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Practical principles for transient ischaemic attack (TIA)

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Practical principles for transient ischaemic attack (TIA)
One of a set of eight practical principles publications.
The full set are:
1 - Improving psychological care after stroke
2 - Developing an early supported discharge service
3 - Improving access to CT scanning
4 - Transient Ischaemic Attack (TIA)
5 - How to establish joint care planning
6 - How to manage reviews for stroke survivors
7 - Being the best in acute stroke
8 - Developing a community stroke service
(Published November 2011)

Published in: Health & Medicine
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Practical principles for transient ischaemic attack (TIA)

  1. 1. NHS NHS ImprovementPRACTICAL PRINCIPLESfor Transient Ischaemic Attack (TIA) 1. Streamline the referral route with a single point of contact for high and lower risk 2. Employ a comprehensive communication strategy 3. Tailor the weekend service to local needs and demands 4. Develop a sustainable data and audit system 5. Provide access to specialist follow up for all TIA patients 6. Agree a pathway for timely access to carotid intervention QUALITY 4& ACCELERATING MARKER 5 STROKE IMPROVEMENT 5Streamline the referral route with a CASE STUDYsingle point of contact for high andlower risk North Bristol NHS Trust appointed a TIA co-ordinator as a single• A single point of contact simplifies point of referral to ensure timely the referral process for the referrer, is and efficient booking of patients, more efficient for coordinating the according to ABCD2 prioritisation. service and data collection can begin This is particularly efficient if at one entry point appointments are given to• A simple clear referral proforma is patients while still with the essential and needs to: referrer, reducing any time delay • be appropriate to the referrer in contacting the patient. • highlight the pathway • aid diagnosis (clear information for Tailor the weekend service to local ABCD2 assessment) needs and demands • give essential information for Employ a comprehensive patients. communication strategy • Work with commissioners to achieve a properly funded service from the • Raising the awareness in primary outset CASE STUDY • Understand the projected numbers care, ambulance service, A&E and any other referral points of the TIA for your local population in order to Surrey and Sussex Healthcare develop the most cost effective way NHS Trust implemented a pathway is essential • This supports implementation of the of providing the service dedicated TIA bleep holder to • A seven day service ensures a take all calls. This has been shown pathway and ensures patients enter the right pathway of care as soon as backlog free Monday for both to be an effective method of assessment and imaging referral and popular; GPs say that possible • It should emphasise the importance • Getting patients to attend at this sort of access is exactly what weekends is rarely a problem – no they want. This system also of early referral and enable education in the ABCD2 score more than during the week when ensures an ABCD2 score is asked to attend at short notice included in the referral and ensuring appropriate referrals and effective triage • Educate staff on the clinical benefits reduces inappropriate referrals. of providing a seven day service. • The communication strategy should be an ongoing plan with regular follow up. CASE STUDY CASE STUDY Doncaster Royal Infirmary provided a fax and dedicated North West London Cardiovascular and Stroke Network created a phone on the acute stroke unit communication plan to improve the awareness of TIA in primary care and that is checked 24/7 enabling support the consistency of approach to TIA diagnosis and referral. This is rapid response by skilled staff. now being replicated in North Central London.
  2. 2. NHS NHS ImprovementEvidence is emerging that not all sites CASE STUDY • Nurses, whether in the acute settingwill be able to sustain a weekend service or in the community, are ideally placedand alternative models need to be North Bristol NHS Trust provides to deliver the serviceconsidered. Many of the sites currently the weekend high risk TIA service • There should be a clear rapid pathwaysustaining a weekend service cover for the Bristol, North Somerset back into the acute TIA service and topopulations of around 800,000 to one and South Gloucestershire health carotid intervention if requiredmillion, although there are exceptions to community. • There should be a standard processthis. This suggests that many trusts will agreed locally with core content to beneed to work in partnership to deliver covered by all providers. This shouldsustainable comprehensive weekend include:services. Interest is also developing in the CASE STUDY • Secondary prevention – medicinesuse of telemedicine to deliver weekend management, blood pressure,services. Models emerging include: Northampton General Hospital lifestyle (diet, exercise, smoking) NHS Trust provides the weekend • Education and information, including• Stand alone one site serving their own service for Northampton, use of the FAST test local population Kettering and Milton Keynes. • Clear instructions on driving• Network wide solutions, where hyper • Point of contact and handover to acute centres provide weekend the GP services based on thrombolysis cover Develop a sustainable data and audit • Emotional and psychological• Multi site trusts, where only one site system issues. operates or the site rotates at weekends • This is essential for taking the service The availability of a specialist follow up• Partnership with neighbouring trusts forward, developing business cases, review following a TIA is an integral part showing outcomes and return on of the best practice tariff for TIA. investment CASE STUDY • Electronic audit tools standardise note keeping and letters to GPs, and gather CASE STUDY University Hospitals of Leicester NHS Trust and University audit data that is reliable and easy to use Oxford Radcliffe Hospitals NHS Hospitals Coventry and Trust and The Royal Bournemouth Warwickshire NHS Trust provide • Robust data collection and continuous ongoing audit enables the service to and Christchurch Hospitals NHS comprehensive seven day services Foundation Trust both provide for local catchment areas. be altered quickly when problems