Improving the TIA pathway for high and low risk patients across North Central London
| Barnet and Chase Farm Hospitals | University College Hospital | |
|---|---|---|
|
Barnet and Chase Farm Hospitals TIA referral form Word Version |
University College London Hospitals TIA referral form Word version | |
| Royal Free Hospital | North Middlesex Hospital | |
| Royal Free Hospital TIA referral form Word version | North Middlesex Hospital TIA referral form Word version |
TIAs are now considered as a medical emergency, as the risk of stroke is high in the days following a TIA, but can be reduced by about 80% if the patient is appropriately assessed and treated urgently. Services for stroke and transient ischaemic attack (TIA) have re-organised across London, including the designation of new centres for TIA management. As part of this process, new TIA referral forms have been created for the North Central sector. These forms incorporate the key information you need to assess and refer patients with suspected TIA.
Background
Prevention of stroke is a high priority in the NHS, because this condition is so devastating for patients and their families, and so costly for health and social services. 150,000 people have a stroke in England each year, around a third of whom die. Stroke is the largest single cause of adult disability and there are around 300,000 people living with moderate to severe disabilities as a result of a stroke.
An important strategy for stroke prevention is the recognition and urgent management of TIAs, as can be seen from the following three facts:
- About 20% of patients with a completed stroke have previously had a TIA
- Most of their stroke risk is incurred within the first few days of their TIA
- Their stroke risk can be reduced by about 80% if these patients are urgently assessed and treated
Improvement of TIA services is therefore a high priority nationally, and in Greater London, TIA services have been re-organised alongside services for stroke care. As part of this process, new TIA referral pathways have been created for the North Central sector. The referrals forms described in these web pages incorporate the key information you need regarding diagnosis of TIA, referral pathways, and out of hours service arrangements across the North Central London sector.
The new referral forms
These forms, for use by GPs and medical practitioners in the community, are attached in PDF, Locked Word, Vision and EMIS format for immediate use. They have been designed in black and white to ensure they are fax friendly.
To access the form you need, please click on the hospital that you refer your TIA patients to and select the format that you wish to use.
Specialist assessment and treatment services for TIA are available at the following hospital trusts in North Central London:
Barnet and Chase Farm Hospital
North Middlesex Hospital
Royal Free Hospital
University College Hospital
Nearly half of the stroke risk following a TIA is incurred within the first two days, so immediate action may be necessary to prevent the impending stroke.
Use of Referral Forms
The relevant form should be completed as soon as possible and then either given to the patient to bring with them or sent by fax to the preferred unit or clinic, as instructed in the referral form. If there is a witness to the patient's attack, the patient should be asked if possible to bring that witness along with them to the consultation, as that individual may provide extra information which the patient cannot possibly know about what actually happened.
The referral form includes the contact details of all TIA services for weekdays, evenings and weekends
The form comprises:
- Patient and GP details
- Atypical onset features
- Space for brief description of attack
- ABCD2 test for assessing the patient’s risk of imminent stroke
- Referral algorithm which tells you which TIA (or stroke) pathway to access
- Contact numbers
Atypical Onset Features
Only about half of the patients referred to TIA clinics turn out to have had a TIA. In many cases this is still have been an entirely appropriate pathway for the patient; even if the main purpose of the visit is to exclude a TIA in a migraine patient for example. Sometimes it is difficult even for an expert to be sure whether a patient has had a TIA, and the most important priority is to avoid missing this diagnosis and leaving a patient at risk of stroke.
All the same, there are certain clinical situations in which an alternative diagnosis should be considered, and in some cases referral to the local neurology service is a more appropriate route for the patient. With this in mind, the referral form list some of the symptoms that suggest that you may not be dealing with a TIA after all (see Differential Diagnosis section).
| Atypical Symptoms | Yes/No | |
|---|---|---|
|
If ‘Yes’ to any of these at onset, TIA is an unlikely diagnosis, so consider alternative referral route. If in doubt discuss with Stroke Doctor (local details provided on each referral form) |
Gradual onset or spread of symptoms |
|
|
Seizure or loss of consciousness |
||
|
Transient amnesia |
||
|
Isolated vertigo with no other cranial nerve features |
ABCD2 TEST
The ABCD2 score is a simple assessment tool for establishing the risk of imminent stroke in a patient who has just had a TIA. It is not a tool for diagnosing TIA and you should only move on to scoring the patient’s attack after you have decided that they have had a TIA and not some other transient neurological disturbance (see Differential Diagnosis section).
Patients can only receive one score per feature, i.e. 0, 1 or in some cases 2.
Maximum score is 7.
| Clinical Feature | Category | Score |
|---|---|---|
|
Age
|
60 years or older |
1 |
|
BP on earliest assessment |
Systolic BP > 140mm Hg or Diastolic ≥ 90mm Hg |
1 |
|
Clinical features
|
Unilateral weakness |
2 |
|
Duration
|
60 minutes or longer |
2 |
|
Diabetes
|
Present |
1 |
Patients scoring 4 or more on this scale are at high risk of stroke and need to be referred to the TIA service immediately. As you will see on the form, TIA services are available on a 24/7 basis, although out-of-hours you will be directed to UCLH or the Royal Free even if the patient’s local service is Barnet or North Middlesex Hospitals.
Referral Algorithm
At the bottom of the form there is a ‘Referral Algorithm’, which is a flow diagram enabling you to access the appropriate part of the service for your particular patient.
Stroke patients should be sent into hospital by ambulance:
The first thing to be sure about it whether the patient still has symptoms or signs from a recent stroke. If so, then their condition must be treated as a stroke, not a TIA. Aspirin should not be given as there is no way of knowing if the patient has had an ischaemic stroke (in which aspirin is beneficial) or a haemorrhagic stroke (where aspirin could be very harmful).
A patient with residual symptoms, i.e. a stroke, needs to be sent into hospital as soon as possible, for three reasons:
- A brain scan (usually by CT) is the only way to distinguish between ischaemic and haemorrhagic stroke, so that the appropriate treatment can be started
- These patients are at high risk of a further stroke
- Their current neurological impairment may immediately pose other risks (e.g. of falls or aspiration)
They should usually be sent into hospital immediately by ambulance (although if the stroke happened more than two weeks ago then you may wish to contact the local stroke service for an immediate discussion, as a more measured approach may be appropriate for some patients).
High risk TIAs:
If on the other hand you are dealing with a TIA rather than a stroke (i.e. the symptoms and signs have completely resolved), then aspirin can be given safely, as the probability that the symptoms were caused by haemorrhage is extremely low. It is perfectly safe to give 300mg aspirin even if the patient reports that they were already taking aspirin. Do not however give aspirin to patients who you suspect may be intolerant of this medication (e.g. those with recent peptic ulcer disease, severe asthma exacerbated by non-steroidal anti-inflammatories or known aspirin intolerance).
The correct TIA pathway then depends on the patient’s risk of imminent stroke. Patients with an ABCD2 score of 4 or more are at high risk (see above). Other indicators of high risk are patients on warfarin (whose INR will often turn out to be sub-therapeutic), patients in atrial fibrillation and those with recurrent TIAs. If any of these apply, then the patient needs to be referred immediately, by telephoning the relevant TIA service. Without treatment the patient may have a stroke within hours so there really is no time to lose.
Low risk TIAs:
If the patient does not fulfil any of these criteria then they are at lower risk of an immediate stroke. For most TIA services the correct referral pathway is to fax the completed referral form to the number given on the form, although in the case of UCLH the patient can simply be given the completed form and asked to present themselves to the Hyperacute Stroke Unit, 7th Floor, UCH Tower at 8.30am the following morning.