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Lessons Learned Establishing a 24/7 Rapid Access TIA Service

Open ArchivePublished:January 24, 2020DOI:https://doi.org/10.1016/j.ejvs.2020.01.006
      In 2007, the UK Department of Health (DOH) published its National Stroke Strategy, which detailed 20 quality markers for delivering a high quality stroke service, one of which was that patients suffering a transient ischaemic attack (TIA) or minor stroke should be investigated and treated more quickly after symptom onset. Interestingly, the National Stroke Strategy also advised that carotid endarterectomy (CEA) should be performed within 48 h of symptom onset, although no evidence was provided to support this threshold. The 2018 European Society of Vascular Surgery (ESVS) guidelines recommend a 14 day threshold,
      • Naylor A.R.
      • Ricco J.B.
      • de Borst G.J.
      • Debus S.
      • de Haro J.
      • Halliday A.
      • et al.
      Management of atherosclerotic carotid and vertebral artery disease: 2017 Clinical practice guidelines of the European Society for Vascular Surgery (ESVS).
      and this is in line with most international guidelines.
      Three key drivers underpinning the National Stroke Strategy were: (i) awareness that the highest risk period for recurrent stroke was the first 7–14 days after the index TIA, (ii) “best medical therapy” (BMT) had to be started quickly, while (iii) meta-analyses showed that carotid endarterectomy (CEA) conferred maximum benefit (over BMT) when performed with minimal delay.
      • Rothwell P.M.
      • Eliasziw M.
      • Gutnikov S.A.
      • Warlow C.P.
      • Barnett H.J.M.
      For the Carotid Endarterectomy Trialists Collaboration
      Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery.
      However, when Leicester started planning its own rapid access TIA service, numerous conceptual, logistical, administrative, and financial barriers had to be overcome. These included: (i) family doctors saw no need for urgent referral, as they saw no evidence that secondary care offered expedited pathways for investigation/treatment; (ii) TIA patients were (historically) referred to multiple specialties (Vascular Surgery, Ophthalmology, Neurology, Stroke Medicine), who did not necessarily prioritise TIA referrals; (iii) TIA patients faced an average 32 day delay to be seen by a Stroke Physician/Neurologist and single visit investigations were unavailable; (iv) Vascular Surgeons tended to focus on identifying patients for CEA, while perhaps not always offering an effective service regarding risk factor modification and BMT implementation for the remainder. Only 8–10% of patients in a TIA clinic will have significant carotid stenoses that might benefit from CEA; (v) in Leicester (2006), the median time from symptom onset to CEA was 42 days and efforts by motivated surgeons (on their own) had little impact on reducing delays.
      • Brown C.
      • Naylor A.R.
      Improving the provision of carotid endarterectomy in line with UK Government targets will require more than motivated surgeons!.
      Accordingly, it was clear that a radical overhaul of practice was required.
      During 2007–2008, a multidisciplinary Working Group (WG) involving Stroke Physicians, Vascular Surgeons, Radiologists, Vascular Technologists, Hospital Administrators, and Commissioners met to develop an integrated TIA service. The WG was positively influenced by the EXPRESS study.
      • Rothwell P.M.
      • Giles M.F.
      • Chandratheva A.
      • Marquardt L.
      • Geraghty O.
      • Redgrave J.N.
      • et al.
      Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population based sequential comparison.
      ,
      • Luengo-Fernandez R.
      • Gray A.M.
      • Rothwell P.M.
      Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS Study): a prospective population based sequential comparison.
      EXPRESS showed that a single visit clinic (including magnetic resonance [MR] brain imaging, carotid duplex ultrasound [DUS], electrocardiography [ECG], and baseline blood tests), along with risk factor modification and starting BMT in the clinic (antiplatelet, statins, antihypertensive therapy) was associated with an 80% decrease in 90 day stroke (2.1% vs. 10.3%), a significant reduction in fatal stroke (1% vs. 3%), significantly fewer readmissions for recurrent stroke (2% vs. 8%), and significantly reduced inpatient bed stay (four days per patient), with average hospital savings of £624 per patient.
      • Rothwell P.M.
      • Giles M.F.
      • Chandratheva A.
      • Marquardt L.
      • Geraghty O.
      • Redgrave J.N.
      • et al.
      Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population based sequential comparison.
      ,
      • Luengo-Fernandez R.
      • Gray A.M.
      • Rothwell P.M.
      Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS Study): a prospective population based sequential comparison.
