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All Wales Stroke Services
Improvement Collaborative
How to Guide
Improving the Reliability
of TIA Services
Reducing the incidence of stroke by improving the
reliability of TIA services
TRANSIENT ISCHAEMIC ATTACK (TIA)
Transient Ischaemic Attack (TIA) refers to a clinical syndrome characterised by
an acute loss of focal cerebral or ocular function with symptoms lasting less
than 24 hours. This is due to inadequate cerebral or ocular blood supply as a
result of poor or low blood flow, thrombosis, or embolism associated with
vascular diseases of the blood, heart or blood vessels1. TIAs affect 35 people
per 100,000 of the population of the UK each year.
TIA is often described as a mini stroke and is the only warning sign an individual
may experience that a major stroke may be imminent. The Oxford Vascular
Study is a prospective, population-based incidence study of TIA and stroke with
complete follow-up. It found that patients who have a TIA have a 5% risk of
going on to have a stroke. It also found that nearly half of all strokes that
happened during the 30 days after a first TIA occurred within the first 24
hours2.
Therefore TIAs serve as an early warning sign of stroke and require immediate
medical attention. The window of opportunity to do this effectively is small and
requires such patients to have a specialist assessment as early as possible
following the event.
AIM OF THE GUIDE
The aim of this guide is to support local teams of healthcare professionals make
improvements in the reliability of integrated care for the management of
individuals who present with a TIA.
Recent evidence has shown that timely management of higher risk TIAs can
reduce the incidence of stroke. However this timely management is not always
delivered consistently- for all patients, every day of the week, wherever they
live. The Oxford Vascular Study found that although 64% of the cases sought
urgent medical attention prior to the recurrent stroke, none of them received
antiplatelet treatment acutely2.
The Driver Diagrams and Care Bundles in this guide have been developed by
a core group of specialist clinicians in Wales, based on the evidence and
recommendations in the National Stroke Guidelines, 3rd Edition published by
Royal College of Physicians (RCP) in 20083, the National Stroke Strategy,
published by the Department of Health4 and the National Guideline for
Management of patients with stroke or TIA, published by the Scottish
Intercollegiate Guidelines Network (SIGN) in 20085. The Driver Diagram and
Care Bundles form part of the new improvement targets, called Intelligent
Targets, which will be included in the Annual Operating Framework for the
new Health Boards in Wales for 2010.
2
Contents
NICE TIA Pathway
High Level Patient Journey
Driver Diagram
Measures
Page no
5
6
7
8
Where are we?
Stroke and TIA Incidence, Mortality and Morbidity
TIA Services in Wales
8
8
8
Where do we want to be?
10
How will we get there?
Reducing the variation in patient care
Simplifying the patient pathway- Driver Diagrams
Using a “Care Bundles” approach
A Collaborative Approach for Wales
The “Model for Improvement”
10
10
11
11
12
13
Getting Started
Getting leadership support
Forming a team
Project lead
15
15
16
16
Key to success- Communication
16
Bundles
First Contact
Management of high risk TIAs
Management of low risk TIAs
Secondary Prevention
17
17
19
20
23
References
27
3
Appendices
1
2
3
4
5
Membership of core group
ABCD2 Scoring Sheet
TIA minimum Dataset
Data Collection Planner
PDSA Form
27
28
29
30
32
4
TIA Pathway from
NICE Guideline 68
Figure 1: TIA Care Pathway from NICE Guideline6
5
Patients journey following onset of TIA symptoms
Figure 2: Summary of patient’s journey following TIA
6
Driver Diagram for TIA
Timely specialist
management of
Low Risk TIAs
(ABCD2 Score
=/<3)
Ongoing
secondary
prevention and
risk management
following TIA
Target Two
Prevent
stroke
through
timely
management
of TIA
Timely specialist
management of
high risk TIAs
(ABCD2 Score =/>
4)
Target Three
First Point of
Contact- symptom
recognition and
referral
Interventions
Target One
Drivers
Target Four
Content
2
•
Use ABCD to stratify risk
•
Give aspirin immediately
•
Refer immediately onto appropriate pathway,
electronically or by telephone and fax
•
Give patient information in appropriate format
•
Assessment and commence investigations
within 24 hours of onset of symptoms
•
Referral if appropriate for carotid investigation
within 48hrs of onset of symptoms
•
Give Patient information in appropriate format
•
Carotid intervention, if appropriate within 7
days of symptom onset
•
Communicate treatment plan back to GP
within 24 hours
•
Assessment and commence investigations
within 7 days of onset of symptoms
•
Referral if appropriate for carotid investigation
within 7 days of onset of symptoms
•
Carotid intervention, if appropriate within 14
days of symptom onset
•
Give Patient information in appropriate format
•
Communicate treatment plan back to GP
within 24 hours
•
Individualised secondary prevention strategy
started at initial specialist assessment, within
7 days of onset of symptoms
•
Strategy reinforced by a healthcare
professional
Strategy provided to patient in appropriate
format
•
•
Follow up at one month in either primary or
secondary care
Figure 3: Driver Diagram for TIA
7
Measures
Process Measures
Outcome Measures
Compliance with First Contact
Bundle
Compliance with High Risk TIA
Bundle
Compliance with Low Risk TIA
Bundle
% of people with suspected TIA that go
on to develop stroke within 28 days
% of people with suspected TIAs who
have their diagnosis confirmed
Compliance with Secondary
Prevention Bundle
Fig 4: Measures for TIA
Where are we?
