Abstract
A transient ischaemic attack (TIA) is a common medical encounter, which is often managed suboptimally in the acute phase. A TIA should be treated as a medical emergency as studies have shown that high-risk patients can go on to have a stroke within seven days of a TIA. An audit was completed looking at referrals to the TIA clinic. Results prompted the production of a TIA care pathway, which prompted health-care teams on the appropriate management of these patients.
Introduction
Stroke is the third most common cause of death, but the most common cause of severe disability in the UK. 1 Ischaemic strokes are often preceded by transient ischaemic attacks (TIAs) and studies have shown that these can be up to 30% in those who are at high risk. This narrow time window provides a potential opportunity for stroke prevention and the notion that in some cases a TIA should be regarded as a ‘medical emergency’.
Background
There is considerable variation throughout the country on the management of TIAs with no official guidelines in place. Practice can vary from, on the one hand, all TIA patients being admitted and receiving inpatient investigations, to the converse of all TIA patients being managed as outpatients by specialists. This lack of standardized care leads to suboptimal care and inappropriate use of resources.
The Royal College of Physicians has provided brief guidelines recommending that all patients with a diagnosis of a TIA should be seen within seven days by a specialist. 2 However, this is frequently not achieved. Studies have shown that only one-third of patients are seen and there is a mean wait of 14 days. 3 The reasons for this are many, simply due to an overwhelming number of referrals and lack of specialists, and also most importantly the overdiagnosis of a TIA. With the lack of clinical signs, a diagnosis of a TIA can be difficult as health-care professionals are solely reliant on the history from the patient. Studies have shown that only 50% of patients that present to a TIA clinic have the diagnosis of TIA made, 4 highlighting the difficulty in diagnosis and also the inappropriate use of specialist clinics.
Risk Stratification
TIA specialists, like all specialists, are dependent on risk stratifying the patient on the referrals they receive. The Oxford research group has devised the ABCD score. 4 It is a simple score that predicts the risk of stroke within seven days of a TIA (Table 1). A score of 6 gives you a 31% risk of having a stroke within seven days of a TIA and a score of 5 gives a 12% risk of a stroke within seven days of a TIA.
Tia Audit 5
Literature suggests that we must do better in both the diagnosis and management of patients presenting with a TIA. It was important to find out what service we were offering at our Trust and whether we were a reflection of what is occurring nationwide.
ABCD score
A score of 6=31% chance of having a stroke within seven days of a TIA
Aims and objectives
How many referrals?
Source of referral?
Score patient using ABCD score (Table 1)
Number of high-risk patients?
Methods
Referrals from January 2004 to December 2006 were analysed.
Patients were scored using the ABCD score at referral and at the time of review in clinic.
Results
Two hundred and thirty-eight patients referred.
Source of data: general practitioner (GP) (58%), accident and emergency (A&E) (27%), physicians (11%), ophthalmology (3%).
Only 29% had fall data (i.e. ABCD).
Other clinical features (i.e. vertigo, dizziness, tinnitus, blackouts) were a common reason for referral.
GPs did best at recording ABCD data and other risk factors.
ABCD score of 6 at referral was 11%, and at the time of review in clinic it was 28%.
56% of patients who had an ABCD score of 6 had significant carotid stenosis.
Discussion
Referrals were poor and incomplete with blood pressure being the most common omission.
GPs do the best in providing information.
Clinical features are variable, suggesting that TIA is often misdiagnosed by junior staff.
The population group is at high risk of a stroke within seven days after a TIA.
The Need for an Integrated Care Pathway
With our audit results reflecting our population group being at high risk of a stroke within seven days of a TIA, it was vital to improve the TIA service we offered. A TIA care pathway has been created which is currently in use. It directs health-care professionals to risk stratify patients and act according to their risk of stroke after a TIA. High-risk patients (with ABCD scores of 5 and 6) will get urgent carotid Dopplers and a computed tomography (CT) Head within working hours and fast tracked to the vascular team, if required.
This pathway was developed with reference to, and in agreement with, the whole of the multidisciplinary team who deal with the management of patients with a TIA. These included the acute physicians, emergency care physicians, elderly care physicians and radiologists. The nursing staff and paramedics were also consulted.
Education
A ‘TIA Roadshow’ also took place prior to the pathway being implemented. This was to educate all health-care staff not only on the pathway but also on what a TIA is and how patients present, and the importance of secondary prevention and education provision for patients.
Due to the recent publication of validation of the ABCD score, both the pathway and the referral form have been slightly modified to accommodate this new data. A new score termed ABCD2 has been derived which incorporates diabetes as an additional factor. 6 This new score has been found to be a more accurate predictor of stroke within two days of a TIA. 6
The ICP is to be audited with plans for thrombolysis for ischaemic strokes being our next goal (Figures 1, 2 and 3).
City Hospital TIA pathway
TIA/minor stroke referral form
Management of TIA