TIA Management
Outcome: TIA Management Leads: Linda Prosser, Habib Naqvi, Rachel Anthwal & Viv Harrison
A Executive Summary
Stroke is a major cause of death and disability. It is the third largest cause of death, largest single cause of disability and many strokes
are preventable (see B1).
People from certain ethnic minorities are at a higher risk of stroke (see B1).
The 2006 stroke mortality rate (per 100,000 population) for Bristol (46.27) is both slightly lower than that for England (49.74) and lower
than the Regional Centres rate (49.88) (see B10).
Transient Ischaemic Attack (TIA) is an indicator of a high risk of stroke. However with fast action people that have had a TIA can be
treated to reduce the risk of Stroke.
The Bristol PCT target is that 98% of appropriate cases are seen in specialised TIA clinics within 7 days by March 2009 (see B2), in order
to have appropriate investigations and treatment. Cases that are assessed as high risk are assessed within 24 hours (at least 33%).
The PCT has already commissioned TIA clinics at both NBT and UHBristol - we are one of the first PCTs to do this nationally. Since this
decision the National Stroke Strategy published in December 2007 includes this as a recommendation.
Short term work is to validate the appropriateness and effectiveness of access to the TIA clinics (see delivery plan C).
Long term work is to get better quality assurance on appropriateness of attendance, followed by an audit of the ratio of TIA to stroke,
ultimately to change the relationship between TIAs and stroke (see delivery plan C).
Total new investment 2009/10-2012/13 = £330,000 (see delivery plan D).
Partnership arrangements: Bristol Urgent Care Service Development Group with membership including Primary Care clinicians and
management; Practice Based Commissioning Consortia; Great Western Ambulance Service; UHBristol; North Bristol NHS Trust;
Patient representation (see delivery plan E).
B Background
B1 The impact of stroke:
Key data which give a context to the scale of stroke include:
• Every year approximately 750 to 800 people in Bristol have a Stroke and 250 to 300 have a TIA.
• Stroke is one of the major causes of death in Bristol: approximately 350 deaths a year in Bristol are as a result of stroke. Stroke
contributes to the gap in life expectancy between the most deprived areas and the population as a whole.
• Nationally, 20% to 30% of people who have a stroke die within a month and 25% of strokes occur in people who are under the age of 65
• Stroke is the single largest cause of adult disability. Approximately 2000 people in Bristol live with moderate to severe disability as a result
of Stroke.
• Prevalence of stroke is higher in BME groups such as black african caribbean and south asian.
B2 Brief description of health outcome:
To reduce the incidence of stroke by having 98% of people who have had a known TIA (Transient Ischaemic Attack) access a specialist TIA
clinic within 7 days and those who have assessed as being high risk (at least 33%) to be fully assessed within 24 hours.
B3 Please state the rationale for choosing this health outcome:
TIA is an indicator of high risk of stroke. A TIA is a temporary interruption of blood supply to the brain resulting in brief neurological
dysfunction that usually lasts less than 24 hours. People who have had TIA are at a greater risk of stroke. Of those who go on to stroke
within 3 months 50% will be within 7 days. Stroke is a major cause of mortality. Monitoring of TIA management will facilitate improvements
in our understanding and ability to influence both the prevalence of subsequent strokes as well as to alter the relationship between TIA and
stroke.
B4 Brief description of service:
Patients presenting with TIA either to their GP or to A&E are to be assessed using a scoring system known as the ABCD2. Patients are to
be referred to hospital either to A&E, as an inpatient or to a clinic. TIA clinics provide the following service: a one stop clinic offering
assessment, investigation, diagnosis, treatment and advice to prevent going on to stroke e.g. medication, surgical intervention,
physiotherapy. There are set referral forms for access to this service. This is a one stop service, with follow up offered in primary care
within one month of attendance at the clinic. The service which relies on A&E and in patient care as well as weekday clinics, needs to be
developed to ensure that all those patients who are initially screened (using the ABCD2 scoring system) as high risk can be fully assessed
within 24 hours, on any day of the week.
B5 Brief description of indicator:
Number of patients attending TIA clinic and diagnosed with TIA - expressed as a % of expected TIA incidence. The denominator will be 270
cases, this is on the basis that 267 were admitted last year and that evidence from Oxford points to a rate of 0.51 per 1,000 population =
210 TIAs per year (Rothwell et al., 2004). Bristol would expect a higher rate than Oxford due to population factors.
In addition the number and percentage of TIAs accessing TIA investigations within 24 hours is to be reported.
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TIA Management
B6 Causation Analysis and Evidence Base
Investigating and treating high-risk patients with TIA within 24 hours could produce an 80 per cent reduction in the number of people who go
on to have a full stroke (Rothwell PM, et al., 2007, ‘Effect of urgent treatment of transient ischaemic attack and minor stroke on early
recurrent stroke (EXPRESS study): a prospective population-based sequential comparison’, Lancet 370, 1432–42).
TIA and minor stroke have a number of Quality Requirements within the National Stroke Strategy which was published in December 2007,
these are:
- Assessment – referral to specialist. The markers of this service include:
• 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 are assessed within seven days
• Provision to enable brain imaging within 24 hours and carotid intervention, echocardiography and ECG within 48 hours where clinically
indicated.
- Treatment
• All patients with TIA or minor stroke are followed up one month after the event, either in primary or secondary care.