Stroke and TIA Incidence, Mortality and Morbidity
Every year in Wales an estimated 7,500 people have a first stroke with a
further 3500 - 4000 estimated second strokes and TIA per year7.
Between 20 and 30 percent of people die within the first month of having a
stroke, while a further 30 percent are left with a lifelong disability. Stroke
is the third most common cause of death in the UK, and the most common
cause of disability in adults4.
TIA Services in Wales
Do you know what standard of care your current TIA services provide? For
example:
• What percentage of people with a suspected TIA are given aspirin and
advice not to drive at their first contact with healthcare?
• What percentage of people who have had a TIA and are at higher risk
of having a stroke have a specialist assessment within 24 hours of
symptom onset?
• What percentage of patients who have had a TIA are helped to
understand what lifestyle changes could reduce the risk of them going
on to have a stroke?
The most recent National Stroke Sentinel Audit was carried out by the Royal
College of Physicians in the spring of 2008. The organisational report,
published in August 20088, reflected TIA and associated services as they
were on 1st April 2008, as shown in figure 5.
8
Many health organisations have continued to develop their services over the
past 18 months and are already carrying out regular audits to investigate the
reliability of certain aspects of their service. There is not currently a
process that monitors the reliability of TIA services for the whole of the
pathway.
Average CT scan
waiting time weekdays
Average CT wait times
weekends
Average MRI wait time
weekdays
Average MRI wait times
weekends
Neurovascular clinic
TIA Clinics
Neurovascular clinic
average wait time
All high risk patients
seen and investigated
within 24 hours
All low risk TIA patients
seen and investigated
within one week
The first year of the All Wales Stroke Service Collaborative (AWSSIC), which
was launched in September 2008, helped organisations and local
multidisciplinary teams to make significant improvements to the reliability
of the care they provided to people in the first seven days following a
stroke. The same improvement model is being used to improve TIA services.
Gwent Healthcare RGH
5-24 hrs
5-24 hrs
25-48 hrs
>48 hrs
Yes
Yes
10
Yes
No
Neville Hall Hospital
5-24 hrs
5-24 hrs
25-48 hrs
>48 hrs
Yes
Yes
28
Yes
No
Llandough Hospital
5-24 hrs
>48 hrs
>48 hrs
>48 hrs
Yes
Yes
5
No
No
UHW
5-24 hrs
>48 hrs
0-4 hrs
>48 hrs
Yes
Yes
7
Yes
Yes
Prince Charles Hospital
5-24 hrs
5-24 hrs
>48 hrs
>48 hrs
N/A
No
N/A
N/A
N/
A
Royal Glamorgan Hospital
25-48 hrs
>48 hrs
>48 hrs
>48 hrs
Yes
Yes
14
Yes
No
Glan Clywd Hospital
5-24 hrs
>48 hrs
25-48 hrs
>48 hrs
Yes
Yes
7
No
Yes
Ysbyty Gwynedd
5-24 hrs
25-48 hrs
25-48 hrs
25-48 hrs
N/A
No
N/A
N/A
N/
A
Wrexham Maelor
5-24 hrs
>48 hrs
25-48 hrs
>48 hrs
Yes
Yes
5
No
No
Prince Phillip Hospital
5-24 hrs
5-24 hrs
25-48 hrs
>48 hrs
Yes
Yes
0
Yes
Yes
WWGH
5-24 hrs
5-24 hrs
0-4 hrs
>48 hrs
Yes
Yes
1
Yes
No
Bronglais Hospital
0-4 hrs
5-24 hrs
>48 hrs
>48 hrs
Yes
Yes
7
No
Yes
Withybush Hospital
5-24 hrs
5-24 hrs
25-48 hrs
>48 hrs
Yes
Yes
7
No
No
Bronllys Hospital
>48 hrs
>48 hrs
>48 hrs
>48 hrs
N/A
No
N/A
N/A
N/
A
Morriston Hospital
5-24 hrs
25-48 hrs
>48 hrs
>48 hrs
No
Yes
N/A
No
Yes
Singleton Hospital
5-24 hrs
>48 hrs
25-48 hrs
>48 hrs
Yes
Yes
60
No
No
Neath Port Talbot Hospital
5-24 hrs
25-48 hrs
>48 hrs
>48 hrs
No
Yes
N/A
No
Yes
Princess of Wales Hospital
5-24 hrs
25-48 hrs
>48 hrs
>48 hrs
Yes
Yes
5
No
Yes
Site Name
Fig 5: RCP Organisational Audit Results 2008
9
Where do we want to be?
The Welsh Health Circular (WHC) 0829 published by the Welsh Assembly
Government (WAG) in December 2007 set out a programme of work for
developing services for people at risk of, or have had a stroke in Wales.
This programme of work included a target for TIA services:
“Refer all TIA patients within 24 hours of onset of symptoms to a one-stop
assessment and investigation service in line with Royal College of Physicians
guidelines by December 2009”
More recently WAG has invited a core group of clinicians with a special
interest in stroke to develop new improvement targets to be incorporated
into the Annual Operating Framework for Health Boards in April 2010. The
Core Group identified TIA, acute stroke and early rehabilitation as the three
priority areas for these Intelligent Targets. Appendix One shows the
members of this core group who were involved in setting out the key
standards for TIA services set out in this guide.
How will we get there?
Reducing the variation in the current processes of patient care
What does it matter if there is variation within the processes of care
delivered within and between hospitals? If you, or a member of your family,
have a TIA you want to know that whatever day of the week its is, time of
the day, or whichever GP or hospital you go to that the care that is provided
for you is of the same high standard and quality, to ensure you get the best
outcome possible.
