Referral Guideline for Patients with TIA

Transcription

1 DERBYSHIRE COUNTY PCT & NHS DERBY CITY Clinical Effectiveness & Guidelines Group Referral Guideline for Patients with TIA Key Messages This is a revised guideline for patients referred to the TIA service at Chesterfield Royal Hospital Foundation Trust and Royal Derby Hospital Foundation Trust TIA Referral Guideline Derbyshire County PCT CEGG Guideline Produced: October 2009 Review date October 2011 Older Peoples Programme Board AH/SP/PG TIA Referral Guideline October

2 TIA is a Medical Emergency A TIA is an acute loss of focal cerebral function resulting in sudden onset of face and limb weakness, sensory disturbance or speech disturbance lasting less than 24 hours and believed to be of vascular origin. The main importance of the diagnosis is the implication for future vascular, especially cerebrovascular, risk. In the highest risk category on the ABCD2 score, 8.1% of patients may have a stroke in the next 2 days, so they need same day assessment. Even lower risk TIA should be assessed within a week. If your patient has a symptomatic Carotid Artery Stenosis > 70% they have a 25% chance of having disabling stroke in the next 18 months. The median duration of TIA is 14 minutes; events lasting more than a few hours are increasingly likely to represent infarction, even with 24 hours. Haemorrhage can rarely present and resolve in < 24 hours, but is much less likely with transient events. Differential diagnoses of transient motor or sensory features: Metabolic, eg hypoglycaemia; temporal arthritis; tumour; subdural haematoma; focal seizure; myasthenia gravis; peripheral nerve lesions; migraine; transient global amnesia; labyrinthine disorders. Symptoms rarely due to TIA:- consider alternative referral Alteration of conscious level; (unless at least one focal feature) Global symptoms; eg dizziness, syncope, unsteadiness, general weakness, confusion, isolated amnesia, drop attacks (double vision) Gradual onset Positive symptoms in isolation e.g. tingling, jerkiness, twitching, involuntary movements If you would like these symptoms to be investigated please refer to General Medical clinic. Have you informed your TIA patient not to drive? The DVLA advise that TIA patients do not drive for at least one month following their event. Features compatible with Posterior/Vertebrobasilar circulation TIA: Hemiparesis, unilateral face/arm/leg sensory loss (usually with other posterior features) Bilateral weakness or sensory loss Isolated homonymous hemianopia Bilateral cortical blindness Diplopia Dysphagia Ataxia Vertigo (rarely vascular when in isolation) TIA Referral Guideline October

3 Refer to TIA clinic or admit? If sudden focal neurological deficit of probable vascular aetiology with continuing deficit admit to hospital as probable stroke. If resolved do ABCD2 score High risk ABCD2 Score 4 2 TIA s in 1 week Low risk ABCD2 score < 4 Immediate referral to Specialist TIA Initiate referral to Specialist TIA Services for assessment and Service for assessment and Investigations within 24 hours of Investigation within 7 days of Referral Referral See individual referral forms for Chesterfield Royal Hospital Foundation Trust and Royal Derby Hospital Foundation Trust. TIA Referral Guideline October

4 Referral to Chesterfield Royal Hospital foundation Trust LOW RISK TIA ABCD ² less than 4 HIGH RISK TIA ABCD ² SCORE more than 4 Or 2 TIA s in 1 week Refer to Rapid Access TIA Clinic using proforma only DO NOT USE CHOOSE AND BOOK SLOTS Needs specialist inpatient assessment Send the patient to emergency department (ED) Fax TIA Clinic Referral Proforma to Fax TIA Clinic Referral Proforma to Dr Punnoose s secretary on Patient will be seen within 7 days By a stroke physician CT Brain on arrival DIRECT ADMISSION TO STROKE UNIT For review by stroke physician and for further imaging (MRI/ECHO/Dopplers) Start Aspirin 300 mg Start Simvastatin 40 mg Treat hypertension Address lifestyle issues (smoking, diet, exercise) Advise not to drive for one month All patients attending ED with persisting neurological symptoms should be admitted to the stroke unit For further advice during 9 5 Mon to Fri contact Dr S Punnoose, Consultant Stroke Physician bleep 757 Sue Potter, Stroke Specialist Nurse bleep 760 Joanne Scott Secretary For further advice After 5 p.m. and during weekends contact ED middle grade or Medical Registrar on call TIA Referral Guideline October

