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					                                                                  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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                                                                TIA Management



                     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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