TIA Service Research Articles

103 New zealand hospital stroke service provision: a national survey

IntroductionThe REGIONS Care study assesses stroke care throughout New Zealand. It includes a national audit and here we present organisational survey results assessing current availability of interventions and management approaches in each hospital.MethodsAll 20 District Health Boards were invited to complete a survey about patients managed per annum, care setting, and service provision. Results were grouped into rural and urban groups to assess for geographic differences.ResultsAll NZ hospitals managing stroke patients completed the survey. Results found that of these hospitals 92% have an acute stroke unit, 85% have a TIA pathway, but only 58% offer rapid access specialist TIA services. 100% offer thrombolysis, 92% use pre-hospital notification and rapid ED triage system, and 73% an in-hospital ‘code stroke’ alert. 50% have access to thrombectomy. Only 32% offer a dedicated inpatient stroke rehabilitation unit. While 92% provide community rehabilitation, only 11% offer early supported discharge programmes. 87% routinely provide stroke patient education, but only 54% provide individualised stroke care plans at discharge. Only 28% have access to a psychologist. In-hospital stroke alerts (p=0.014), access to thrombectomy (p=0.016), access to stroke unit care (p=0.027), and routine referral to stroke foundation (p=0.049) were more common in urban areas.ConclusionThe results of this organisational survey indicates that stroke care provision has improved since the last audit in 2009, but important gaps remain. These results will help services focus on specific areas for improvement, some of which such as pre-hospital alerts should be relatively easy to address.

Abstract WP406: New Zealand Hospital Stroke Service Provision: A National Survey

Introduction: The REGIONS Care project is a New Zealand (NZ) based nationwide project that aims to capture all stroke patients admitted to NZ hospitals exploring ethic and geographic inequities in stroke care access and patient outcomes. Findings from this study will advise the National Stroke Programme strategy. This project includes an organisational survey to assess current availability of interventions and general management approaches in each hospital. Methods: This is a prospective registry based study with up to one year follow-up. Patients are registered into a central database by hospital teams and follow-up is achieved primarily via telephone calls. The outcome data will be adjusted for baseline function and stroke severity among other factors. At this stage the main study is ongoing, but the organisational survey has been completed. Analysis has not yet been finalised. Final and validated results will be presented at the meeting. Results: All NZ hospitals were approached and 100% completed the online survey. Preliminary results found that of these hospitals 82% have an acute stroke unit, 86% have a TIA pathway, but only 57% offer rapid access specialist TIA services. 100% offer thrombolysis, 93% use an EMS pre-notification and rapid ED triage system, and 75% an in-hospital ‘code stroke’ alert. 11% offer onsite thrombectomy, and a further 41% access thrombectomy via rapid inter-hospital transfer. 82% offer inter-disciplinary team review within 24 hours of admission and while 100% have access to OT, PT, and SLT, only 27% have access to a psychologist. 100% offer inpatient and 92% community rehabilitation service while only 11% offer early supported discharge programmes. Only 31% of hospitals have a dedicated stroke rehab unit. While 88% routinely provide stroke patient education, only 52% provide individualised stroke care plans at discharge. Conclusion: These preliminary results show good access to thrombolysis and multi-disciplinary stroke care. However, improvements are needed in access to thrombectomy, rapid specialist TIA services, early supported discharge, dedicated stroke rehabilitation units, psychologists, and individualised patient care plans. Final and additional results will be presented at the conference.

Cardiac diagnostic work-up for atrial fibrillation after transient ischaemic attacks in England and Wales: results from a cross-sectional survey

ObjectivesTransient ischaemic attacks (TIAs) are an important precursor of stroke. Atrial fibrillation (AF) is among the most dangerous aetiologies shared between TIAs and strokes. Detection of AF after TIAs is...

Abstract TMP95: Large Centralized TIA Assessment Unit Associated With Reduction of Recurrent Stroke by up to 70%

