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Service Delivery Innovation Profile

Outpatient Center Evaluates Stable Patients Experiencing Recent Ministroke, Leading to Timely, Comprehensive Care and Lower Costs


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Snapshot

Summary

Located in a hospital with a primary stroke center, the TIA Rapid Evaluation Center provides a timely, comprehensive evaluation on an outpatient basis of stable patients who have experienced a recent transient ischemic attack (a minor stroke that comes and goes quickly). Rather than admitting these patients to the hospital (as is common in most of the country), emergency department and community-based physicians refer them to the center for needed tests and a neurological examination, which typically take place the next day. Based on the results, the neurologist develops a personalized plan to reduce the risk of recurrent stroke. During its first 6 months of operation, the center has served 80 percent of stable patients presenting to the hospital with a transient ischemic attack, providing them with more comprehensive and timely services than those received by similar patients on an inpatient basis. During this time, the program has eliminated the need for 36 inpatient admissions, generating cost savings of more than $150,000. No patient served by the program has experienced a recurrent stroke.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key quality and efficiency measures between 39 patients served by the program during its first 6 months of operation and approximately 400 similar patients admitted to the hospital during the 4 years before program launch. These metrics evaluated the timeliness, comprehensiveness, and cost of services.
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Developing Organizations

Monmouth Medical Center
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Use By Other Organizations

Similar programs have been used in parts of Europe and Canada for a number of years. In these countries, stable TIA patients have traditionally been served on an outpatient basis, with TREC-like centers being created to address the fragmented nature of such care, which required patients to schedule and attend multiple visits over a lengthy period of time.

Date First Implemented

2012
The center opened in June 2012.

Problem Addressed

Asymptomatic patients who have recently experienced a transient ischemic attack (TIA) traditionally get admitted to the hospital for testing and a neurologist evaluation to determine appropriate steps to reduce the risk of recurrent stroke. These workups often stretch over a period of several days, and patients sometimes do not get all needed services during the stay. If well coordinated, the same services can be offered on a timely basis in the outpatient setting at a lower cost. Yet this approach is not widely used in the United States.
  • Inpatient admission as traditional approach: Many community-based and emergency department (ED) physicians routinely admit stable, asymptomatic patients who have recently experienced a TIA to the hospital for a series of tests and a neurological examination, with the goal of determining appropriate preventive steps to reduce the substantial risk of recurrent stroke (up to 10 percent of patients experience a stroke within 1 week of the initial TIA).1 The goal is to provide rapid, aggressive intervention to these patients, which can reduce the risk of a second stroke by up to 90 percent.1
  • Lengthy, expensive stays, often with incomplete services: Although the goal is to provide rapid, comprehensive care, many hospitals routinely fail to do so, taking 3 days or more to perform the inpatient workup, with stays typically costing $5,000 or more and testing often not completed. At Monmouth Medical Center, a review of 400 admitted TIA patients over a 4-year period found an average stay of 3 days at a cost of $5,400 per stay. The same review found that only 60 percent of patients received all needed tests during their time in the hospital.
  • Unrealized potential of outpatient workup: Studies from Europe and Canada suggest that stable patients who have recently experienced a TIA can be safely and quickly evaluated in the outpatient setting, at much lower cost and without the associated risks and inconvenience of an inpatient stay.2,3,4 Yet this alternative is not widely offered by hospitals in the United States.

What They Did

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Description of the Innovative Activity

