, KS: data collection, reviewing manuscript, LKC: study design, reviewing manuscript, MKK: study design, reviewing manuscript, JF: analysis, reviewing manuscript, SS: study design, reviewing manuscript, RHS: study design, reviewing manuscript, AYXY: study design, data collection, analysis, drafting manuscript, funding.

Corresponding author

Correspondence to Amy Y. X. Yu.

Ethics declarations

Conflict of interest

The authors report no disclosure related to this study.

Ethics approval

This study was approved by the Sunnybrook Health Sciences Centre Research Ethics Board with a waiver of individual patient consent.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kapoor, A., Verma, A., Kim, I.J. et al. Multidisciplinary quality improvement initiative to optimize acute neurovascular imaging for transient ischemic attack or minor stroke. Can J Emerg Med 23, 820–827 (2021). https://doi.org/10.1007/s43678-021-00180-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s43678-021-00180-1

Keywords

Search

Navigation