arise. follow up within the acute setting by a nurse specialist. CASE STUDY CASE STUDY University Hospitals of Leicester North West London NHS Trust, Surrey and Sussex CASE STUDY Cardiovascular and Stroke Healthcare NHS Trust, North Network, the two hyper acute Bristol NHS Trust and Lancashire Avon, Gloucestershire, Wiltshire stroke centres in north west Teaching Hospitals NHS and Somerset Cardiac and Stroke London provide the weekend TIA Foundation Trust have all Network have developed service which is provided by six developed robust data and audit standards for TIA follow up in sites Monday to Friday systems primary care. CASE STUDY Provide access to specialist follow up CASE STUDY for all TIA patients East Kent Hospitals University The Royal Wolverhampton NHS Foundation Trust based on • This can be provided in various settings Hospitals NHS Trust use band 7 three sites delivers a TIA service and by various professionals but community stroke coordinators to Monday to Friday on each site should have a specialist element based deliver one month TIA reviews in with the weekend service on clinical knowledge and agreed a community setting. delivered at one site on a rotating competencies basis.
  3. 3. NHS NHS ImprovementAgree a pathway for timely access tocarotid intervention• Agree and communicate a pathway between the stroke team, imaging and vascular team that covers seven days a week• Understand where delays are in the pathway from symptom onset to intervention• An intensive therapy unit or high dependency unit bed is not an essential requirement for undertaking carotid endarterectomy. Handover of the patient from theatre to recovery to a ward with appropriately skilled staff is the key• It is important to have an anaesthetist who is familiar with the procedure and has experience and expertise in anaesthesia for vascular surgery• Good information for the patient should be available explaining risks, CASE STUDY side effects and benefits. East Kent Hospitals UniversityAll patients requiring carotid intervention NHS Foundation Trustfollowing a TIA should have the implemented the Rapid Accessprocedure within 14 days of onset as an Carotid Endarterectomy (RACE)absolute maximum as detailed in the programme in 2008 which takesNICE guidelines1, with providers working referrals direct from the seventowards the 48 hours ideal as stated in day TIA clinics.the National Stroke Strategy. Furtherwork to support services in providingtimely access to carotid intervention isongoing and updates will be available onthe NHS Improvement website. Data on high risk TIA patients is collected by all trusts as a DH Integrated Performance CASE STUDY Measure (IPMR). There is a new treatment function code for TIA University College London that supports the best practice Hospitals NHS Foundation Trust tariff for TIA. has written a protocol for the management of chronic stenosis in patients with TIA or minor For more information and case stroke with a clear pathway for studies, please visit the NHS weekday and weekend referrals. Improvement website: www.improvement.nhs.uk/stroke1 Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA), National Institute for Health and Clinical Excellence clinical guideline 68, 2008
  4. 4. NHS NHS ImprovementPRACTICAL PRINCIPLESfocus on TIA imaging 1. Review and streamline the existing imaging pathway 2. Involve all members of the team 3. Train imaging staff in imaging for TIA 4. Introduce simple changes in imaging departments to ensure best practiceReview and streamline the existing Involve all members of the team CASE STUDYimaging pathway • Involve all members of the team who Royal Devon and Exeter NHS• Review working patterns for imaging have input into the TIA pathway as Foundation Trust have trained teams, including extended days and often you are not aware of how the their stroke nurse practitioners to weekend working pathway works outside of your own undertake carotid screening.• In areas where there are significant department (stroke unit or radiology capacity/staffing issues look at department) alternative examinations where slots • Encourage attendance at are more readily available i.e. MRA or multidisciplinary meetings so all staff CASE STUDY CTA working within the pathway can raise• Due to capacity issues within the MRI and discuss issues and look at new University Hospitals of Leicester department, short sequence MRI scans ways of working. NHS Trust introduced a specialist have been developed TIA service with access to both• MRI questionnaires and cannulation (if carotid doppler and MRI. required) can be carried out by CASE STUDY departmental assistants prior to scanning The Great Western Hospitals NHS• The introduction of a dedicated TIA Foundation Trust implemented a Introduce simple changes in imaging service with linked appointments will new TIA imaging booking system departments to ensure best practice significantly reduce the patient to complement the new TIA pathway. service. • Review the booking process – appointments linked to clinic times can significantly reduce the patient CASE STUDY pathway Train imaging staff in imaging for TIA • Sign up to a digital image transfer Salford Royal NHS Foundation system so diagnostic information can Trust implemented a seven day • Review the skill mix available and be shared effectively and safely TIA service using ultrasound identify areas for training between trusts Monday to Friday, and MRI at • Due to the shortage of sonographers, • Use the best practice tariff for TIA. weekends. many trusts are looking to other health care professionals to undertake Two publications are available to scanning. This can include vascular support access to imaging for TIA: technicians, nurse practitioners and CASE STUDY stroke doctors • ‘Why treat stroke and transient • Review other areas of ultrasound. For ischaemic attacks (TIAs) as Central Manchester University example, can obstetrics be run by emergencies?’ Hospitals NHS Foundation Trust midwives, which frees up • ‘A guide to achieving changes in has introduced short sequence sonographers for more complex examinations? imaging services to support new MRI scans, with the total scan stroke pathways’ time reduced to three minutes. To access the above publication and for more information and case studies, please visit the NHS Improvement website: ACCELERATING www.improvement.nhs.ukdiagnostics STROKE IMPROVEMENT

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