Before we can start improving the current process of patient care, we have
to have a robust understanding of what the variation in them is as a
baseline- are we actually doing what we think we’re doing?
The first year of AWSSIC focussed on the first seven days following stroke,
and highlighted the difficulties in collecting data on every stroke patient
that was admitted to hospital. The majority of teams involved were able to
develop systems to facilitate this. They found analysing the data they had
collected invaluable in identifying which parts of the care processes were
not being delivered consistently and also to evaluate the changes and
service improvements they instigated.
The exercise of collecting the data also facilitated a better communication
and understanding of all the roles and responsibilities of the members of the
teams involved.
10
Simplifying the patient pathway- Driver Diagrams
The Intelligent Targets Stroke Core Group (see appendix one) have
simplified the TIA patient pathway into a driver diagram consisting of 4 Care
Bundles.
Organisations and clinicians should aim to deliver all the interventions in the
care bundles within the timeframes set out for every patient who has a TIA.
All of the interventions are taken from the:
•
•
•
National Clinical Guideline for Stroke3 which incorporate the
recommendations from Stroke: national clinical guideline for
diagnosis and initial management of acute stroke and TIA, by the
National Institute for Clinical Excellence6
The National Stroke Strategy4
Management of patients with stroke or TIA: assessment, investigation,
immediate management and secondary prevention. A national clinical
guideline p Published by SIGN5
The interventions in these bundles were considered to be the ones that
would have the greatest impact on outcome following TIA.
Using a “Care Bundle” approach to improve the reliability of
patient care
A “Care Bundle” is a term or concept developed by the Institute for
Healthcare Improvement (IHI)10 as a way to describe a collection of
processes needed to effectively care for patients undergoing particular
treatments with inherent risks. The idea is to bundle together several
evidence-based interventions essential to improving clinical outcomes. A
Bundle should be relatively small and straightforward- a set of three to five
interventions is ideal.
The power of a Bundle comes from the body of science behind it and the
method of execution: with complete consistency. The interventions in a
Bundle are well established best practices, but they are often not
performed uniformly making treatment unreliable. A Bundle ties the
interventions together into a package that people know must be followed
for every patient, every single time. The steps must all be completed to
succeed; the “all or none” feature is the source of the Bundle’s power. The
whole team becomes accountable for delivering all the interventions, not
just their profession specific one.
A Bundle is not just a list of absolutes or precise protocols. It is a set of
steps that experts believe are critical, but in many cases the clinical values
attached to each step are locally defined or may change over time based on
evolving research and the experiences of users.
11
Implementing Care Bundles in the AWSSIC has encouraged teams to
reconsider their professional roles within teams and has encouraged the
development of interdisciplinary teams and also facilitated training and set
competencies required to carry out specific tasks.
The usefulness of the Care Bundle approach is that the measurement of
whether clinical guidelines are being followed is done prospectively, and
this data can then be used to influence changes in clinical practice. While
similar to the audit cycle, the difference is the speed with which feedback
takes place. In an audit data is analysed retrospectively, while a care
bundle is monitored prospectively.
Hospital clinical audit/effectiveness departments may have a role to play if
they can facilitate the rapid feedback of data; however the best results
have been obtained where measurement has been incorporated into daily
routine.
A Collaborative Approach for Wales
A Collaborative brings together groups of practitioners from different
healthcare organisations to work in a structured way to improve one aspect
of the quality of their service.
The Collaborative creates a structure in which interested organisations can
easily learn from each other and from recognised experts in topic areas
where they want to make improvements.
The Collaborative will enable teams to share learning across Wales,
accelerating improvement through the local adaptation of models that have
been shown to be successful elsewhere.
Figure 6 : IHI Breakthrough Series Model
12
Framework and Changes
The Driver Diagrams and Care Bundles form the framework for this
Collaborative. The aim of the Collaborative is to support teams and
organisations to make the changes needed to implement these Care Bundles
locally.
Learning Sessions
There will be three learning sessions (LS) during the Collaborative. The
launch event in October 2009, then a follow up session in February 2010,
and a final learning session in July 2010.
Action Periods
In the first Action Period teams are encouraged to concentrate on data
collection, with tests of change and Plan-Do-Study-Act (PDSA) cycles being
introduced once a baseline had been established.
Teams are encouraged to nominate a project lead who was the main point
of contact between the team and the programme manager and NLIAH.
The teams will be supported during the Action Periods with site visits from
the programme manager, monthly telephone conferences and three national
meetings of project leads. Some of the project leads meetings will include
skills sessions.
All the presentations for the learning sessions will be available on the
intranet site, hosted by the NPHS at nww.wales.nhs.uk.
The site also has resources that have already been developed and it can be
used by teams for posting any additional resources which teams develop and
are happy to share, such as documentation, protocols, guidance and
teaching resources.
Model for Improvement
The Institute of Healthcare Improvement’s (IHI) Model for Improvement is a
simple tool for accelerating improvement. It has been used very successfully
by hundreds of health care organizations in many countries to improve many
different health care processes and outcomes. Its use has been promoted in
the first year of the AWSSIC and also in the 1000 Lives Campaign.
The model has two parts:
1. Three
a.
b.
c.
fundamental questions
What are we trying to accomplish?
How will we know if a change is an improvement?
What change will result in improvement?
13
2. The Plan-Do-Study-Act (PDSA) cycle to test and implement changes in
real work settings. The PDSA cycle guides the test of a change to
determine if the change is an improvement
Fig 7: IHI Model for Improvement
Measurement
Measurement is the only way to know whether a change represents an
improvement. Teams will be required to collect a minimum dataset on every
patient who is referred with a TIA. This dataset is outlined in Appendix 3.