5 TIA referral form Patient s name: Hospital no: Patient s address & tel no: Date of birth: Date of onset of symptoms: Time : hrs Date of referral: Name of referring doctor: Referring practice: Doctor s tel no: Exclusion criteria Isolated dizziness Isolated headache Blackouts Isolated vertigo Epilepsy Vague sensory symptoms Isolated memory loss Acute confusional state Isolated diplopia Loss of balance Generalised weakness Source of referral (please tick relevant box) GP A&E EMAU Other Symptoms (should have at least one of the following) Loss of power Left Right Sensory loss Left Right Brief history/ other relevant details: Face Arm Leg Face Arm Leg Dysphasia Hemianopia Unilateral blindness Risk factor profile Previous Stroke/TIA Atrial fibrillation Intermittent claudication Hypertension Smoker Previous MI/ Angina Diabetes mellitus Family history of Stroke Alcohol excess Hypercholestrolaemia ABCD 2 Score:. (Circle relevant numbers) Duration of symptoms:. minutes Age: >60 = 1 <60 = 0 BP: >140/90 = 1 <140/90 =0 Use ABCD 2 score only when symptoms Clinical: Hemi paresis = 2 Dysphasia = 1 Others = 0 have disappeared Duration: >60 minutes = mts= 1 <10 mts = 0 Score should be based on symptoms when they were present Diabetes Yes = 1 No= 0 Low risk Fax this form to as soon as possible ABCD 2 score < 4 Start Aspirin 300mg (Clopidogrel 75mg if allergic to Aspirin) Address smoking Treat hypertension Treat hypercholestrolaemia Advice not to drive for a month High risk Aspirin 300 mg stat Refer the patient ABCD 2 score 4 or more Crescendo TIA s (2 or more TIA s in a week) Send list of current medication to ED For patients referred from ED, keep this form, copies of ED card, blood results and ECG in the TIA collection box Do not refer TIA s via Choose and Book For further advice Mon-Fri 9-5 bleep on call stroke physician, Out of hours bleep Medical Registrar or ED middle grade TIA Referral Guideline October

6 TIA clinic - further information for general practitioners 1. Our aim is to see low risk TIA patients within seven days of the event. 2. All low risk TIA patients should be referred to Dr Punnoose by faxing the standardised referral form to his secretary on Please note that risk stratification by ABCD score is absolutely essential for prioritisation of referrals 4. Patients referred inappropriately or who had the event more than two weeks before the referral may be diverted to the general medical clinic and their clinic appointment may take few weeks depending on the clinic slot availability. 5. All patients referred to the TIA clinic with suspected TIA should be started on antiplatelets and preferably a statin 6. All TIA patients should be advised not to drive (as per DVLA regulations) until they are assessed in the clinic 7. Routine blood tests and ECG will be performed during the clinic visit 8. Patients who need Carotid Dopplers and CT scans will have the tests done on the same day. 9. All patients who need further secondary prophylaxis will be started on appropriate tablets and one month s supply of tablets will be issued from the hospital pharmacy 10. Following the initial appointment, under normal circumstances, patients will not be seen in the clinic again. 11. The doctor who saw the patient will write to the GP when the results of the tests are available. 12. There might be a delay of up to ten working days before the GP receives the letter. 13. GP will be contacted urgently, if the scans or blood tests are abnormal. 14. There is no need for patients to telephone secretaries for the results as they will be sent to your GP as soon as they are available. 15. Patients will be told to book an appointment to see their GP in approximately four weeks after the clinic appointment, so that the GP can update the patient about the results and reinforce secondary prevention issues. 16. If the GP by any chance did not receive the results after ten working days, they need to contact Dr Punnoose s secretary and she will then either fax or send a copy of the results by post as quickly as possible. 17. Please inform the patient that they may be given a clinic slot at very short notice and they should plan or go for any holidays prior to the clinic visit. TIA Referral Guideline October