      This meant that for a population of a million, an EXPRESS style clinic could prevent about 165 strokes per year, save 4790 hospital bed days per year, and provide a saving of £1.2 million per year (1.4 million Euros) through reduced bed usage and stroke rehabilitation costs.
      • Rothwell P.M.
      • Giles M.F.
      • Chandratheva A.
      • Marquardt L.
      • Geraghty O.
      • Redgrave J.N.
      • et al.
      Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population based sequential comparison.
      ,
      • Luengo-Fernandez R.
      • Gray A.M.
      • Rothwell P.M.
      Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS Study): a prospective population based sequential comparison.
      In October 2008, a TIA clinic was funded to run every day of the year. Six suspected TIA patients could be seen in a single visit clinic, staffed by a consultant in Stroke Medicine, supported by specialist nurses and administrative staff. TIA referrals to other specialties ceased. The referring doctor (primary care, ophthalmology, emergency department [ED]) started each patient on 300 mg aspirin and 40 mg simvastatin as soon as a diagnosis of suspected TIA was made and he/she faxed a referral to the clinic, where it was triaged and priority allocated on the basis of the patient's ABCD2 score.
      • Johnston S.C.
      • Rothwell P.M.
      • Nguyen-Huynh M.N.
      • Giles M.F.
      • Elkins J.S.
      • Bernstein A.L.
      • et al.
      Validation and refinement of scores to predict very early stroke after transient ischaemic attack.
      An ABCD2 score of 4–7 defined a “high risk” TIA patient, while a 0–3 score defined a “low risk” patient.
      • Johnston S.C.
      • Rothwell P.M.
      • Nguyen-Huynh M.N.
      • Giles M.F.
      • Elkins J.S.
      • Bernstein A.L.
      • et al.
      Validation and refinement of scores to predict very early stroke after transient ischaemic attack.
      Four “ring fenced” MR slots were allocated to each clinic, based on the assumption that 40% of referrals would be given a non-TIA diagnosis. The initial Key Performance Indicator (KPI) mandated by the Commissioners was that 60% of high risk patients should receive specialist assessment within 24 h of first healthcare contact. High risk patients comprised 50% of all referrals from the outset. The KPI for lower risk patients was that 90% should be seen within seven days of first healthcare contact. All patients received risk factor modification advice and BMT medications were prescribed and started in the clinic. Any patient with an ipsilateral 50–99% carotid stenosis was transferred directly from the clinic to the Vascular Surgery Unit for consideration for expedited CEA. The Vascular Surgery Unit ring fenced two “urgent CEA” theatre slots (Tuesday and Friday mornings) to minimise delays to CEA. The operations were performed by the consultant surgeon allocated to the CEA list, irrespective of whether the patient had been admitted under the care of another consultant surgeon.
      Over the next 11 years, the service has been accessible to a population of one million people in Leicestershire, but a variety of unforeseen practical and logistical issues had to be resolved. First, was the rapidly increasing referral numbers, which threatened to overwhelm the service. In 2009, 1193 referrals were made, increasing to 1919 in 2013 (60% increase) and 2549 in 2017 (113% increase). Interestingly, and despite repeated advice to referring doctors, 60% of referrals ultimately received a non-TIA diagnosis, a proportion that has not changed. One early lesson, therefore, was that the rapid access TIA clinic was in danger of becoming a “funny turn” service, thereby allowing primary care and the ED to offload non-TIA patients who should have been seen in a different environment. To date, we have not found a solution to this problem. The rapid increase in referrals led to a gradual failure to achieve the 60% KPI for high risk patients and this required a series of modifications to the service. These included: (i) daily appointments increasing from six to 10 (2016) and 13 (2018), provided a registrar was available; (ii) daily number of MR slots increased to six; and (iii) funded consultant Physician time increased from four to six hours daily; (iv) an online electronic referral system with automated appointment scheduling replaced faxes, which avoided delays associated with completing, sending, receiving, and triaging faxes; (v) mobile text messaging of appointments reduced DNA rates; (vi) weekend and bank holiday slots were prioritised for higher risk patients, with more lower risk slots on a Monday; (vii) the proportion of higher risk appointments per clinic was increased, but this led to a reduction in the 90% lower risk KPI; (viii) reallocating referrals, where the most recent symptom was more than four weeks to routine outpatient appointments, on the basis that the risk of stroke was now low; (ix) Ophthalmology referrals were restricted to carotid DUS and ECG, with risk factor management and BMT remaining the responsibility of the referring doctor; (x) overbooking daily appointments on the basis of an 8% DNA rate; (xi) specialist nurses now triaged patients in the morning, investigations were prioritised and ordered and the consultant Stroke Physician then saw each patient when the results were available; and (xii) identification of referrals where clinical details suggested a non-TIA diagnosis generated a standardised rejection letter to the referrer. The latter practice has, however, turned out to be risky, because primary clinical assessment in the community or ED is not always sufficiently rigorous.