Each team or organisation will need to develop a method of collecting the
data that suits their own service model. A data collection planner is
included in Appendix 4.
Tracking Measures over Time
Improvement takes place over time. Determining if improvement has really
occurred and if it is a lasting effect requires observing patterns over time.
Run charts are graphs of data over time and are one of the single most
important tools in performance improvement. Using run charts has a variety
of benefits:
•
They help teams formulate aims by depicting how well (or poorly) a
process is performing
•
They help in determining when changes are truly improvements by
displaying a pattern of data that you can observe as you make
changes
•
They give direction as you work on improvement and information
about the value of particular changes
14
Each team will be given a data collection tool into which they can input
their data. The tool will automatically produce run charts on a weekly or
monthly basis, enabling the teams to track their compliance rates and
interventions rates over time. Teams will need to devise a way to review
the data they collect and share it with managers and executives to ensure
that it informs robust service planning.
Making changes
Having data on every patient and being able to monitor it on a weekly or
monthly basis will enable teams to make small tests of change using the
PDSA cycle. Only those changes that show an improvement in patient care
need to be taken forward, minimising the need for disruptive organisational
changes that do not have an impact on patient care or efficiency of
services.
First test of change
Once a team has prepared the way for change by studying the current
process and educated the involved parties, the next step is to begin testing
the intervention.
•
•
•
•
•
Start small- with one patient, one clinic or one GP practice
Work with everyone involved with the change to make sure they
understand and are able to make the change
If successful, make sure that the change can be achieved at a wider
level
Process feedback and incorporate suggestions for improvements
Try the change on a bigger scale
Getting Started
Teams cannot implement these bundles overnight. A successful program
involves careful planning, testing to determine if any changes result in an
improvement, making modifications, re-testing and careful implementation.
There are a number of considerations you should make before you start:
Getting leadership support
Changing practice requires a change in organisational culture and attitudes.
The organisational culture within an individual organisation, hospital,
department or patient care unit, develops based on the overt and subtle
messages employees receive. Leadership actions strongly influence
employee beliefs as to what leaders consider important, even more so than
what is actually said.
Engage senior leadership support and buy in from both executives and
physicians. There needs to be a united message “We are going to do this;
this is important and the right thing to do for our patients”.
15
Forming a team
Teamwork is essential in healthcare today, and communication within the
team is indicative of the organisational culture. Everyone must be
considered as an equally important member of the team, regardless of their
role, and not only encouraged to speak up, but required to do so.
Teams should be multidisciplinary and involve all stakeholders involved in
the patient journey. Different professions will have different approaches;
however the whole team should have the same aim in mind. The value in
bringing diverse personnel together is that all members of the team are
given a stake in the outcome and work to achieve the same goal.
Some of the ways to attract and retain team members are:
• Use data to find and solve the problems
• Find a champion within the hospital who is sufficiently high profile
and visibility to lend the effort immediate credibility
• Work with those who want to work on the project rather that trying
to convince those who do not
Project Lead
Each team needs someone who is going to co-ordinate the teams work. Feedback
for the project leads for the first year of AWSSIC identified some of the roles and
responsibilities of the project lead as;
•
•
•
•
Communication within and without the team
Engaging and motivating local teams
Co-ordinating meetings, data collection and PDSAs
Organising and attending meetings
Key to Success- Communication
Communicate, communicate, communicate- you cannot do enough of this.
Particularly at the beginning, get the word out often. Be systematic and
relentless in your communication. Tell people what you are doing and why,
and get people’s ideas on what might make your processes of care more
effective. Use the data you collect to motivate staff involved in TIA services
and report your data to directorate and executive teams.
Think about education and share success stories widely for example with
primary care, in outpatient clinics, with staff in the radiology departments
and of course with those people using your services. This will help maintain
the momentum, motivation and enthusiasm in everyone involved to continue
making improvements in the quality and effectiveness of services provided.
16
Care Bundles
First Point of Contact- symptom recognition and referral
Elements and evidence-based recommendations
Use ABCD2 to stratify risk at first point of contact
• Any patient who presents with transient neurological symptoms
suggestive of a cerebrovascular event should be considered to have
had a TIA (RCP 4.2.1 A)
• People who have had a suspected TIA, that is, they have no
neurological symptoms at the time of assessment (within 24 hours),
should be assessed as soon as possible for their risk of subsequent
stroke using a validated scoring system, such as ABCD2 (RCP 4.2.1 B)
Give aspirin immediately
• People who have had a suspected TIA should have aspirin (300 mg
daily) started immediately (RCP 4.2.1 C& E), unless there are
contraindications when alternative antiplatelet drugs such as
clopidogrel should be started (RCP 4.4.1 B)
Refer immediately onto appropriate pathway, electronically or by
telephone and fax
• People who have had a suspected TIA who are at high risk of stroke
(that is, with an ABCD2 score of 4 or above) should have specialist
assessment and investigation within 24 hours of onset of symptoms
(RCP 4.2.1 C)
• People with crescendo TIA (two or more TIAs in a week) should be
treated as being at high risk of stroke even though they may have an
ABCD2 score of 3 or below (RCP 4.2.1 D)
• People who have had a suspected TIA who are at lower risk of stroke
(that is, with an ABCD2 score of 3 or below) should have specialist
assessment and investigation as soon as possible, but definitely within
one week of onset of symptoms (RCP 4.2.1 E)
• People who have had a TIA but who present late (more than one week
after their last symptom has resolved) should be treated as though
they are at lower risk of stroke (RCP 4.2.1 F)
Give patient information in appropriate format
• Every person who has a stroke or a TIA should be told that they must
not drive for a minimum of four weeks (RCP 6.48.1 E)
• Every healthcare professional giving advice on driving should ensure
that it is accurate and up to date (RCP 6.48.1 C)
• For those individuals attending primary care advice needs to be given
about taking aspirin and avoiding driving (QM 5 Rational 4 National
Stroke Strategy)
It is recognised that this scoring system may exclude certain populations
who may be at particularly high risk of stroke such as those with recurrent
17
events and those on anticoagulation who also need urgent evaluation. They
also may not be relevant to patients who present late. However the aim of
the collaborative is to improve the reliability of patient care, and in the
absence of a more sensitive tool, then the ABCD2 risk assessment is
recommended for use across Wales.
