Transient Ischaemic Attack (TIA)

Stroke Improvement Programme National Project 2009-10

Quality Markers 5 and 6
The TIA national project covers implementation of quality markers five and six of the National Stroke
Strategy.

‘Assessment – referral to specialist: immediate referral for appropriately urgent specialist assessment and investigation is considered in all patients presenting with a recent TIA or minor stroke- A system which identifies as urgent those with early risk of potentially preventable full stroke – to be assessed within 24 hours in high risk cases; all other cases assessed within seven days – provision to enable brain imaging  within 24 hours and carotid intervention, echocardiography and ECG within 48 hours.’

‘Treatment – All patients with TIA or minor stroke are followed up one month after the event, either in primary or secondary care.’

Project objectives
The project aimed to identify models of care that should be available for the treatment and prevention of TIA and minor stroke focusing on how to deliver TIA assessment and care appropriately to the needs of local populations.
• To agree pathways of care for high and lower risk patients, delivering improved access to services for patients with TIA or minor stroke.
• To implement improved services, involving local staff and patients to define and determine how best to
achieve the ambitions of the relevant quality markers.
• To establish sustainable access to imaging services needed to support TIA assessment.
• To support and guide the commissioning process underpinning service development.
• To improve performance of the vital sign relevant to TIA.
• To demonstrate local improvement against the National Stroke Strategy quality markers five and six.

Local aims and objectives
• Universal use of the ABCD2 score.
• Developing a workforce to ensure all TIA patients receive care from staff with appropriate levels of
expertise.
•Developing a network solution for out of hours seven day high risk TIA.
• Providing an equitable accessible service across a large geographical area within one acute trust.
• Nurse led secondary prevention.
• Duplex ultrasound screening for risk stratification at weekends – delivered by stroke nurse practitioners or ED medics.

Project sites
There were 10 project sites involved in piloting innovative work and testing solutions for national dissemination and learning, each working to a locally defined project plan to deliver quality markers five and six. Different models emerged dependent on local situations with a common focus on nationally agreed metrics.
• Buckinghamshire Hospitals NHS Trust
• Epsom General Hospital
• North West London Cardiac and Stroke Network
• Lancashire Teaching Hospitals NHS Foundation Trust
• Milton Keynes Hospital NHS Foundation Trust
• North Bristol NHS Trust
• Royal Devon and Exeter Hospital NHS Foundation Trust
• Royal United Hospital, Bath
• Surrey and Sussex Healthcare NHS Trust
• United Lincolnshire Hospitals NHS Trust.

Measures/anticipated outcomes
High risk:
• Percentage of high risk TIA cases treated within 24 hours (Vital Sign definition).
• Percentage of patients for whom it is appropriate who receive carotid imaging within 24 hours.
• Percentage of patients who require brain imaging who receive brain imaging (MRI) within 24 hours.
• Percentage of confirmed TIA patients with high grade stenosis who receive carotid intervention
within 48 hours.

Lower risk:
• Percentage of lower risk TIA cases treated within seven days.
• Percentage of patients for whom it is appropriate who receive carotid imaging within seven days.
• Percentage of confirmed TIA patients with high grade stenosis who receive carotid intervention
within two weeks.
• Time from first contact to TIA clinic.
• Time from first contact to carotid imaging.
• Time from first contact to brain imaging.
• Time from first contact to carotid intervention.
• Time from seen in clinic to carotid imaging.
• Time from seen in clinic to brain imaging (MRI).
• Time from carotid imaging to referral for carotid intervention
• Time from referral for carotid intervention to carotid intervention.
• Time from carotid imaging to carotid intervention.
• Percentage of confirmed TIA patients having follow up at one month after event (primary or secondary care).
• Percentage of confirmed TIA patients who have had a stroke at 30 days following event.
• Percentage of all patients seen confirmed as TIA high and low risk.
• Percentage of confirmed TIA patients who are high risk.
• Percentage of confirmed TIA patients who are lower risk.
• Percentage of confirmed TIA patients who are in atrial fibrillation (AF).
• Percentage of confirmed TIA patients who have AF receiving anticoagulation therapy.
• Percentage of confirmed patients who have AF who are commenced on anticoagulation or referred for
anticoagulation.

National policy/strategy
Imaging - Meeting the imaging requirements of the National Stroke Strategy is a significant challenge for
many organisations. The NHS Improvement Diagnostics team are working with the Stroke Improvement team and are available to support imaging departments in finding solutions to deliver the imaging for TIA. The National Imaging Board are kept informed of key issues enabling them to give guidance where appropriate.

Tariff - Tariff is a key issue for TIA services. Throughout the year the Stroke Improvement Programme
have been facilitating discussion between clinical teams and the PbR best practice tariff team for stroke,
linking them with teams that have been doing detailed work on tariff. It is anticipated that guidance will be
issued for 2010/11.

Prevention - In order to maximize the preventative element of TIA, the work is being aligned with the
Stroke Prevention in Primary Care workstream. Measures relating to the incidence of AF in confirmed TIA patients have been included to establish incidence in this group of patients and percentage of patients
receiving appropriate treatment.

Learning from the projects
• Going up a gear: practical steps to improve stroke care publication, June 10
• Project case studies
• Presentations and posters from the Accelerating Progress in Stroke Care event, 22 June 10

Contact details
Project lead: Barbara Zutshi
National Improvement Lead
NHS Stroke Improvement Programme
Email: barbara.zutshi@improvement.nhs.uk
Tel: 07900 223136

Resources
Stroke and TIA Vital Signs Frequently Asked Questions
The final version of the Stroke and TIA Vital Signs frequently asked questions (FAQ) can now be downloaded.  A number of different clinical and pathway scenarios, and individual points of clarity have now been addressed to aid in the interpretation of the vital signs monitoring return guidance. However, several guiding principles have also been established based on the feedback that has been given to date:
• The FAQ does not deal with clinical issues (e.g. what is the definition of a stroke unit? or what blood tests should patients be given?) Those questions are addressed in the relevant guidance such as the RCP's National Clinical Guideline for Stroke (third edition) and The National Stroke Strategy.
• A revised version of the full Vital Signs Monitoring Return guidance for stroke has been published. If you are in doubt about whether you are using the latest version, please download it again. Among other changes, the revised version contains clearer information about TIA clinics.
• Patients should always be cared for in the most appropriate clinical setting irrespective of the requirements of the stroke vital signs.
• This guidance, like The Stroke Strategy itself, applies and refers to adult patients only.

NHS Doncaster’s innovative approach to redesign its TIA pathway, to introduce a rapid access one stop TIA clinic that includes immediate preventative treatment and vascular review
National Stroke Strategy Quality Marker 5
NHS Doncaster redesigned their TIA pathway, removing between 21 and 41 days from the old TIA pathway of care and reducing the median waiting time from 20 days to 9 days in just 7 months.  To find out how they did this, please click here.

Useful links
• Diagnostics Improvement
• Department of Health (DH)
• Stroke Care Networks
• The Royal College of Physicians (RCP)
• National Institute for Clinical Excellence (NICE)
• The Stroke Association
• Different Strokes
• Connect
• Crossroads Care
• Care Quality Commission (CQC)


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