Clinical Guidelines for Acute Stroke Management - Living on the EDge

1.2 Organisation of services <strong>for</strong>
transient ischaemic attack (TIA)
There are various models suggested <strong>for</strong> organising
services <strong>for</strong> those with TIA. Such models include direct
hospital admission to a stroke unit, rapid outpatient
clinics <strong>for</strong> TIA, or management by a general
practitioner.
Admission to hospital
While there is very strong evidence <strong>for</strong> admission to
hospital and care on a stroke unit <strong>for</strong> all levels of stroke
severity 6 it is unclear if there are benefits <strong>for</strong> those with
TIA and very minor stroke. Analyses undertaken
revealed that mild strokes (presumably including TIA)
did not appear to benefit from stroke unit care
(compared to general ward) in terms of reduced risk
of death alone or death or institutional care. However,
mild stroke patients managed in stroke units reduced
the risk of being dependent if they survived. 6
Furthermore, hospital admission to a stroke unit
increased the likelihood of undertaking necessary
diagnostic tests (e.g. carotid ultrasound, MRI) and had
higher adherence to protocols and processes of care
consistent with best practice stroke care compared to
conventional hospital ward. 24
While mild or recovering symptoms are one reason <strong>for</strong>
not administering rt-PA initially, there is some indication
of a correlation between TIA and a subsequent
deterioration in symptoms in a significant minority of
cases. 25-27 Hence a short hospital admission may
provide opportunity <strong>for</strong> administration of rt-PA should
the patient deteriorate. One study found a policy of
admission to hospital <strong>for</strong> 24 hours after TIA is cost
neutral if considering rt-PA alone. 28
Rapid TIA clinic
No robust data were found to determine the outcomes
of this model of care. One retrospective study in the
UK found that a clinic was cost effective if all relevant
investigations had been completed prior to the visit
allowing in<strong>for</strong>med decisions to be made at a “one
stop” service. 29 Another case series reported a rapid
assessment clinic was useful to screen <strong>for</strong> patients
eligible <strong>for</strong> carotid surgery but found only a small
number of patients (4.8%) underwent carotid surgery. 30
There is currently no national data <strong>for</strong> stroke or TIA
care provided in emergency departments or outpatient
clinics. Only 5% of hospitals surveyed in 2007 have a
rapid assessment outpatient clinic <strong>for</strong> TIAs or mild
stroke. Availability of such services was significantly
more common where there was a stroke care unit.
There are no Australian data to indicate the average
waiting times from referral to actually being seen in a
clinic. Data from the UK indicate while 78% of
hospitals have a neurovascular clinic only 34% are
seen within 7 days with the average waiting time being
12 days. 31 Local services have begun to provide earlier
access to special clinics <strong>for</strong> people with stroke,
especially <strong>for</strong> those assessed as having a lower risk of
stroke. It is vital that any such service should provide
timely access to routine investigations.
<strong>Management</strong> by primary care
The role of the GP in initial assessment and
management of TIA and stroke in Australia is unclear.
In<strong>for</strong>mation collected in one ongoing Australian study
found that TIA represents only 0.1% of GP
consultations. 32 Furthermore, tests and imaging was
requested in only a small number of contacts <strong>for</strong>
people with stroke (full blood count 2%; lipid test 1%;
CT brain 2%; Doppler ultrasound of carotid arteries
1%). 33 MRI is not available in some areas especially in
rural and remote centres 34 and GPs are unable to
request MRI. Often people will present to the GP
several hours or even days after the event due to
underestimation of the need <strong>for</strong> rapid assessment and
management. Given the small numbers of people with
stroke or TIA who normally present to the GP and the
fact that TIA is often over diagnosed, it appears that
GPs are best placed to provide initial screening and
referral to specialist stroke services <strong>for</strong> full assessment
and early management. Long term management of
risk factors, however, is the primary role of GPs.
In conclusion, there is very little direct evidence to
guide administrators and clinicians in the most
appropriate organisation of services <strong>for</strong> people with
TIA. It is clear, however, that whichever model is
utilised it should focus on rapid assessment and early
management and be based on local resources and
needs. Similar to stroke services, development of
networks between general practitioners and stroke
centres would enable appropriate use of more
intensive resources. Access to services should be
determined on the basis of risk of stroke. While
recognising its limitations, the ABCD 2 tool is a useful
screening tool that should be used to determine high
and low risk in patients with TIA (see assessment of
TIA section 3.1).
Section 1 Organisation of Services
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