The NICE Guideline states that “Specialist Assessment” includes exclusion of
stroke mimics, identification of vascular territory, identification of likely
causes, and appropriate investigation and treatment. There are currently no
guidelines on what constitutes who should provide this specialist
assessment, and what training and competencies are required.
The Care Bundles and Driver Diagrams do not specify what service structure
or model should be adopted, as different systems may work differently in
different settings, and will depend on existing infrastructures.
As well as information on driving it is also recommended that patients
should be given information on their local TIA Service and why it is
important that they attend a specialist assessment as quickly as possible.
Suggested Actions
•
•
•
Engagement with and involvement of primary care, out of hours
services, A&E Departments, NHS Direct, Welsh Ambulance Service
Trust to ensure awareness and use of ABCD2 scoring system
Develop appropriate local care pathway, including protocols, polices
and documentation for referral from first point of contact to
specialist TIA services
Development of patient information leaflets to support verbal
information given
Measures
•
•
•
•
•
Compliance with bundle- the percentage of people presenting with
suspected TIA who received all of the interventions in the bundle
within the set timeframe
Percentage of people presenting with suspected TIA who were
screened using ABCD2 tool at first contact
Percentage of people presenting with suspected TIA who were given
aspirin at first contact
Percentage of people presenting with suspected TIA who were
immediately referred onto the appropriate pathway for specialist
assessment at first contact
Percentage of people presenting with suspected TIA who were given
appropriate information at time of first contact
18
Data Collection
•
•
•
•
•
•
•
•
Date/Time of onset
Date/Time seen by GP/paramedics/A&E
Profession/place of first contact
Date/Time given aspirin
Date/Time ABCD2 score
ABCD2 Score
Date/Time referral sent
Information Given Y/N
Timely management of TIAs
Elements and evidence-based recommendations
High Risk TIAs (ABCD2 Score =/> 4)
Assessment and commence investigations within 24 hours of onset of
symptoms
•
•
•
•
•
All higher-risk patients with TIA and minor stroke need to be assessed
by a specialist and treated within 24 hours (QM5 Rationale 5, National
Stroke Strategy)
People who have had a suspected TIA who are at high risk of stroke
(that is, with an ABCD2 score of 4 or above) should have specialist
assessment and investigation within 24 hours of onset of symptoms
(RCP 4.2.1 C)
People with crescendo TIA (two or more TIAs in a week) should be
treated as being at high risk of stroke even though they may have an
ABCD2 score of 3 or below (RCP 4.2.1 D)
People who have had a suspected TIA should be assessed by a
specialist before a decision on brain imaging is made (RCP 4.3.1 A)
People who have had a suspected TIA who are at high risk of stroke in
whom the vascular territory or pathology is uncertain should undergo
urgent brain imaging- defined as ‘within 24 hours of onset of
symptoms’ in the National Stroke Strategy.
Referral if appropriate for carotid intervention within 48hrs of onset of
symptoms (following MRI/CT/Carotid Doppler as required)
•
•
Carotid imaging should ideally be performed at initial specialist
assessment and should not be delayed more than 24 hours after first
clinical assessment of higher-risk patients (QM5 Rationale 9, National
Stroke Strategy)
Carotid endarterectomy should be considered when carotid stenosis is
measured at greater than:
o 70% as measured using the ECST methods, or
o 50% as measured using the NASCET methods (RCP 5.7.1 B)
19
Give patient information in appropriate format
•
•
People who have had a TIA need information and advice on smoking
cessation, diet, exercise, alcohol, driving and what to do in the event
of a recurrent TIA or stroke (QM6 Rationale 16 National Stroke
Strategy)
All patients receiving medication for secondary prevention should
o be given information about the reason for the medication, how
and when to take it and any possible common side effects
o receive verbal and written information about their medicines
in a format appropriate to their needs and abilities
o have compliance aids such as large-print labels and nonchildproof tops provided, according to their level of manual
dexterity, cognitive impairment and personal preference and
compatible with safety in the home environment
o be aware how to obtain further supplies of medication (RCP
5.2.1 D)
Carotid intervention, if appropriate within 7 days of symptom onset
•
•
Carotid intervention for recently symptomatic severe carotid stenosis
should be regarded as an emergency procedure in patients who are
neurologically stable, and should ideally be performed within 48
hours of a TIA or minor stroke (QM6 Rationale 13 of Stroke Strategy)
People with significant carotid stenosis should (as above):
o be assessed and referred for carotid endarterectomy within
one week of onset of stroke or TIA symptoms
o undergo surgery within a maximum of two weeks of onset of
stroke or TIA symptoms (RCP 4.4.1 E)
Communicate treatment plan back to GP within 24 hours of specialist
assessment
•
•
Patients should have their risk factors reviewed and monitored
regularly in primary care, at a minimum on a yearly basis (RCP 5.2.1
C)
All patients receiving medication for secondary prevention should
have a regular review of their medication (RCP 5.2.1 D)
Low Risk TIAs (ABCD2 Score =/< 3)
Assessment and commence investigations within 7 days of onset of
symptoms
•
People who have had a suspected TIA who are at lower risk of stroke
(that is, with an ABCD2 score of 3 or below) should have specialist
assessment and investigation as soon as possible, but definitely within
one week of onset of symptoms (RCP 4.2.1 E)
20
•
•
•
People who have had a TIA but who present late (more than one week
after their last symptom has resolved) should be treated as though
they are at lower risk of stroke (RCP 4.2.1 F)
People who have had a suspected TIA who are at lower risk of stroke
in whom the vascular territory or pathology is uncertain should
undergo brain imaging - defined as ‘within one week of onset of
symptoms’ in with the National Stroke Strategy.