The Strategic Health Authority has also set ambitions relating to TIA, this being - full implementation of all Quality Markers of the National
Stroke Strategy in all PCTs by March 2011.
VITAL SIGNS (2008/9 OPERATIONAL PLAN) has a Tier one national requirement which states that 33% of higher risk TIA cases are
treated within 24 hours by March 2009.
The PCT has also evidenced clear local ambitions for TIA services through the following ambition, stated within the PCT Strategic
Framework document: People who have suffered a transient-ischaemic attack to receive an appropriate scan (CT, MRI or Doppler) within 24
hours as needed.
B7 Is the national data robust? How have we come to this conclusion?
There is currently no national data on TIA assessments.
B8 Please state current performance against target outcome:
There were 267 admissions of TIAs in Bristol during 2007/08.
This would indicate a monthly figure of 22.
Initial data from both trusts are outlined below:
Number of patients attending Bristol TIA clinics
Number of TIA clinic UHBristol NBT Total % of expected
patients (BPCT figure TIA's (22 per
=estimate only) month)
Apr-08 50 (BPCT 25) 29 (BPCT 14) 39 177
May-08 42 (BPCT 21) 29 (BPCT 11) 32 145
Jun-08 43 (BPCT 21) 20 (BPCT 11) 32 145
These figures indicate that our understanding is very early. We need to get accurate data, to do more work to understand expected
incidence and also to validate the number of referrals that were actually TIAs.
B9 Do we know the current rate of improvement? If so, please provide details:
Too early to know as clinics started in April 2008.
B10 Include benchmarking data where available - comparison with SHA - ONS comparison - 'cluster' comparable cities:
Directly Age Standardised mortality rate per 100,000 due to stroke, core city comparison
120
Manchester
100
Liverpool
80 Sheffield
Newcastle
DSR
60
Birmingham
40 Leeds
Nottingham
20
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TIA Management
Bristol
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
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Directly Age Standardised mortality rate per 100,000 due to stroke, national and regional
comparisons
90
80 ENGLAND
70
60 REGIONAL
CENTRES
50
DSR
40
South West
30 SHA
20
Bristol
10
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
B11 Are there any links to other WCC health outcomes? If so, please provide details:
Health inequalities
Life expectancy
CVD mortality
Alcohol misuse
Smoking quitters.
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Delivery Plan
C Delivery Plan Actions & Indicators
Please state the main actions to be undertaken in order to improve health outcomes:
No Actions Delivery Indicators/Data Collection Evidence Base
Date
Specify the units of activity and exactly what outcome When will What data/indicators will be collected/used to Why will the action be carried out?
this will lead to. the action demonstrate success?
be carried
out?
2008/09
1 TIA clinics commenced: Apr-08 See appendix 1 for evidence of referral The evidence base for this includes:
- UHBristol - 5 clinics - one daily Mon - Fri guidelines. - National Clinical guidelines for diagnosis and initial
- NBT - Mon; Tues (2) & Thur - 4 clinics run management of acute stroke and transient ischaemic
These have been commended by national attack
stroke lead. - National Stroke Strategy
With single referral protocol. - National Sentinel Stroke Audits
- DH - Improving Stroke Services: a guide for
commissioners
- Implementing the National Stroke Strategy – an imaging
guide.
2 Review publicity plans of both NBT and Dec-08 Communication plans for both NBT As above.
UHBristol to ensure that all clinicians are and UHBristol.
aware of TIA clinics both within primary and
secondary care.
3 Implementation of AGWS Cardiac & Stroke Jan-09 AGWS TIA clinic standards. As above.
Network TIA clinic standards.
2009/10
4 At end of year validate % of attendees that Jun-09 See appendix 1 for evidence of data
had a TIA. Review of referrals (GP and collection.
consultants), appropriate uptake and under Compare with 08/09 admission data.
represented groups and age groups.
5 At year end review patient experience of Jun-09 Patient experience data. As above.
TIA clinic.
Following this review implement any
resulting service improvements.
6 Increase number of diagnosed TIAs that Jun-09 Referral review.
present at the clinic if analysis from year 1 TIA action plan.
shows this is necessary.
7 Audit against referral criteria, and AGWS Jan-10 Audit and resulting action plan.
TIA clinic standards.
Conduct equality impact assessment once
there is sufficient data.
Produce baseline data - ratio of TIA to
stroke.
2010/11
8 Determine trajectory and action plans Apr-10 Referral review.
based on knowledge gained in previous Audit.
years to change relationship of TIAs Equality impact assessment.
compared with strokes.
9 Year end validation of reduction in stroke Jun-10 Audit.
and repeat TIAs.
10 Clinical review of practice and best practice Sep-10
if outcomes are not delivered as expected by
TIA clinics.
Overall, as this is in line with the National Stroke Strategy the evidence base is robust.
D Total Investment
D1 Please provide details of the total new investment between 2009/10-2012/13:
£330,000
D2 Please include comments if funding is subject to Operational Planning Process (OPP) approval:
E Partnership Arrangements
E1 Which organisations will help us deliver this plan? If key posts are part of another organisation please provide details:
This Delivery Plan will be monitored and progressed through the Bristol Urgent Care Service Development Group, which includes membership from:
Practice Based Commissioning Consortia
Primary Care clinicians and management
Great Western Ambulance Service
UHBristol
North Bristol NHS Trust
Patient representation
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