Reducing delays to outpatient assessment of strokes and TIAs

Transcription

1 Reducing delays to outpatient assessment of strokes and TIAs Prof Martin Dennis Stroke Physician (Lothian) Clinical lead for Scottish Stroke Care Audit

2 The patient pathway Step 1 Possible TIA, minor stroke identified by GP Emergency dept SAS personnel

3 High early risk of stroke after TIA 14 Risk of stroke (%) % risk of stroke by 7 days Lancet 2005; 366: Days

4 Aspirin has a much greater effect in the acute phase, than in the chronic phase (Lancet , DOI: ( /S (16) ) Copyright 016 Rothwell et al. Open Access article distributed under the terms of CC BY Terms and Conditions

5 Pooled analysis of the effect of aspirin versus control in secondary prevention after TIA & ischaemic stroke on the absolute risk of recurrent ischaemic stroke The Lancet , DOI: ( /S (16) ) Copyright 2016 Rothwell et al. Open Access article distributed under the terms of CC BY Terms and Conditions

6 Implications of these data Antiplatelet treatment should be started immediately, unless a clear contraindication exists This might be achieved by: Clear protocol for GPs, OOH, ED dept TIA treatment packs available in ED TIA hotline Can be monitored by SSCA % of patients on antiplatelet when 1 st assessed

7 % of patients with TIA/ischaemic stroke on antiplatelets at 1 st assessment

8 Patient pathway Step 2a Refine the diagnosis to: Distinguish TIAs from some mimics Provide the patient with an explanation

9 This is achieved through Specialist interpretation of history This might be achieved by: Referral via , with specialist review e.g. SCI gateway with specialist review TIA hotline to specialist Virtual clinic (telephone consultation)

10 Patient pathway Step 2b Further refinement of diagnosis by tailored investigation Brain imaging (CT or MRI) Vascular imaging (Duplex or CTA or MRA) Cardiac investigations (ECG, monitoring & echo) Identification of vascular risk factors (Blood tests)

11 This might be achieved This requires the patient to attend hospital Admission Day hospital/stroke unit TIA clinic with one stop imaging Prompt outpatient investigations

12 Patient pathway Step 3 Refine treatment Anticoagulation if patient has AF Carotid endarterectomy if symptomatic severe stenosis Treatment or referral for some mimics This requires prompt communication with GP, vascular surgery or other services.

13 Carotid Surgery should be performed early after TIA / Minor ischaemic stroke Absolute reduction in risk Rothwell, ECST & NASCET investigators, Lancet 2004; 363:

14 A&E a European model Always promptly available 24/7 In Scotland lack of access to TIA specialist mis-diagnoses frequent In Scotland lack of access to immediate investigation Tendency to admit unnecessarily for investigation

15 Daily TIA clinics Can offer prompt assessment/investigation Seems to reduce risks EXPRESS study A challenge to staff (esp at weekends) A challenge to provide imaging support Likely to have lots of wasted capacity

16 TIA clinic Offers a convenient method of bringing together specialist and investigations But will generally have fixed capacity If enough slots to cope with peaks in demand lots of waste If not, then need a system to cope with patients who cannot be accommodated

17 Performance against TIA clinic standard

18 TIA clinics in GG&C Site No. of referral in 2015 No. (%) fast tracked No. (%) see in 4 days Inverclyde (48%) 165 (99%) GRI/Stobhill (72%) 535 (80%) RAH/VoL (74%) 427 (79%) WIG (90%) 165 (45%) Victoria (77%) 181 (38%) QEUH (79%) 18 (5%) Overall (74%) 1491 (57%)

19 The outpatient bundle

20 330,000 population Served by a DGH 1000 referrals to NV Clinic per yr 20/week

21 Variation in referrals in Lothian (800,000) over 17 weeks (excluding hotline only patients) The smaller the population, the greater the variation Effective clinic capacity depends on no. of wasted slots which depends on Actual timing of referrals Distribution of clinics through week Cannot afford to book ahead

22 Traditional clinics vs Rapid access service Referrals Referrals Waiting list Patients Seen Waiting list allows fluctuation in No. referral Clinic capacity Waiting lists = preventable strokes Patient seen

23 A TIA service Referrals Early Triage TIA Clinic Fixed capacity Specialist Early access to imaging Early treatment Communication Alternatives pathways Virtual (telephone) assessments ED dept See on stroke unit Admission

24 To ensure The service needs active management Capacity is maintained 52 weeks of year Triage is responsive to peaks and troughs in demand

25 Mega rota Date Day Front door Hotline / Triage Stroke Unit TIA CLINIC LEAVE A B C D 22/8 Mon A B C C B A/L 23/8 Tue C B B B A/L 24/8 Wed A A A B C A/L 25/8 Thu B C C C A/L 26/8 Fri C B B B A A/L 27/8 Sat B B B B A/L 28/8 Sun B B B B A/L By pooling resources we provide a more consistent, resilient system Need to coordinate job plans and leave Weekly timetables vary PAs are annualised

26 Forward planning Essential to ensure TIA service capacity maintained despite annual leave etc Plan staff for Hotline and every clinic over next few months

27 Components of TIA service Local referral guidelines TIA Hotline Electronic referral ( SCI gateway, ) Enhanced services in A&E Rapid access, one stop TIA clinics Stroke clinic on stroke unit? Inpatient care Coordination & active management

28 QUESTIONS?

29 Our results in Western General Hospital before & after introduction of Hotline Mean days from referral to examination for DEFCVD patients _ X=11.31 Days / / / / / / /2007 Date UCL=5.69 _ X=3.33 LCL= / / / / /2007

30 Bundle Specialist clinical assessment to make diagnosis Early investigations where indicated Bloods, ECG, Brain imaging, Non invasive vascular imaging, Echocardiography, Rhythm monitoring Early initiation of secondary prevention medication and carotid surgery where indicated