All patients with a TIA or stroke that resolves completely affecting
the carotid circulation should have investigation for carotid stenosis
as soon as possible and no later than seven days after the event by
screening using Doppler ultrasound or other non-invasive test (RCP
4.4.1 C)
Referral if appropriate for carotid intervention within 7 days of onset
of symptoms (following MRI/CT/Carotid Doppler as required)
•
All people with suspected non-disabling stroke or TIA who after
specialist assessment are considered as candidates for carotid
endarterectomy should have carotid imaging within one week of
onset (RCP 4.4.1 C)
Carotid intervention, if appropriate within 14 days of symptom onset
•
People with stable neurological symptoms from acute non-disabling
stroke or TIA who have symptomatic carotid stenosis of 50-99%
according to NASCET criteria or 70-99% according to ESCT criteria
should undergo endarterectomy within a maximum of two weeks of
onset of symptoms
Give Patient information in appropriate format
As per bundle two, page 21.
Communicate treatment plan back to GP within 24 hours of specialist
assessment
As per bundle two, page 21.
Suggested Actions
•
•
•
•
Develop appropriate local care pathway, including protocols, polices
and documentation for referral from first point of contact to
specialist TIA services
Ensure processes and protocols in place for prioritising high risk and
low risk patients
Ensure pathway, process and protocols in place for access to
specialist assessment within appropriate timeframe, dependant on
risk
Local agreement of skills and competencies and training programme
for specialist staff
21
•
•
•
Ensure pathway, processes and protocols in place for appropriate
investigations to be done in appropriate timeframes
Develop Patient Information in appropriate formats
Ensure robust communication processes in place for ensuring that the
GP is provided with the treatment plan
Measures
Bundle Two- Higher Risk TIAs- ABCD2 score =>4
•
•
•
•
•
•
Compliance with bundle 2 for patients with a suspected TIA with an
ABCD2 score of =/>4 who receive all interventions in bundle 2 within
agreed timeframes
Percentage of patients with suspected TIA, with ABCD2=>4, who
received specialist assessment within 24 hours of symptom onset
Percentage of patients with TIA with ABCD2 =>4, who had Carotid
Investigation within 48 hours of symptom onset
Percentage of patients with confirmed TIA, with ABCD2 score of =>4,
who had carotid intervention within 7 days of symptom onset
Percentage of patients with confirmed TIA, with ABCD2=>4, who were
given information
Percentage of patients with confirmed TIA, with ABCD2=>4, whose GP
were sent relevant treatment plan within 24 hours
Bundle Three- Lower Risk TIAs- ABCD2 score < =3
•
•
•
•
•
•
Compliance with bundle 3 for patients with a suspected TIA with an
ABCD2 score of =/< 3 who receive all interventions in bundle 3 within
agreed timeframes
Percentage of patients with confirmed TIA, with a ABCD2 <= 3, who
received specialist assessment within seven days of symptom onset
Percentage of patients with TIA with ABCD2 <=3, who had Carotid
Investigation within 7 days of symptom onset
Percentage of patients with confirmed TIA, with ABCD2 score of <=3,
who had carotid intervention within 14 days of symptom onset
Percentage of patients with confirmed TIA, with ABCD2 score of <=3,
who were given information
Percentage of patients with confirmed TIA, with ABCD2 score of <=3,
whose GP were sent relevant treatment plan within 24 hours
Additional measures
•
•
•
•
Percentage of patients referred to specialist assessment who have a
confirmed TIA
Percentage of patients with confirmed TIA who require CT
Percentage of patients with TIA who require Carotid Investigation
Percentage of patients with confirmed TIA who required carotid
intervention
22
•
•
Percentage of patients with confirmed TIA who were given
information
Percentage of patients with confirmed TIA whose GP were sent
relevant treatment plan within 24 hours
Data Collection
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Date/Time referral received specialist assessment
Date/Time first seen/assessed specialist assessment
Investigations requested CT/MRI/Carotid Intervention/Other
Date/Time CT/MRI
Diagnosis confirmed Yes/No
Alternative diagnosis
Date/Time Carotid investigation
Degree of carotid stenosis
Date/Time ECG
Date/Time referred for carotid intervention
Date of carotid intervention
Date information given to patient
Date/Time summary sent to GP
Date/Time of Stroke
Ongoing secondary prevention and risk management following
TIA
Elements and evidence-based recommendations
Individualised secondary prevention strategy started at initial
specialist assessment, within 7 days of onset of symptoms
•
•
•
•
For each patient, an individualised and comprehensive strategy for
stroke prevention should be implemented as soon as possible
following a TIA or stroke (RCP 5.2.1 A) to include:
Lifestyle measures: smoking cessation, exercise, diet, weight control,
blood pressure, alcohol intake (RCP 5.3.1)
Every patient who has had a stroke (including TIA and SAH) and in