Introduction: Transient neurological symptoms are a common presentation in emergency departments (ED). Access to stroke specialists and advanced imaging to identify acute cerebrovascular syndrome is resource intensive. Diversion to specialized TIA units improves logistics but incurs delay. Observational studies suggest efficacy of TIA units but are limited by sample size. We hypothesized that management through a centralized TIA service reduces risk of recurrent stroke. Methods: Vancouver Island (VI) introduced a centralized TIA unit in 2004 to which over 15,000 referrals (ED & GP) have been made. Long-term follow-up is possible as all VI residents (∼750,000) have one electronic health record for ED visits and hospital admissions. Large referral volumes and variable unit capacity have subjected patients to a wide range of delays-to-treatment. We used variation in secondary prevention delays to examine unit efficacy. We assessed hospitalized stroke and stroke death in all ED-referred patients comparing those seen in the unit within 90 days of symptom onset with those not seen within that time. Results: Between 2005 and 2013 there were 11,330 referrals, of which 4,017 were from the ED and referred within 2 weeks of symptom onset. The transition times between symptom onset, referral, arrival at the unit and stroke (or censoring time) were modeled using a multi-state model (Putter et al. 2007). Age, ABCDD, gender and the unit intervention were found to be associated with transition times. The hazard of stroke for patients who attended the unit was estimated as 30% that of those who did not attend (p=0.098). Predicted stroke-free survival curves are shown for a 70 year old woman. ARR at 90-days ranged from 4.2% downto 1.4% for High to Low ABCDD respectively. Conclusion: This large observational study reinforces published studies suggesting TIA units reduce risk of recurrent stroke within 90 days.

Transient ischemic attack service provision: A review of available service models.

TIAs are predictors of high risk of subsequent stroke and require urgent intervention to maximize secondary prevention and minimize adverse health outcomes. TIA patients are often admitted to the hospital to facilitate rapid investigation and comprehensive management. However, over the last 2 decades, alternative service models have emerged in an effort to optimize health resource utilization without compromising patient outcomes. This article reviews recommended interventions and then discusses the inpatient and 6 alternative TIA service models to help modern stroke services determine the model best suited to their local health service environment.

Yield of ultra-rapid carotid ultrasound and stroke specialist assessment in patients with TIA and minor stroke: an Italian TIA service audit.

In Italy the vast majority of TIA and minor strokes are seen in the A&E. Early diagnosis and management of TIA and minor stroke in this setting is habitually difficult and often lead to cost-ineffective hospital admissions. We set up an ultra-rapid TIA service run by neurovascular physicians based on early specialist assessment and ultrasound vascular imaging. We audit the clinical effectiveness and feasibility of the service and the impact of this service on TIA and minor strokes hospital admissions. We compared the rate of TIA and minor stroke admissions/discharges in the year before (T0) and in the year during which the TIA service was operating (T1). At T1 57 patients had specialist evaluation and 51 (89.5 %) of them were discharged home. Two (3.5 %) patients had recurrent symptoms after discharge. Seven had a pathological carotid Doppler ultrasound. Four of them had hospital admission and subsequent carotid endoarterectomy within a week. Taking the whole neurology department into consideration at T1 there was a 30-41 % reduction in discharges of patients with TIA or minor stroke. Taking the stroke unit section into consideration at T1 there was a 25 % reduction in admissions of patients with NIHSS score <4 and 40 % reduction in admissions of patients with Barthel Index above 80. The model of TIA service we implemented based on ultra-rapid stroke physician assessment and carotid ultrasound investigation is feasible and clinically valid. Indirect evidence suggests that it reduced the rate of expensive TIA/minor stroke hospital admissions.

PP58 Prevention of Stroke following a TIA – who Receives Care? A descriptive study of Patients Referred to TIA Clinics between 2007-2010 in a NHS Foundation Trust

BackgroundA TIA can offer a vital warning to the risk of a disabling or fatal stroke. Appropriate help seeking behaviour, followed by referral to TIA services allows diagnosis and treatment...

Transient neurological symptoms in the older population: report of a prospective cohort study—the Medical Research Council Cognitive Function and Ageing Study (CFAS)

ObjectiveTransient ischaemic attack (TIA) is a recognised risk factor for stroke in the older population requiring timely assessment and treatment by a specialist. The need for such TIA services is...

Guidance from a Royal College, does it have the force of law?

When a Royal College issues clear guidance on clinical practice, do NHS Trusts throughout the UK have to comply with that and if so how long do the Trusts have to implement the changes? Is cost relevant to the decision? And if a Trust fails to implement the changes necessary to comply with the guidance and patients suffer as a result, will the Trust become liable in law for the injuries and damage caused? These were the issues in a recent clinical negligence claim brought by Mr L against the Mid Essex NHS Trust. Mr L suffered a transient ischaemic attack and attended his general practitioner and later his local A &amp; E department. Neither referred him to the local TIA service. Eleven days later he suffered a massive stroke and is now paralysed down one side.

MISTAKEN TETANY: HYPOPARATHYROIDISM IN THE TIA CLINIC

BackgroundOur TIA service has assessed approximately 400 patients over the last 6 months. Just over half of these were TIA mimics. We present an interesting case that was initially referred...