Located in a hospital with a stroke center, the TIA Rapid Evaluation Center (TREC) provides a timely, comprehensive workup in the outpatient setting to stable patients who have experienced a recent TIA. Rather than admitting these patients to the hospital, ED and community-based physicians refer them to the center for needed tests and a neurological examination, typically performed the next day. Based on the results, the neurologist develops a personalized plan to reduce the risk of recurrent stroke. Key program elements are outlined below:
  • Offering TREC option to patient: Whenever an ED-based physician sees a stable patient who has experienced a recent TIA, the doctor explains the TREC program to the patient, presenting it as an alternative to an immediate inpatient admission. The physician reviews a three-page referral form, including educational information that explains what a TIA is, quantifies the significant risk of recurrent stroke, and describes how a comprehensive workup and associated care plan can reduce that risk. The form also explains how the TREC works, presenting it as an attractive option to an inpatient admission. Some community-based physicians offer the same option to their patients, although to date the focus has been primarily on patients presenting to the ED. Going forward, program leaders hope to get more community-based doctors to follow this approach; see the Planning and Development Process section for more details.
  • Patient consent: Patients can select either option—the TREC or an inpatient admission. To date, all patients offered the TREC have chosen it. Patients sign the referral form (indicating their consent) and are usually told to come to the center the next morning at 8 a.m. (unless it’s a Friday or Saturday, because the center is not open on weekends). They also receive information on where the center is located.
  • Precertification and scheduling: The ED faxes the referral form to the TREC office, where a part-time administrative assistant takes charge of securing needed preauthorizations from insurance companies and scheduling the tests.
  • Comprehensive, 1-day evaluation: Patients arrive at 8 a.m., where a nurse practitioner meets them, conducts a brief evaluation, explains how the day will work, and provides a written schedule and map showing where all testing will take place. (The center makes use of existing equipment and staff within various departments of the hospital.) If necessary, a volunteer can be made available to help the patient navigate his or her way around the hospital. The evaluation consists of testing followed by a neurological examination, as outlined below.
    • Testing, with rapid turnaround: The patient follows the schedule, moving from department to department to receive necessary blood work (e.g., cholesterol, blood glucose), cardiac testing (e.g., electrocardiogram, carotid Doppler, transthoracic echocardiogram), and magnetic resonance imaging (MRI) tests. Staff within these departments adhere to agreed-upon standards for how quickly tests are interpreted (e.g., 30 minutes for MRIs and echocardiograms), thus allowing TREC patients to receive all needed services by the end of the day. As part of a primary stroke center, the departments are accustomed to abiding by these kinds of requirements for stroke patients admitted to the hospital.
    • Neurologist examination: Once all testing has been completed, the patient returns to the TREC office (usually between 1 and 2 p.m.), where a neurologist reviews the results, conducts an examination, and develops a personalized treatment plan to reduce the risk of recurrent stroke. This plan may include counseling, changing medications (such as adding cholesterol-lowering or blood-thinning drugs), and arranging for further testing and followup visits if needed.
  • Followup with no-shows: The administrative assistant attempts to contact any patient referred to the TREC who does not show up for the scheduled evaluation, and urges them to come to the center as soon as possible.
  • Communication with regular physician: Following the evaluation, the neurologist telephones the office of the patient’s primary care physician (PCP) to alert him or her of the visit to the TREC, and then faxes written information about what transpired, including any changes to medications. Contact is made with the PCPs of all patients, regardless of whether that doctor referred the patient to the TREC.

Context of the Innovation

Neurology Specialists of Monmouth County is an eight-physician neurology practice that offers a full range of inpatient and outpatient neurological services. Monmouth Medical Center is a 537-bed community teaching hospital in Long Branch, NJ. In January 2012, the hospital opened The Neuroscience Institute at Monmouth Medical Center, which serves as a comprehensive, multidisciplinary program for the treatment of brain, spine, and neuromuscular conditions across the life span.

The impetus for the TREC came from the leadership of the Neuroscience Institute, who had a sense that TIA patients often ended up staying in the hospital for a long time, and even then did not receive all needed care. To test their hypotheses, they conducted a retrospective review of 400 TIA patients seen in the hospital over the previous 4 years. As noted earlier, this analysis found that patients stayed an average of 3 days at a cost of more than $5,000, yet frequently did not get all needed tests. Their suspicions confirmed, these doctors began thinking of ways to better serve patients in the outpatient setting. Because outpatient care tends to be fragmented and TIA patients need multiple tests and a neurologist consult (care that is difficult and time-consuming for a patient to orchestrate on his or her own), the physicians decided to create a center to coordinate the provision of all needed services in a single day. They were aware of the aforementioned studies from Europe and Canada that demonstrate the potential benefits of this approach.

Did It Work?