whom preventative interventions would be appropriate should be
investigated for risk factors as soon as possible, certainly within one
week of onset. At a minimum this includes checking for and managed:
o raised blood pressure (sustained over 130/90 mmHg) (RCP
5.4.1)
o hyperlipidaemia (RCP 5.5.1)
o diabetes mellitus (RCP 5.1.1 A)
For patients who have had an ischaemic stroke or TIA the following
risk factors should also be checked for:
o atrial fibrillation and other arrhythmias
o structural cardiac disease
23
o carotid artery stenosis (only for individuals with a non-disabling
carotid territory event likely to benefit from surgery for
stenosis) (RCP 5.1.1 B)
•
In any patient where no common cause is identified, fuller
investigation for other rare causes should be undertaken (RCP 5.1.1
C)
Strategy reinforced by health care professional
•
•
For each patient, information about stroke and risk factors should be
reinforced at every opportunity by all health professionals involved in
the care of the patient (RCP 5.1.2 B)
Patients should be encouraged to take responsibility for their own
health and be supported to identify, prioritise and manage their risk
factor (SIGN Guideline 12.1)
Strategy provided to patient in appropriate format
•
For each patient, information about stroke and risk factors should be
provided in an appropriate format (RCP 5.2.1 B)
Follow up at one month in either primary or secondary care
•
•
All patients receiving medication for secondary prevention should
have a regular review of their medication (RCP 5.2.1 D)
All patients with TIA or minor stroke are followed up one month after
the event, either in primary or secondary care (QM6 National Stroke
Strategy)
Suggested Actions
•
•
•
•
Develop local protocols and documentation for individualised
secondary prevention management plans, which facilitate
communication of relevant information to patients and their GPs
Develop patient information leaflets
Agree local protocols and competencies for staff reinforcing medical
management plan and lifestyle advice
Identify local resources for lifestyle management support, e.g.
exercise on prescription schemes, lifestyle coaches, community
therapists, patient credit schemes
Measures
•
•
Compliance with bundle, i.e. percentage of patients who receive all
elements of the secondary prevention bundle
Percentage of patients with confirmed TIA who are screened for
medical risk factors
24
•
•
•
•
•
Percentage of patients with confirmed TIA who are commenced on
medical management plan at initial specialist assessment
Percentage of patients with confirmed TIA who are given an
individualised secondary prevention strategy started at initial
specialist assessment, within 7 days of onset of symptoms
Percentage of patients with confirmed TIA with whom this strategy is
reinforced by healthcare professional
Percentage of patients with confirmed TIA to whom this strategy is
provided in appropriate format
Percentage of patients with confirmed TIA who are followed up at
one month in either primary or secondary care
Data Collection
•
•
•
•
•
•
•
•
•
Date patient screened for medical risk factors
Date medical management commenced
Date patient advised on lifestyle risk factors
Profession of person providing advice
Date information provided
Date management plan communicated to patient and primary care
Date of follow up
Place of follow up- primary/secondary care
Health care professional carrying out follow up- Consultant/GP/
Nurse/ Therapist
25
References
1. Hankey,G and Warlow,C (1994) Transient ischaemic attacks of the
brain and eye. London: WB Saunders.
2. Chandratheva A., Mehta Z., Geraghty O. C. et al (2009), Populationbased study of risk and predictors of stroke in the first few hours
after a TIA. Neurology; 72: 1941 - 1947.
3. Royal College of Physicians (2008) National Clinical Guideline on the
Management of People with Stroke (3rd Edition). London. RCP
Intercollegiate Stroke Working Party.
4. Department of Health (2007) National Stroke Strategy. London.
Department of Health.
5. Scottish Intercollegiate Guidelines Network (2008) Management of
patients with stroke or TIA: assessment, investigation, immediate
management and secondary prevention. A national clinical guideline.
Edinburgh. Scottish Intercollegiate Guidelines Network
6. Clinical Effectiveness and Evaluation Unit (2008) National Clinical
Guidelines for Stroke. London. Royal College of Physicians.
7. Stroke Services Improvement Programme Workstream A (2008) Care
Pathway, Gap Analysis, Indicators and Outcomes Workstream Report.
Cardiff. National Public Health Service, Welsh Centre for Health,
National Leadership and Innovation Agency for Healthcare.
8. Royal College of Physicians (2008) National Sentinel Stroke Audit
Phase One Organisational Audit 2008 Report for England, Wales and
Northern Ireland. London. RCP Clinical Effectiveness and Evaluation
Unit.
9. Welsh Assembly Government (2007) Welsh Health Circular (2007) 082.
Cardiff. Welsh Assembly Government.
10. The Breakthrough Series: IHI’s Collaborative Model for Achieving
Breakthrough Improvement. IHI Innovation Series white paper.