7 ONE STOP T.I.A CLINIC Information and Appointment Details Your general practitioner has asked for you to attend the TIA outpatient clinic at the Chesterfield Royal Hospital. TIA and Stroke TIA (Transient Ischemic Attack) is sometimes referred to as a mini-stroke. A small blood clot temporarily obstructs a blood vessel to the brain, causing a lack of blood flow, and then clears again restoring normal blood flow. No damage occurs in a TIA. If damage is sustained this becomes a stroke. One TIA, or stroke with good recovery, indicates increased risk of further TIA or stroke. So the purpose of attending the clinic is to confirm the diagnosis, assess future risk, and advise on ways of reducing the chance of further TIA s or stroke. Please do not drive until you are assessed in the clinic, as you will be breaking the law if you do so. The Appointment The Consultant Stroke Physician s secretary will contact you with a date and time for your appointment. If you do not hear from the office within 2 days of your GP making the referral, please telephone to confirm details of the appointment. We need to confirm if you are going to attend, because the appointments at the specialist clinic are very limited. The TIA Clinic is a new service, which will be taking place at Suite 3 at the Royal on Tuesdays, Thursdays and Fridays and at Suite 4 on Wednesdays. Dr Punnoose will be supervising the clinic on Tuesdays and Thursdays and Dr Agarwal on the other days The Clinic appointment is expected to last between 30 and 45 minutes and you will have to spend another hour in hospital if scans have to be done on the same day. Please note that you may be given a clinic slot at very short notice and you should not plan or go for any holidays prior to the clinic visit. Could you please: Bring a list of medicines prescribed by your doctor. Bringing a Relative or Friend If you are not able to describe what happened in full detail yourself, it may be very helpful if you bring someone with you who can tell us what they saw and heard at the time of the TIA /stroke incident. If you like they could also accompany you during the tests and consultations. You may want to bring a list of any questions that you wish to discuss. TIA Referral Guideline October

8 This is what will happen on the day of your appointment: Tuesday and Thursday clinics are one stop clinics where all the investigations (blood tests, ECG and scans will be done on the same day). A nurse will escort you to the X-ray department from the clinic Patients attending clinics on Wednesday and Friday will have to come back for the scans and we aim to get the scans done within 5 working days. What happens next? It is most likely that you will be discharged back to your GP. The Consultant looking after you will get the scan, blood and ECG results within three working days and your GP should get the results within ten working days. Please book an appointment to see your GP in two weeks time to receive the results of the tests. Please do not ring the secretaries for results as they are not allowed to disclose results over the phone. Be assured that all abnormal/urgent test results will be acted upon quickly and either you or your GP will be contacted as soon as possible. You will not be seen routinely in this clinic after the first appointment. Please allow plenty of time to park if someone is bringing you by car. Car Park / Directions When you receive your appointment details in a few days through the post, there will also be an outpatient booklet which will have a map enclosed. This will give you directions on how to get to the clinic. The car parks will also be shown on the map. TIA Referral Guideline October

9 Derby Acute Hospitals Foundation Trust TIA Clinic Referral Form Patient name: Date of Birth: Hospital No: Address: Tel no (home) Tel no (mobile) Referring Dr : Referring Practice: criteria against stroke or TIA Dizzy spells Blackouts Isolated vertigo Epilepsy Vague sensory symptoms Isolated memory loss Acute confusional state Isolated diplopia Loss of balance Generalised weakness If TIA with ABCD2 >= 4, or >1 event in a week, refer directly for investigation within 24hr Date / Time first health professional contact: History and Examination Event symptoms: focal, neural deficit, sudden onset, maximal at onset? Date of event : Time of event : Symptoms and Duration (please tick relevant boxes) Loss of power Right Left Sensory loss Right Left Deficit duration Face Face <1hr Arm Arm >1hr but resolved Leg Leg Ongoing Dysphasia Hemianopia Monocular blindness Other past medical history TIA Referral Guideline October

