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

2. TIA Definition Acute neurovascular event
Signs disappearing within 24 hours

3. 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.

4. 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’.

5. 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.

6. 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.

7. 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

8. Interval between TIA and CVA admission in England

11. Impact of early Intervention

12. 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

13. 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

14. 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

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

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

17. Non Contrast CT
Demonstrating haemorrhage

18. 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

19. FAST

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

21. 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

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

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