      The next problem related to the definition of “high risk.” There was growing awareness that the ABCD2 score was not the best way to identify high risk patients, unless the patient scored 6 or 7, i.e. general “neurological” and “medical” diagnoses could generate an ABCD2 score of 3–4, if misdiagnosed as a TIA. In addition, the ABCD2 score was unable to predict the presence of a 50–99% carotid stenosis.
      • Walker J.
      • Isherwood J.
      • Eveson D.
      • Naylor A.R.
      Triaging TIA/minor stroke patients using the ABCD2 score does not predict those with significant carotid disease.
      In 2016, the Royal College of Physicians and then NICE (2018) recommended against the ABCD2 score in favour of considering all patients whose symptom onset was within the preceding seven days as being “high risk of stroke.” This led to over 80% of referrals being classed as “high risk” and 80% of daily appointments were reallocated to being “high risk.”
      The third issue related to delays in transferring patients to the Vascular Surgeons. It was not uncommon to receive CEA referrals at about 3:00–4:00 p.m., meaning that potential CEA patients did not arrive on the vascular ward until early evening, which delayed initiation of an effective workup for theatre. This was resolved by the Stroke Physician agreeing to review any TIA patient with a 50–99% stenosis first on his/her list, once the investigations were available. Most referrals are now made between 12:00 and13:00 p.m.
      The fourth issue was raised following an audit showing that 13% suffered recurrent TIA/stroke in the 48–72 h period between being seen in the TIA clinic and undergoing expedited CEA. It was, therefore, decided to add 75 mg clopidogrel to the pre-existing aspirin therapy, with dual antiplatelet therapy (DAPT) starting in the TIA clinic, once MR had excluded haemorrhage. A subsequent audit showed that recurrent TIA/stroke before CEA fell to 3%, without increasing bleeding complications after CEA.
      • Batchelder A.J.
      • Hunter J.
      • Robertson V.
      • Sandford R.
      • Munshi A.
      • Naylor A.R.
      Dual antiplatelet therapy prior to expedited carotid surgery reduces recurrent events prior to surgery without increasing peri-operative bleeding complications.
      The success of the DAPT policy also means that it is rarely necessary to undertake emergency CEA. The only remaining indications being crescendo TIAs despite DAPT (not encountered so far) or mobile intraluminal thrombus on DUS. To date, no guidelines recommend routine DAPT for ischaemic TIA patients, but this is likely to change following meta-analyses of the CHANCE and POINT randomised trials, which revealed a significant reduction in early recurrent stroke in patients with ischaemic TIAs randomised to DAPT.
      • Hao Q.
      • Tampi M.
      • O'Donnell M.
      • Foroutan F.
      • Siemieniuk R.A.C.
      • Guyatt G.
      Clopidogrel plus aspirin versus aspirin alone for acute minor stroke or high risk transient ischaemic attack: systematic review and meta-analysis.
      The “Rapid Access” TIA clinic has greatly improved the management of TIA in our region (regardless of the aetiology), but it has required regular modifications to maintain its delivery. The 60% KPI for seeing high risk patients within 24 h of first healthcare contact has been exceeded and about 80% of patients with symptomatic 50–99% stenoses undergo CEA within 14 days of symptom onset (45% within seven days). The median delay to CEA in Leicester is currently nine days, compared with 42 in 2006 and the 30 day death/stroke rate remains around 1–2%. Interestingly, the introduction of the TIA clinic in 2008 was immediately associated with a 40% increase in annual CEA numbers, which have since declined considerably, especially over the last three years. This phenomenon (a 25–30% decline in annual symptomatic CEA numbers) has been noted throughout England and Wales and may reflect temporal changes in the aetiology of ischaemic stroke, possibly because more patients are now prescribed statins, antihypertensive, and antiplatelet therapy for primary/secondary risk prevention.
      • Johal A.S.
      • Loftus I.M.
      • Boyle J.R.
      • Naylor A.R.
      • Waton S.
      • Heikkila K.
      • et al.
      Changing patterns of carotid endarterectomy between 2011 and 2017 in England: a population based cohort study.
      This will inevitably disappoint the surgeons, but the remaining TIA patients can be reassured that a dedicated physician led clinic ensures that risk factor modification and BMT implementation can now be delivered more quickly and effectively than ever before.

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