10 Risk factor profile (please tick relevant boxes) Previous Stroke/TIA Atrial fibrillation Intermittent claudication Hypertension Smoker Previous MI/ Angina Diabetes mellitus Family history of Stroke Alcohol excess Hypercholestrolaemia ABCD2 Scoring for TIA Age (max 1pt) > 60yr : 1 <or = 60yr : 0 BP (max 1pt) >140 systolic and / or diastolic > 90 : 1 otherwise 0 Clinical: (max 2) Unilateral weakness: 2 abnormal speech without weakness: 1 Other 0 Duration (max 2) >=60 min: min: 1 <10min : 0 Diabetes (max 1) diabetes: 1 no diabetes: 0 Total = BP: ECG: Current medications: Aspirin / antiplatelet given? No / yes + date/time: Tests requested by referrer / GP in advance of clinic: (see GP info sheet) FBC Biochemical Profile Fasting lipids Others: ESR TFT Fasting glucose From A/E / CDU /MAU: Carotid duplex Echo Brain imaging I am aware a CT scan of the head may be required on this patient as part of the TIA Clinic assessment. Name: Signed Date: If ABCD2 >=4 or >1 TIA in a week, then High Risk; refer directly for assessment within 24 hr Aspirin 300mg stat then daily for 2wks and then 75mg OD Ask patient not to drive Fax the request to for OP clinic referral fax an accompanying letter/ printout if you wish TIA Referral Guideline October

11 Derby Hospitals Foundation Trust TIA Clinics Information for referrers If Higher Risk, ie ABCD2 score >= 4 or more than 1 event in a week refer for for same day assessment. At present to MAU/CDU at Derby City Hospital/Royal Derby Hospital, but this function will move to the Acute Stroke Unit shortly. If lower risk TIA : refer to specialist TIA clinic via proforma faxed on day of event; for assessment within a week, aiming at one-stop assessment (if the patient is robust enough for this approach). Please note if the data on the form suggests it is not a TIA or the event was a long time ago, the one-stop clinic slot may be reserved for a more urgent case. Please refer by fax rather than post, in the interest of urgency of assessment. There is no Choose and Book service for TIA for the same reason. Investigation/Management/how the clinic will run (1) At the surgery: Fax referral form to , who will contact the patient to arrange an appointment and fax back details to you. Please give patient the patient information leaflet and ask them to contact the OP office on the phone number provided, if they have not heard back within 2 days Give the patient a form for FBC, ESR, biochemical profile, fasting glucose and cholesterol and TFT (unless recent TFT result available), and have blood taken as soon as possible. It may be better to do the fasting levels on a day other than the day of the clinic, because this will be quite a long day for the patient and anybody attending with them. When the appointment is in the next day or so the priority is to get the bloods taken so that results are available at the consultation rather than that they are fasting samples. It is usually appropriate to start aspirin unless there is a contraindication when TIA is diagnosed. Patients should be advised that they must not drive for one month after one TIA and for three months after a cluster of TIAs [for group 1 licence; more severe for group2]. Give patient a bottle to use to bring a fresh early morning urine sample to the clinic Note standard transport may not be able to cope with the timing of the clinic. (2) At the clinic The procedure will be : Arrive at appointment time given - [morning clinics approx 10.30am, for afternoon clinics approx 11 am] See specialist nurse who will request brain scan (usually CT, though national advice is to move to MR), echo, carotid duplex, etc., if appropriate to the case) Have ECG, urine testing and any further bloods needed Have brain imaging, CXR, Echocardiogram, Carotid duplex if required 2 00 p.m. -3 pm see consultant with results (late morning on Weds) Assessment completed, diagnosis to patient, advice given, any further tests requested. One-stop clinic summary proforma completed, sent electronically to GP within 24 hours +/- letter. Some patients may need further investigation (e.g. transoesophageal echo, vasculitis / immunological blood tests, MR scan, CT angiogram) or referral to vascular surgery or neurology. However, the aim is that usually the assessment and management / secondary prevention advice will be completed at this one attendance. TIA Referral Guideline October