ACUTE NEUROLOGICAL CARE: LESSONS LEARNT FROM TIA

ObjectivesThe ABN's 2011 report on local services proposed a shift to take control of acute neurological presentations. 15% of admissions are neurological (33% stroke, 25% seizures, 20% headache), the 3rd...

Triaging TIA/Minor Stroke Patients using the ABCD2 Score Does Not Predict those with Significant Carotid Disease

Background‘Rapid Access’ TIA Clinics use the ABCD2 score to triage patients as it is not possible to see everyone with a suspected TIA <24 h. Those scoring 0–3 are seen within seven days, while patients scoring 4–7 are seen as soon as possible (preferably <24 h). It was hypothesized that patients scoring 4–7 would have a higher yield of significant carotid disease. MethodsProspective study of correlation between Family Doctor (FD) or Emergency Department (ED) ABCD2 score and specialist consultant Stroke Physician measured ABCD2 score and prevalence of ≥50% ipsilateral carotid stenosis or occlusion in patients presenting with ‘any territory’ TIA/minor stroke or ‘carotid territory’ TIA/minor stroke. ResultsBetween 1.10.2008 and 31.04.2011, 2452 patients were referred to the Leicester Rapid Access TIA Service. After Stroke Physician review, 1273 (52%) were thought to have suffered a minor stroke/TIA. Of these, both FD/ED referrer and Specialist Stroke Consultant ABCD2 scores and carotid Duplex ultrasound studies were available for 843 (66%). The yield for identifying a ≥50% stenosis or carotid occlusion was 109/843 (12.9%) in patients with ‘any territory’ TIA/minor stroke and 101/740 (13.6%) in those with a clinical diagnosis of ‘carotid territory’ TIA/minor stroke. There was no association between ABCD2 score and the likelihood of encountering significant carotid disease and analyses of the area under the receiver operating characteristic curve (AUC) for FD/ED referrer and stroke specialist ABCD2 scores showed no prediction of carotid stenosis (FD/ED: AUC 0.50 (95%CI 0.44–0.55, p = 0.9), Specialist: AUC 0.51 (95%CI 0.45–0.57, p = 0.78). ConclusionsThe ABCD2 score was unable to identify TIA/minor stroke patients with a higher prevalence of clinically important ipsilateral carotid disease.

Equality of Access to “Fast-Track” Stroke Services in an Older, Socio-Economically Deprived Scottish Population

Unequal access to specialist stroke services may contribute to the disproportionate stroke burden in certain populations. We evaluated the relationship between access to TIA services, deprivation and age. We prospectively recorded referral pattern data on consecutive TIA service patients. Socio-economic deprivation was derived from postcode and census data. Associations were described using Kruskal-Wallis statistics. Of 3,462 patients assessed, there was no association between time to clinic referral or attendance and increasing deprivation or age. Inequality of access to TIA services for older, deprived patients was not evident. However, delay to assessment and prevalence of risk factors was substantial for all patients.

43. Substantial Under-Provision of TIA Services in New Zealand

43. Substantial Under-Provision of TIA Services in New Zealand

Introduction of an embolus detection guided TIA service at the HAGA Teaching Hospitals, The Netherlands

Introduction of an embolus detection guided TIA service at the HAGA Teaching Hospitals, The Netherlands

Outcomes of patients with transient ischaemic attack after hospital admission or discharge from the emergency department

To compare outcomes at 28 days and 1 year between patients admitted to hospital and those discharged after presenting to the emergency department (ED) with transient ischaemic attack (TIA). All TIA presentations to EDs in a large metropolitan and rural region of Sydney and its surroundings, New South Wales, between 2001 and 2005 were extracted from state health department databases and followed up over 1 year. Admission and discharge data and subsequent TIA or stroke presentations were identified. TIA recurrence or stroke. Of 2535 presentations to an ED with TIA during the 5-year period, 1816 patients were admitted to hospital (71.6%) and 719 were discharged from the ED (28.4%). At 28 days, the discharged group had significantly higher rates of recurrence than the admitted group for all events (TIA or stroke) (5.3% v 2.3%, P < 0.001), stroke (2.1% v 0.7%, P = 0.002), and recurrent TIA (3.2% v 1.6%, P = 0.01). During the 29-365-day follow-up period, there was no significant difference between the discharged and admitted groups for all events (4.2% v 5.1%; P = 0.37), stroke (1.3% v 2.5%; P = 0.06) or recurrent TIA (2.9% v 2.6%; P = 0.65). Patients with an ED diagnosis of TIA may benefit from admission to hospital through a reduced risk of early stroke.