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Results

During its first 6 months of operation, the center served 80 percent of stable patients presenting to the hospital with a TIA, providing them with more comprehensive and timely services than those received in the past by similar patients seen on an inpatient basis. During this time, the program eliminated the need for 36 inpatient admissions, generating cost savings of more than $150,000. No patient served by the program has experienced a recurrent stroke.
  • More comprehensive, timely services for most stable TIA patients: The center has been able to serve the vast majority of stable TIA patients in a more timely, comprehensive manner than those admitted to the hospital.
    • Reaching most TIA patients: The TREC handled 39 patients during the first 6 months of operation, representing an estimated 80 percent of TIA patients served by the hospital. Some patients are still admitted to the hospital, including those determined to be high risk through use of a validated risk factor scale (known as ABCD 2) and some patients who come to the ED on Friday or Saturday, since the TREC is not open on weekends and hence cannot serve them the next day.
    • More timely service: A retrospective review of TIA patients admitted to the hospital in the 4 years before the opening of TREC found that it took, on average, 3 days to provide the workup, well above the 1.2-day average for TREC patients. More than three-quarters of TREC patients received the workup the same day or the day after being referred, with the rest visiting the TREC within 2 or 3 days of the referral.
    • More comprehensive service: Ninety-three percent of TREC patients had all needed tests performed, compared to only 60 percent of similar TIA patients admitted to the hospital in the 4 years before the program began.
  • Lower costs due to avoided admissions: The TREC eliminated the need for 36 inpatient admissions during its first 6 months of operation. (Two patients who came to the center were admitted to the hospital, and one other patient required admission several weeks later for a separate problem indirectly related to the TIA.) Each avoided admission saves an estimated $4,000 (the $5,400 average cost of an inpatient TIA admission less the roughly $1,200 cost of delivering the services through TREC). In total, therefore, the program saved more than $150,000 in its first 6 months of operation. (Monmouth Medical Center treats roughly 100 TIA patients a year; savings at smaller or larger facilities would vary accordingly.)
  • No recurrent strokes: No patient served by TREC in its first 6 months of operation experienced a recurrent stroke.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key quality and efficiency measures between 39 patients served by the program during its first 6 months of operation and approximately 400 similar patients admitted to the hospital during the 4 years before program launch. These metrics evaluated the timeliness, comprehensiveness, and cost of services.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Winning administrator approval: The leader of the Neuroscience Institute approached hospital administration about the idea of creating the TREC. They quickly supported the concept, recognizing its potential to enhance the timeliness and quality of care, and its contribution to  hospital efforts to respond to external pressures to curb costs and transition care to the outpatient setting.
  • Securing ED physician support: The medical director presented the concept to ED physicians at a regularly scheduled department meeting. He stressed that the program is intended to serve stable patients experiencing a recent TIA, and that unstable patients (including those with an ABCD 2 score above 5) and those with a major deficit that requires rehabilitation should still be admitted to the hospital. The physicians initially pushed back against the idea, noting the potential legal liability if they sent a patient home who subsequently experienced a stroke. To address this concern, the medical director oversaw the previously mentioned retrospective analysis of stable TIA patients who had been admitted to the hospital, and then shared the results with the ED physicians. The analysis showed that none of them had experienced another event during the admission. He also agreed to include a place on the referral form for patients to give consent to receiving care at the TREC. Together, these two steps convinced the ED physicians to support the concept.
  • Finding space for registration area: Program leaders needed a space where patients could register, be evaluated by a nurse practitioner, and receive their schedule and map. Initially, they found available space in an existing infusion center at the hospital. At the end of 2012, the center moved to newer, nicer outpatient space at the hospital.
  • Setting expectations for timeliness with relevant departments: Since Monmouth Medical Center is a primary stroke center, physicians and staff already have to adhere to timeliness guidelines for stroke patients admitted to the hospital. The medical director met with various department leaders (e.g., cardiac imaging, MRI) to explain the TREC and create similar protocols for identifying and serving TREC patients, including guidelines for how quickly test results are needed.
  • Educating referring physicians: Although the initial effort focused primarily on securing ED physician support, the medical director also met with the entire hospital staff (including the medical staff) before the launch to explain the program. However, many physicians missed this session and others did not retain the information presented. As a result, the medical director recently began having a member of the hospital’s physician relations staff distribute information about the TREC during her regularly scheduled meetings with referring physicians in the community.
  • Educating patients and community: Although patients cannot directly refer themselves to the TREC, the medical director has tried to raise awareness about the program and the importance of timely care after a TIA through press releases, local television, a Web page and blog, and presentations at local senior centers.

Resources Used and Skills Needed

  • Staffing: The program requires no incremental staff, as existing inpatient staff shift some of their time to TREC-related activities, including the nurse practitioner who meets and orients patients each morning and an administrative assistant who works a few hours a day doing precertification and scheduling. Any primary stroke center should have most if not all of the staff in place for this type of program.
  • Costs: The program required minimal financial outlays, since it makes use of existing staff and equipment within the hospital. A small amount of money was spent to print referral forms and brochures. As noted earlier, the program saves several thousand dollars per case (versus the cost of providing the same care in the inpatient setting).
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Funding Sources

Monmouth Medical Center
The program is funded internally by Monmouth Medical Center.end fs

Tools and Other Resources

Warrior L, Prabhakaran S. Transient ischemic attack evaluation models: hospitalization, same-day clinics, or rapid evaluation units. Am J Ther. 2011;18:45-50. [PubMed]

