Variables associated with discordance between emergency physician and neurologist diagnoses of transient ischemic attacks in the emergency department.

STUDY OBJECTIVE: Transient ischemic attack is a common clinical diagnosis in emergency department (ED) patients with acute neurologic complaints. Accurate diagnosis of transient ischemic attack is essential to help guide evaluation and avoid treatment delays. We seek to determine the prevalence of discordant diagnosis for patients receiving an ED diagnosis of transient ischemic attack compared with neurologist final diagnosis. Secondary goals are to evaluate the influence of atypical transient ischemic attack symptoms, the ABCD2 score, and emergency physician experience on discordant diagnoses. METHODS: We performed a retrospective cohort study evaluating all ED patients receiving a diagnosis of transient ischemic attack during a 4-year period. The emergency physician diagnosis was compared with that of the neurologist. The neurologist's final diagnosis was considered the criterion standard diagnosis. Subject demographic and clinical information was collected with a structured instrument. The following atypical symptoms present at the ED evaluation were evaluated with logistic regression: headache, tingling, involuntary movement, seeing flashing lights or wavy lines, dizziness, confusion, incontinence, and ABCD2 score of 4 or greater. Bivariate analysis was used to evaluate the influence of emergency physician experience (≤6 years versus >6 years) on discordant diagnosis. Odds ratios (ORs) and proportions are reported with 95% confidence intervals (CIs), interquartile range was used where appropriate. RESULTS: We evaluated 436 subjects, of whom 7 were excluded, allowing 429 subjects for evaluation. Of these individuals, 156 (36%; 95% CI 32% to 41%) received a discordant diagnosis. The median emergency physician time in clinical practice was 6 years (interquartile range 2 to 12 years). Features associated with a discordant transient ischemic attack diagnosis included headache (OR 2.52; 95% CI 1.59 to 3.99), involuntary movement (OR 3.19; 95% CI 1.35 to 7.54), and dizziness (OR 1.92; 95% CI 1.22 to 3.02). Incontinence, confusion, and seeing wavy lines or flashing lights were not significantly associated with a discordant diagnosis. Patients with tingling and a high ABCD2 score had an increased odds of concordant transient ischemic attack diagnosis (OR 0.54, 95% CI 0.32 to 0.92; OR 0.53, 95% CI 0.35 to 0.82, respectively). CONCLUSION: Discordant diagnoses between emergency physicians and neurologists were observed in 36% of patients. The presence of headache, involuntary movement, and dizziness predicted discordant diagnoses, whereas the presence of tingling and an increased ABCD2 score predicted concordant transient ischemic attack diagnosis.

Can the ABCD2 risk score predict positive diagnostic testing for emergency department patients admitted for transient ischemic attack?

BACKGROUND AND PURPOSE: We sought to determine if the ABCD2 score, typically used for risk stratification, could predict having a positive diagnostic test in patients evaluated acutely for transient ischemic attack. METHODS: We performed a retrospective cohort study for patients admitted from our emergency department with a new diagnosis of transient ischemic attack confirmed by a neurologist. ABCD2 scores were calculated and patients with a score of > or = 4 were placed in the high-risk cohort. Tests evaluated included electrocardiogram, CT, MRI, MR angiography, carotid ultrasonography, and echocardiography. Specific test findings considered to signify positive diagnostic tests were created a priori. RESULTS: We identified 256 patients with transient ischemic attack for inclusion; 167 (61%) were female, the median age was 60 years (interquartile range, 50 to 72), and 162 (63%) patients had an ABCD2 score of > or = 4. Rates of completion of diagnostic testing were electrocardiogram, 270 (100%); CT, 224 (88%); MRI, 89 (35%); MR angiography, 68 (27%); carotid ultrasonography, 125 (49%); and echocardiography, 135 (53%). Univariate analysis found a significant association only with elevated ABCD2 score and carotid duplex testing (P<0.05). CONCLUSION: An elevated ABCD2 score may help predict patients with severe carotid occlusive disease but does not predict positive outcome in other commonly ordered tests for patients being evaluated for transient ischemic attack. An elevated ABCD2 score cannot be recommended as a tool to guide diagnostic testing in patients presenting acutely with transient ischemic attack.

Interrater reliability of cardiac output measurements by transcutaneous Doppler ultrasound: implications for noninvasive hemodynamic monitoring in the ED.

INTRODUCTION: Hemodynamic monitoring is an important aspect of caring for the critically ill patients boarding in the emergency department (ED). The purpose of this study is to investigate the interrater agreement of noninvasive cardiac output measurements using transcutaneous Doppler ultrasound technique. METHODS: This is a prospective observational cohort study performed in a 32-bed adult ED of an academic tertiary center with approximately 65000 annual patient visits. Patients were enrolled after verbal consent over a 7-month period. The raters were ED personnel involved in patient care. Paired measurements of cardiac index (CI) and stroke volume index (SVI) were obtained from a transcutaneous Doppler ultrasound cardiac output monitor. RESULTS: A convenience sample of 107 (50 women and 57 men) patients with a median age of 49 (32, 62) years was enrolled. One hundred two paired measurements were performed in 91 patients in whom adequate Doppler ultrasound signals were obtainable. The raters included 35 emergency medicine attending physicians, 31 emergency medicine residents, 80 medical students, 47 nurses, and 11 emergency medical technicians. Cardiac index range was 0.6 to 5.3 L/min per square meter, and SVI range was 7.7 to 63.0 mL/m(2). The correlation of CI measurements between 2 raters was good (r(2) = 0.87; 95% confidence interval, 0.86-1.00; P < .001). Likewise, SVI measurements between 2 raters also showed acceptable correlation (r(2) = 0.84; 95% confidence interval, 0.81-0.96; P < .001). Interrater reliability was strong for CI (kappa = 0.83 with 92.2% agreement) and SVI measurements (kappa = 0.72 with 88.2% agreement). Most patients had an interrater difference below 10% in CI and SVI measurements. CONCLUSIONS: Emergency department personnel, regardless of their role in patient care, are able to obtain reliable cardiac output measurements in ED patients over a wide range of CI and SVI. Transcutaneous Doppler ultrasound technique may be an alternative to traditional invasive hemodynamic monitoring of critically ill patients presenting to the ED.