2023-11-21 00:05:34
LILLE, November 20, 2023 (APMnews) – At the Nantes University Hospital, the 24-hour opening of a bed reserved for suspected transient ischemic attacks (TIA) and headaches within the vascular intensive care unit (USINV ) has made it possible to reduce patients’ access to appropriate care, according to a communication made at the national day of ARS (regional health agencies) referents and facilitators of stroke sectors, last week in Lille .
Before 2018, “and partly still sometimes”, a patient with a suspected TIA was referred to the emergency reception services (SAU) of the Nantes University Hospital, on the Hôtel-Dieu site, then evaluated by a internal, benefiting from the usual assessment, and at the discretion of the emergency doctor, the neurologist was consulted for additional advice and in the event of a confirmed TIA, the patient was released, on the decision of the emergency doctor, to be included in the TIA sector after request sent to the neurovascular department, recalled Dr Simon Lassozé.
The neurologist then took all the requests, sorted them, and possibly proposed the scheduling of different examinations, a neurovascular consultation, and redirected them to the treating physician or a community neurologist. Thus, “consultation times were relatively long and it took between six and nine months to be able to see people again”.
This is how in November 2018, a “AIT-headache bed” was opened within the USINV, therefore access to which is regulated by “the classic neurologist”. This “dedicated” room can thus directly accommodate, without delay, 24 hours a day, seven days a week, patients with a suspected TIA or headache, who are cared for by a trained care team from the USINV.
“The clinical examination is carried out by the intern under the supervision of the senior neurovascularist except at night, by the senior on duty in this room,” explained Dr. Lassozé. On the imaging side, an MRI and an MR angiography (MR angio) are most often performed when the patient arrives during working hours, i.e. from 9 a.m. to 6 p.m. for the AIT bed. headache, and a CT scan and a CT angiogram outside of business hours.
In the event of a suspected TIA, the neurologist may be contacted for an assessment by telephone by the attending physician, general practitioners, sometimes specialists, the Samu or SOS Médecins, according to predefined admission criteria for a TIA or a headache. .
A patient is admitted to confirm or refute the diagnosis, investigate the cause, initiate appropriate treatment, organize follow-up and offer therapeutic education, with the aim of being discharged directly home a few hours later.
A diagnosis of TIA or pathology of the same spectrum in 60% of cases
To better appreciate the functioning of this organization, the neurovascular team used the PMSI coding data at the Nantes University Hospital and between 2018 and 2023, up to 457 patients were coded with a diagnosis of TIA, managed mainly in the emergency room. and at the neurovascular unit (NVU) outside the TIA-headache bed and between 39 and 58 patients only diagnosed at the TIA-headache bed. But the diagnosis of TIA is often overestimated in emergency rooms in general and patients seen in the TIA-headache bed outside of working hours are coded among UNV patients, observed the neurologist.
According to USINV data, between 2018 and 2023, 1,025 patients were admitted to the TIA-headache bed and the diagnosis of TIA was finally confirmed for 276 of them (2.7%) and that of migraine. with or without aura for 9.2%.
Around half (50.5%) had another non-hemorrhagic cerebrovascular pathology, “not strictly speaking TIA but part of the same spectrum” (ischemic stroke, occlusion of the central retinal artery, transient monocular blindness, dissection of the cervical or intracranial artery, focal organic deficit possibly vascular, central vertigo) and the rest covered cerebrovascular pathologies excluding pathologies related to TIA such as vascular headaches, aneurysms, subarachnoid hemorrhages and more rarely amyloid angiopathies or parenchymal hematomas.
Finally, not taken into account in these figures, also appear the diagnoses ruled out upon call by neurological expertise or corrected after imaging: malaise, functional symptom or syndrome, somatoform disorder, peripheral vertigo, epilepsy, neuralgia, cluster headaches of the face, brain tumor, amnesic stroke, disorientation…
Reduced time to access expertise
Dr Lassozé then reported data from a thesis carried out by a general medicine intern, Charlotte de Chillaz, who exhaustively took over all the data from the AIT-headache bed from 2019. It appears that that year , 256 patients were admitted, including 172 for suspected TIA, instead of 198 according to PMSI coding, which represents 55% of hospitalizations for suspected TIA at the hospital level. Ultimately, in 92 of these 172 patients, the diagnosis of TIA or ischemic stroke was confirmed.
According to this work, this AIT bed open 24 hours a day within the USINV allows rapid hospitalization, with three quarters being admitted less than 4.5 hours after the first contact with a doctor, an assessment of the patient upon arrival by trained staff with high reactivity since fibrinolysis can be initiated in the face of an ischemic stroke, brain imaging interpreted by a neuroradiologist for all patients, early initiation of secondary prevention treatment adapted for 80% of patients, but also prolonged monitoring if necessary but with a short length of stay.
Before the establishment of this bed, when the patient was admitted to the SAU, the waiting time for the first clinical evaluation was long, the delay reached several months for a scheduled admission to day hospitalization in neurology, recalled the neurologist . “Seeing people in the acute phase of AIT has made it possible to drastically reduce the number of requests made for AIT consultations and therefore to reduce delays, while offering people care that seems to us much more optimal.”
The advantage of this bed open 24 hours a day is to accommodate patients during night shifts, from 6 p.m., on weekends and public holidays, and they constitute “a significant portion”. “With a traditional bed, they would have been directed to the emergency room, where the wait is prolonged and the expertise is not always optimal” in the absence of a neurologist on site.
Thus, for five years, “we have still had arguments and also the impression of being of service to the population and to general practitioners in particular”, concluded Dr Lassozé.
Joining a session “Controversy over the management of AIT 24 hours a day or working hours”, Dr Pauline Renou from Bordeaux University Hospital came to “defend” the model of an AIT clinic accessible during working hours. working hours.
Launched in November 2022 within the UNV of the University Hospital with the aim of also improving the management of TIAs, the structure has welcomed some 450 patients, 75% of whom had a diagnosis of TIA or confirmed stroke. The neurologist finally concluded at the end of her presentation that the team particularly wanted to welcome patients beyond 6:30 p.m., 24 hours a day, within this “ambulatory” AIT clinic.
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