Joshi JK, Ouyang B, Prabhakaran S. Should TIA patients be hospitalized or referred to a same-day clinic? A decision analysis. Neurology. 2011;77:2082-8. [PubMed]

The referral form is available at http://www.barnabashealth.org/hospitals/monmouth_medical/neuroscience/downloads
/TREC-referral-form.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Adoption Considerations

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Getting Started with This Innovation

  • Consider appropriateness of program: Hospitals with primary stroke centers are best equipped to implement this type of program; other hospitals likely could not implement it as easily or effectively.
  • Leverage existing facilities: Hospitals with stroke centers generally have most if not all the staff and facilities needed to run this program. The only incremental requirement is a small space to be used for patient registration and orientation.
  • Analyze workflow: Spend time upfront figuring out the relevant departments that will serve TREC patients, and then approach department leaders to review expectations with respect to timeliness of testing and interpretation.
  • Share data with physicians on potential quality benefits: ED or community-based physicians may initially resist the idea due to concerns about quality of care and related liability issues if a patient has a recurrent stroke outside the hospital. To alleviate such concerns, share information showing that low-risk, stable TIA patients (with an ABCD 2 score below 5) can safely be treated in the outpatient setting, and that these services can be delivered in a more comprehensive and timely manner through this approach.
  • Focus first on ED-based physicians: In most communities today, stable TIA patients typically present to the ED, either going there on their own or after a referral from their regular doctor. Consequently, early efforts should focus on educating ED-based physicians, who are smaller in number and easier to identify and reach than community-based doctors.
  • Give patients adequate support: As noted, patients need a schedule and map to help them get to the various testing areas on time. Volunteers should be available to help if needed.

Sustaining This Innovation

  • Regularly collect and share data showing program impact: ED and community-based physicians will be more likely to continue referring patients to the TREC if they regularly see evidence that it serves patients more effectively than inpatient care, with no increased risk of recurrent stroke.
  • Continue educational efforts, including expansion to community-based doctors: ED physicians may need regular reminders about the TREC program, such as through presentations at department meetings or brochures or other reminders. (At one point, TREC program leaders gave ED physicians mugs with the printed slogan “If It’s a TIA, We Can Work Them up in a Day,” along with the telephone number for the TREC.) Once the program is accepted among ED doctors, consider expanding educational efforts to community-based doctors.
  • Provide rapid followup to PCPs: PCPs need to be informed quickly about any patients seen in the TREC, including changes in medications and other relevant information. Failing to keep these physicians informed not only undermines quality of care, but also could result in physician backlash against the program.

Use By Other Organizations

Similar programs have been used in parts of Europe and Canada for a number of years. In these countries, stable TIA patients have traditionally been served on an outpatient basis, with TREC-like centers being created to address the fragmented nature of such care, which required patients to schedule and attend multiple visits over a lengthy period of time.

More Information

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Contact the Innovator

Neil R. Holland, MD
Neurology Specialists of Monmouth County
107 Monmouth Road
West Long Branch, NJ 07764
(732) 935-1850
E-mail: nholland@neurologyspecialists.org

Innovator Disclosures

Dr. Holland reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

Recognition

In June 2013, the American Heart Association honored Dr. Neil Holland as a Medical Honoree for Excellence in Stroke care and prevention for his role in developing the TIA Rapid Evaluation Center. More information about this award is available at: http://mmcneuro.wordpress.com/2013/06/23/dr-holland-and-monmouth-neuroscience-institutes-tia-rapid-evaluation-center-honored-at-the-2013-heart-ball
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References/Related Articles

More information about the program is available at the following links:

Footnotes

1 Rothwell PM, Giles MF, Chandratheva A, 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;30(9596):1432-42. [PubMed]
2 Horer S, Schulte-Altedorneburg G, Haberl RL. Management of patients with transient ischemic attack is safe in an outpatient clinic based on rapid diagnosis and risk stratification. Cererbrovasc Dis. 2011;32:504-10. [PubMed]
3 Wasserman J, Perry J, Dowlatshahi D, et al. Stratified, urgent care for transient ischemic attack results in low stroke rates. Stroke. 2010;41(11):2601-5. [PubMed]
4 Martinez-Martinez MM, Martinez-Sanchez P, Fuentes B, et al. Transient ischaemic attacks clinics provide equivalent and more efficient care than early in-hospital assessment. Eur J Neurol. 2013;20(2):338-43. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 13, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 11, 2015.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Neil R. Holland, MD
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