Quality of Referrals Guideline Congruence of referrals to TIAMS clinic TIA and Minor Stroke Quality of Referrals Guideline Congruence of referrals to TIAMS clinic

TIA Definition Acute neurovascular event Signs disappearing within 24 hours

GOALS To examine the associations of both quality of referrals to a specialist acute clinic and of ‘guideline congruence’ of time-to-clinic consultation post- TIA/minor stroke. We hypothesized high-quality referrals containing key clinical elements would be associated with greater guideline congruence.

METHODS A retrospective analysis of referrals to an acute neurovascular clinic within a tertiary care hospital of consecutive patients with TIA/minor stroke. Quality of general practitioner and emergency department referrals were defined on the basis of information content enabling ABCD2-based risk- stratification by the clinic triage service. Time-to-clinic consultation was used to define ’ guideline congruence’.

FINDINGS Referrals of 148 consecutive eligible patients were reviewed. 66% of cases were subsequently neurologist-diagnosed as TIA or minor stroke. 79% were referred by general practitioners. 53% of referrals were of high quality, but quality was not associated with guideline congruence. Of high risk patients, only 3.6% were seen at the clinic within 24 hours of index event, and 31.3% within 24 hours of referral.

CONCLUSIONS Current guidelines are pathophysiologically logical and evidence-based, but are difficult to implement. Improving quality of primary-secondary communication by improved referral quality is unlikely to improve guideline compliance. Alternative strategies are needed to reduce recurrent stroke risk post-TIA/minor stroke.

Predicting Early Risk – ABCD2 Age (>60) = 1 point BP (>140/90) = 1 point Clinical features Speech disturbance (no weakness) = 1 point or Focal weakness = 2 points Duration 60 mins + = 2 points Diabetes = 1 point HIGH RISK ≥ 4, LOW RISK < 4

Interval between TIA and CVA admission in England

Impact of early Intervention

Australian National Stroke Foundation Guidelines for TIA All patients with a suspected TIA should be managed in services that allow assessment and management within 24 hours ABCD2 ≥4 (or less with atrial fibrillation, carotid territory or crescendo TIAs) should be admitted to a stroke unit or specialist TIA clinic within 24 hours ABCD2 score <4 could be managed by a General Practitioner or where possible be referred to a specialist TIA clinic within 7 days

Australian National Stroke Foundation Guidelines for TIA – Investigations All patients with suspected TIA should have an ABCD2 score Investigations at initial healthcare contact – FBC, renal function, electrolytes, cholesterol, glucose, ESR, ECG. ABCD2 ≥ 4 (or AF or carotid territory or crescendo) should have brain imaging with MRI-DWI within 24 hours If carotid territory symptoms and potential candidate for revascularisation - carotid ultrasound within 24 hours ABCD2 < 4 should have brain imaging (preferably MRI- DWI) and carotid ultrasound within 48 hours

Australian National Stroke Foundation Guidelines for TIA - Management Anti-platelets Aspirin + dipyridamole, clopidogrel alone, aspirin alone Is brain imaging always needed before starting? Early Risk Factor Management BP lowering normotensive or hypertensive (unless concerns about postural hypotension) Lipid lowering with statin If in AF, anticoagulate after CT/MRI has ruled out haemorrhage

Australian National Stroke Foundation Guidelines for TIA - Management Carotid endarterectomy - a complex decision! § If symptomatic.... 70 - 99% stenosis should be undertaken 50 - 69% stenosis may be undertaken Depends on complication rate of the surgeon TIA specialists are best placed to make the call

Factors Influencing Delay Opening hours Community education GP triage systems Doctor education Access to imaging Access to specialist clinics or advice

Non Contrast CT Demonstrating haemorrhage

GP Opening Hours Opening hours and GP availability influence patient presentation behaviour after TIA Improved access to primary care and public education about the need for emergency care are required if the relevant targets in the national stroke strategy are to be met. Lasserson DS. et al, (2008), Bmj (Clinical Research Ed.), 337

FAST

The Newcastle Experience Acute Neurovascular clinic Acute stroke team Telephone Advice from Stroke Clinical Nurse Specialist, Neuro Registrar, Fellow or Consultant Private Neurologists

Primary Care Management Clinical assessment including ABCD2 ECG in house Non-Contrast CT Brain available 6 days a week Carotid doppler / Echocardiogram 5 days a week Initiation of definitive medication management ED imaging 24/7 if out of hours

Medications in GP Sinus Rhythm and negative non contrast CT Brain Aspirin and Clopidogrel Aspirin and Dipyridamole Atrial Fibrillation Novel anticoagulants Warfarin / Clexane

A Quality Referral Able to determine the ABCD2 score Quantify risk Influence the urgency of referral Informs need for antiplatelets / anticoagulation