Boston: Institute for Healthcare Improvement; 2003. (Available on
www.IHI.org)
26
Appendix One- Membership of Core Group involved in
developing Driver Diagram and Care Bundles
Name
Role / Profession
Organisation
Alan Willson
Director of R&D
NLIAH
Alun Morgan
Physiotherapist
Cardiff and Vale NHS Trust
Andy Williams
Breeda Worthington
Paramedic
WAST
Facilitator
NLIAH
Carl James
PMWTEC
WAG
Carol Milton
Dietician
ABMU NHS Trust
Carole Saunders
Nurse
ABMU NHS Trust
Caroline Millichip
OT
Cardiff and Vale NHS Trust
Cathy White
DHSS - CPCHSD
Primary Care
WAG
Blaenau Gwent LHB
Conrad Hancock
Dr Anne Freeman
Dr Chris Burton
Chair WSA, Physician
Gwent Healthcare Trust
Education
Bangor University
Dr Dick Dewar
Medicine
Cwm Taf NHS Trust
Dr Ed Wilkins
Dr Hamsaraj Shetty
Chair WMC, Physician
ABMU NHS Trust
Physician
Cardiff and Vale NHS Trust
Dr Mark Vaughan
GP
Llanelli
Dr Salah Elghanzai
Physician
North West Wales NHS Trust
Dr Vijay Sawlani
Neuroradiologist
Morriston Hospital, ABMU
Gwyn Roberts
PMWTEC
WAG
Heather Giles
PMWTEC
WAG
Heather Graz
SALT
Gwent Healthcare Trust
Janet Ivey
OT
Cwm Taf NHS Trust
Joanne Dundon
IHI
Informing Healthcare
Julie Wilcox
Neuropsychologist
Cardiff and Vale NHS Trust
Linda Passey
Orthoptist
Gwent Healthcare Trust
Lynne Hughes
Nurse
North Wales NHS Trust
Michelle Graham
Facilitator
NLIAH
Michelle Price
Facilitator
NLIAH
Nichola Pryce-Howard
WAG
WAG
Nicola Davis
Nurse
Blaenau Gwent LHB
Susan Wilson
Physiotherapist
ABMU NHS Trust
Suzanne Martin
Orthoptist
ABMU NHS Trust
27
Appendix Two: ABCD2 TIA Risk Stratification Scoring
System
ABCD2 Risk Stratification Scoring System
Score
A
Age
Greater than 60 yrs
1
B
Blood Pressure
Greater than 140 systolic and/or
Greater than 80 Diastolic
1
Limb Weakness
1
Speech Difficulty
1
Both of the above
2
Greater than 60 minutes
2
Between 10-59 minutes
1
Less than 10 minutes
0
C
D
Clinical Features
Duration of Symptoms
Diabetes
1
Maximum Score of ABCD2
7
28
Appendix 3: Minimum Dataset TIA
ID Number
Date of
Onset
Time of
Onset
Date
Time
Score
Exception
First Contact
Place of first contact
Aspirin
ABCD2 Score
Referral sent
Information Given Y/N
Referral received specialist service
First seen/assessed specialist service
Investigations requested
C
T
MRI
Carotid Doppler
ECG
Other
CT/MRI
Timely Management
TIA Confirmed
Carotid Doppler
Alternative diagnosis
Y/N
ECG
Referred for carotid intervention
Carotid intervention
Info given to patient Y/N
Y/N
Summary to GP Y/N
Y/N
Patient screened for medical risk factors
Medical management commenced
Ongoing Secondary
Prevention
Patient advised on lifestyle risk factors
Profession of person giving advice
Information provided
Mgt plan communicated to patient
Mgt plan communicated to GP
Date of follow up
29
Appendix 4: Data Collection Planner
Phase
Data item
Date of onset
Timely Management
First Contact
Time of onset
Date seen by
GP/paramedics/A&E
Time seen by
GP/paramedics/A&E
Place of first contact
Date given aspirin
Profession of first
contact
Format
At what
point
Where
is it
stored
How
reliably do
we collect
Issues to
resolve
Date
Time
Date
Time
Place
Date
Profession
Time given aspirin
Time
Date ABCD2 score
Date
Time ABCD2 score
Time
ABCD2 Score
Number
Date referral sent
Date
Time referral sent
Time
Information Given Y/N
Date referral received
by specialist service
Time referral received
specialist service
Date first assessed by
specialist
Time first assessed by
specialist
Place of specialist
assessment
Investigations
requested
Who records
this
Yes/No
Date
Time
Date
Time
Place
CT/MRI/CD/
ECG/ Other
Date CT/MRI
Date
Time CT/MRI
Time
30
CT/MRI
CT/MRI
Diagnosis confirmed
Yes/No
Date Carotid Doppler
Date
Time Carotid Doppler
Time
Carotid stenosis score
%
Date ECG
Date
Ongoing Secondary Prevention
Time ECG
Date referred for
carotid intervention
Time referred for
carotid intervention
Date time of carotid
intervention
Info given to patient
Y/N
Outcome
Summary to GP Y/N
Patient screened for
medical risk factors Y/N
Medical management
commenced Y/N
Patient advised on
lifestyle risk factors Y/N
Information provided
Y/N
HCP providing advice
Management plan
communicated to patient
Management plan
communicated to GP
Date of follow up
Time
Date
Time
Date
Yes/No
Yes/No
Date
Date
Date
Date
Profession
Date
Date
Place of follow up
Place
Date of stroke
Date
31
Appendix 5: Worksheet for Testing Change- PDSA Cycle
Aim: (overall goal you would like to reach)
Every goal will require multiple small tests of change
Describe your first (or next) test of change
Person Responsible
When to be
done
Where to
be done
List the task needed to set up this test of change
Person Responsible
When to be
done
Where to
be done
1.
2.
3.
4.
5.
6.
Predict what will happen when the next test is carried out
Measures to determine if predictions accurate
1.
2.
3.
32
Do
Describe what actually happened when you ran the test
Study
Describe the measured results and how they compared to the predictions
Act
Describe what modifications to the plan will be made for the next cycle
33