Goal is to evaluate and treat patients for "mini strokes" within 24 hours
|RATE patients receive clinical evaluation and diagnostic tests within minutes of their arrival in the emergency department.|
Doctors at the University of Maryland Medical Center are taking an innovative approach to evaluating and treating patients who have a transient ischemic attack (TIA), a disturbance in blood flow to the brain often referred to as a "mini stroke." They have begun the Rapid Assessment of Transient Ischemic Attack Etiology (RATE) project, so that TIA patients have a complete neurological and diagnostic evaluation and receive treatment within 24 hours after they arrive in the emergency department.
"TIA is the single best indicator that someone will have a major, disabling stroke, and the risk of stroke is greatest in the first 24 hours after a TIA," says Marian LaMonte, M.D., director of the Brain Attack Team at the University of Maryland Medical Center and associate professor of neurology at the University of Maryland School of Medicine.
The Medical Center's innovative approach to TIA is believed to be the first of its kind in the United States. "Right now, there is no standard way to evaluate and treat TIA. In some cases, it can take days or weeks for patients to complete the neurological and blood test results needed for their evaluation," explains Dr. LaMonte. By completing the evaluation and beginning treatment for TIA patients within 24 hours, the doctors hope to decrease the occurrence of disabling stroke in these patients.
The multidisciplinary project combines the expertise of doctors and nurses in emergency medicine with the Brain Attack Team, along with the skills of experts in other departments including cardiology, neurosurgery, neuroradiology and vascular surgery. RATE does not change how TIA patients are evaluated and treated. However, it sets a standard procedure to follow to speed up the process and keep the patient in a centralized location.
The RATE approach may also reduce costs, because patients will not be admitted to the hospital for several days while awaiting tests. They will stay in the emergency department and receive all their tests within 24 hours.
"We use a similar approach in evaluating patients who come to us with chest pain, and that has been very successful," says Dick Kuo, M.D., clinical director of emergency services at the University of Maryland Medical Center and assistant professor of surgery at the University of Maryland School of Medicine.
A grant from the National Stroke Council, a special project of the National Emergency Medicine Association, Baltimore, Maryland, funded the purchase of specialized equipment for the emergency department, ensuring that patients will receive all necessary tests to meet the 24-hour goal. The equipment includes everything from palm pilots for data collection to a transcranial Doppler ultrasound machine, which images the blood vessels in the brain and carotid artery.
"A transcranial Doppler is a very specialized piece of equipment that normally wouldn't be used in an emergency room," adds Dr. Kuo. "But with the RATE protocol, we now have access to one, which is a tremendous advantage when you're trying to get all the TIA tests completed in under 24 hours."
With the information quickly assessed, doctors can decide whether the patient needs to be hospitalized or can be safely discharged. Under the RATE program, patients will be scheduled for a follow-up appointment with their primary care physician before they leave the emergency department. If they do not have a primary care physician, the Brain Attack Team can help them find one, even if they don't have insurance.
"Education and follow-up are important components of RATE. The patients themselves must be involved in stroke prevention, whether it's modifying their diet, getting more exercise, consistently taking medication or working with their primary care doctor," explains Elizabeth Zink, MS, CRNP, nurse practitioner for the Brain Attack Team. "As part of RATE, we send a letter to the patient's primary care physician to advise him or her about test results and medications the patient has had. We also counsel patients about managing TIA and stroke risk factors such as high blood pressure, smoking and obesity."
The symptoms of a TIA are similar to stroke. They come on suddenly and include weakness or numbness on one side of the body, trouble seeing, trouble speaking or understanding speech, loss of balance or coordination, or a severe headache with no known cause. However, TIA symptoms usually last between two and 30 minutes and rarely last more than a few hours. Because the symptoms go away, many people just ignore them or do not seek immediate medical attention.
But ignoring the symptoms can be a devastating mistake. About one-third of TIA patients will eventually have a stroke. It can happen days, weeks or even years later. Stroke is the leading cause of adult disability in the United States. According to the American Heart Association, every year about 700,000 Americans have a stroke and more than 150,000 die from a stroke.
"Anyone with even brief symptoms of a stroke should go to their nearest emergency department for evaluation. At the University of Maryland Medical Center, we can now rapidly assess and treat patients with TIA and stroke risk factors," says Dr. LaMonte.
She adds, "We want to get the message out that stroke can be prevented, and we know that people who have had a TIA are at a much greater risk for stroke. Through the RATE project, we are taking a proactive stance and trying to create the gold standard of TIA treatment."
In addition to funding from the National Emergency Medicine Association, the RATE project also received financial support from Boehringer-Ingelheim, a pharmaceutical company.
The Brain Attack Team will host an event on January 6, 2004 to thank these donors.
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