Testing a rapid outpatient management strategy on PTSD, cardiovascular and rehospitalization risk in TIA and minor stroke survivors evaluated in the Emergency Department

测试针对 PTSD、TIA 心血管和再住院风险以及急诊科评估的轻微中风幸存者的快速门诊管理策略

• 批准号: 9754258
• 负责人: Bernard P. Chang
• 金额: $ 67.56万
• 依托单位: COLUMBIA UNIVERSITY HEALTH SCIENCES
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-08-01 至 2023-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9754258
• 关键词: Academic Medical Centers; Accelerometer; Accident and Emergency department; Acute; Admission activity; Affect; Autonomic nervous system; Blood Vessels; Calculi; Cardiovascular Diseases; Cardiovascular system; Caring; Clinic; Clinical; Clinical Practice Variations; Cohort Studies; Development; Devices; Diagnostic Imaging; Disease; Disease Outcome; Electrocardiogram; Eligibility Determination; Emergency Care; Emergency Department evaluation; Enrollment; Environment; Equipoise; Ethics; Evaluation; Event; Exposure to; Funding; Guidelines; Heart Rate; Home environment; Hospitalization; Hour; Infrastructure; Inpatients; Intuition; Ischemia; Knowledge; Link; Measures; Medical; Minor; Monitor; National Heart, Lung, and Blood Institute; Natural experiment; Neurologic Dysfunctions; Neurology; Outcome; Outcome Study; Outpatients; Participant; Pathway interactions; Patient-Focused Outcomes; Patients; Physiological; Post-Traumatic Stress Disorders; Randomized; Recurrence; Relative Risks; Research; Research Design; Risk; Safety; Schedule; Stress; Stroke; Survivors; Symptoms; Testing; Time; Transient Ischemic Attack; United States National Institutes of Health; Variant; acute coronary syndrome; acute stress; adjudicate; cardiovascular disorder risk; clinical decision-making; cost; design; disorder risk; follow-up; heart rate variability; hospital readmission; improved; indexing; inpatient service; mortality; mortality risk; patient-clinician communication; post stroke; primary outcome; psychologic; secondary outcome; stroke patient; stroke risk; stroke survivor; stroke symptom

Recent research suggests that exposure to stressful aspects of emergency department (ED) and inpatient care may increase risk for subsequent posttraumatic stress disorder (PTSD) and recurrent cardiovascular events in patients who present to the ED with transient ischemic attacks and minor strokes (TIAMS). There are currently no established clinical guidelines for emergency department (ED) management of TIAMS after the initial evaluation and safety determination. This study will compare psychological and long-term cardiovascular outcomes associated with the two most widely employed strategies for managing TIAMS patients in US EDs. We will use an observational design to compare TIAMS-induced PTSD symptoms, 30-day rehospitalization, and 1-year cardiovascular disease (CVD)/mortality outcomes in TIAMS patients managed according to (1) ED evaluation followed by inpatient admission strategy, versus (2) rapid ED evaluation and discharge with a scheduled next-day outpatient neurology follow-up. Further, we will assess autonomic nervous system (ANS) reactivity to the 2 strategies using ambulatory ECG. This study design is possible because of a newly established Rapid Access Vascular Evaluation- Neurology (RAVEN) TIAMS care pathway, which will be available for 2 weeks per month (on alternating weeks) at Columbia University Medical Center. We hypothesize that patients treated during RAVEN weeks will have lower PTSD symptoms, reduced 30d rehospitalization, and lower 1- year CVD/mortality risk relative to those treated during the inpatient admission strategy weeks. We will explore whether ANS markers of stress (ambulatory heart rate (HR) and heart rate variability (HRV) in the 3 days after ED presentation) explain any group differences in study outcomes. Nearly 1 in 5 TIA/MS survivors screen positive for PTSD in the month after the event, and research in other CVD patients suggests that PTSD may increase risk for recurrent CVD events. To date, research linking ED/inpatient exposure with subsequent PTSD has been unable to disentangle the stress that results from the medical event itself from stress resulting from the hectic ED/inpatient stay. If our hypothesis is correct -- that rapid ED discharge and outpatient follow-up reduces PTSD symptoms and improves clinical outcomes in TIAMS survivors-- the results of our study will impact clinical guidelines immediately. Furthermore, the study will have broader implications for the clinical calculus of ED care versus outpatient follow-up for many other diseases, such as acute coronary syndrome, traditionally managed with prolonged ED observation and inpatient care.

最近的研究表明，暴露于急诊科（ED）和 住院治疗可能会增加随后的创伤后应激障碍（PTSD）和经常性的风险 瞬时缺血性发作和次要的患者的心血管事件 中风（tiams）。目前尚无针对急诊科的临床指南 （ed）初步评估和安全确定后TIAMS的管理。这项研究会 比较与两个最广泛相关的心理和长期心血管结局 采用在美国EDS中管理TIAMS患者的策略。 我们将使用观测设计比较TIAMS引起的PTSD症状，30天 TIAMS患者的重新住院和1年心血管疾病（CVD）/死亡率 根据（1）ED评估进行管理，然后进行住院入院策略，与（2）快速 ED评估和排放，并计划在第二天的门诊神经病学随访。更远， 我们将使用门诊ECG评估对两种策略的自主神经系统（ANS）反应性。 这项研究设计是可能的，因为新建立的快速访问血管评估 - 神经病学（Raven）Tiams Care Pathway，每月可用2周 交替的几周）在哥伦比亚大学医学中心。我们假设患者接受治疗 在乌鸦周期间，PTSD症状将降低，减少30D重新寄养和降低1- 相对于住院入院策略周期治疗的年份CVD/死亡率风险。我们 将探索压力的ANS标记（卧床心率（HR）和心率变异性是否 （HRV）在ED演示后的3天内）解释研究结果中的任何群体差异。 活动结束后的一个月，近5个TIA/MS幸存者屏幕为PTSD呈阳性，并进行研究 在其他CVD患者中，PTSD可能会增加复发性CVD事件的风险。迄今为止， 将ED/住院接触与随后的PTSD联系起来的研究一直无法解散 医疗事件本身是由忙碌/住院的压力引起的压力 停留。如果我们的假设正确 - 快速ED出院和门诊随访会减少PTSD 症状并改善了提亚姆斯幸存者的临床结果 - 我们的研究结果将影响 临床准则立即。此外，该研究将对 许多其他疾病的ED护理与门诊随访的临床演算，例如急性 冠状动脉综合征，传统上以长期的ED观察和住院护理进行管理。