12 ONE STOP T.I.A. CLINIC Information and Appointment Details You have been referred to the Derby TIA outpatient clinic. It is important that the clinic visit is as soon as possible after the TIA. TIA and Stroke TIA (Transient Ischaemic Attack) is sometimes referred to as a mini-stroke. A small blood clot temporarily obstructs a blood vessel to the brain, causing a lack of blood flow, and then clears again restoring normal blood flow. No damage occurs in a TIA. If damage is sustained this becomes a stroke. One TIA, or stroke with good recovery, indicates increased risk of further TIA or stroke. So the purpose of attending the clinic is to confirm the diagnosis, assess future risk, and advise on ways of reducing the chance of further TIA or stroke. The Appointment The outpatient office will contact you with a date and time for your appointment. If you do not hear from the office within 2 days of your GP making the referral, please telephone to confirm details of the appointment. We need to confirm if you are going to attend, because the appointments at this specialist clinic are very limited. The TIA Clinic service, will be taking place at the Medical Outpatient Clinic at the Royal Derby Hospital. Clinics occur on Monday, Tuesday, Thursday and Friday afternoons and Wednesday mornings. The purpose is to complete the assessment as soon as possible. So the tests, seeing a Specialist Nurse, seeing the doctor, discussion of results and of treatment are scheduled to occur within one hospital visit. Bringing a Relative or Friend If you are not able to describe what happened in full detail yourself, it may be very helpful if you bring someone with you who can tell us what they saw and heard at the time of the TIA / stroke incident. You might also like their company during the tests and consultations, since it can be a long day. You would not be allowed to drive for 4 weeks after a TIA, so a friend or relative may help with transport. You may want to bring a list of any questions that you wish to discuss. Could you please: Bring your medications or a prescription list of drug/ medicines etc prescribed by your doctor. Not use any body cream on your chest area, as when we conduct the ECG heart tracing) test it makes contact with the sticky electrodes difficult. Bring a packed lunch / drink as you could be at the hospital most of the day (there is a café onsite if you prefer) TIA Referral Guideline October

13 What happens at the TIA clinic? At appointment time given, eg 10.30am: Arrive at Reception, Medical Outpatient Clinic, Royal Derby Hospital (Derby City Hospital) Have heart tracing (ECG) See the Specialist Nurse who will do an assessment regarding the suspected TIA and guide you through the rest of the clinic procedure Have brain scan and chest X-Ray if required Have any blood tests still needed Have carotid blood vessel and heart ultrasound imaging scans if needed Time to have lunch and a drink Approx 2pm: See the doctor again to discuss results of the tests and agree what to do to reduce the risk of any recurrence in the future. The Specialist Nurse may also see you again at this point to discuss any lifestyle changes that may be advised. This should all be completed by 5pm, although it may be earlier if some tests are not required. What happens next? It is most likely that you will be discharged back to your GP, but if any other tests are required these will be arranged for a later date. Education and advice will be discussed with you by the Specialist Nurse before leaving the Hospital, and you will be given a contact number should you require any further advice. A follow up appointment will be required with your GP. Car Park / Directions When you receive your appointment details in a few days through the post, there will also be an outpatient booklet which will have a map enclosed. This will give you directions on how to get to the clinic. The car parks will also be shown on the map. Please allow plenty of time for parking if someone is bringing you by car. This can be a long day, but has the benefit of a full specialist assessment and starting treatment as soon as possible. Staff will make your visit with us as good an experience as we can. TIA Referral Guideline October