Practical principles for transient ischaemic attack (TIA) One of a set of eight practical principles publications. The full set are: 1 - Improving psychological care after stroke 2 - Developing an early supported discharge service 3 - Improving access to CT scanning 4 - Transient Ischaemic Attack (TIA) 5 - How to establish joint care planning 6 - How to manage reviews for stroke survivors 7 - Being the best in acute stroke 8 - Developing a community stroke service (Published November 2011)

1. NHS
NHS Improvement
PRACTICAL PRINCIPLES
for Transient Ischaemic Attack (TIA)
1. Streamline the referral route with a single point of contact
for high and lower risk
2. Employ a comprehensive communication strategy
3. Tailor the weekend service to local needs and demands
4. Develop a sustainable data and audit system
5. Provide access to specialist follow up for all TIA patients
6. Agree a pathway for timely access to carotid intervention QUALITY 4& ACCELERATING
MARKER 5 STROKE
IMPROVEMENT
5
Streamline the referral route with a CASE STUDY
single point of contact for high and
lower risk North Bristol NHS Trust appointed
a TIA co-ordinator as a single
• A single point of contact simplifies point of referral to ensure timely
the referral process for the referrer, is and efficient booking of patients,
more efficient for coordinating the according to ABCD2 prioritisation.
service and data collection can begin This is particularly efficient if
at one entry point appointments are given to
• A simple clear referral proforma is patients while still with the
essential and needs to: referrer, reducing any time delay
• be appropriate to the referrer in contacting the patient.
• highlight the pathway
• aid diagnosis (clear information for Tailor the weekend service to local
ABCD2 assessment) needs and demands
• give essential information for Employ a comprehensive
patients. communication strategy • Work with commissioners to achieve
a properly funded service from the
• Raising the awareness in primary outset
CASE STUDY • Understand the projected numbers
care, ambulance service, A&E and
any other referral points of the TIA for your local population in order to
Surrey and Sussex Healthcare develop the most cost effective way
NHS Trust implemented a pathway is essential
• This supports implementation of the of providing the service
dedicated TIA bleep holder to • A seven day service ensures a
take all calls. This has been shown pathway and ensures patients enter
the right pathway of care as soon as backlog free Monday for both
to be an effective method of assessment and imaging
referral and popular; GPs say that possible
• It should emphasise the importance • Getting patients to attend at
this sort of access is exactly what weekends is rarely a problem – no
they want. This system also of early referral and enable
education in the ABCD2 score more than during the week when
ensures an ABCD2 score is asked to attend at short notice
included in the referral and ensuring appropriate referrals and
effective triage • Educate staff on the clinical benefits
reduces inappropriate referrals. of providing a seven day service.
• The communication strategy should
be an ongoing plan with regular
follow up.
CASE STUDY
CASE STUDY
Doncaster Royal Infirmary
provided a fax and dedicated North West London Cardiovascular and Stroke Network created a
phone on the acute stroke unit communication plan to improve the awareness of TIA in primary care and
that is checked 24/7 enabling support the consistency of approach to TIA diagnosis and referral. This is
rapid response by skilled staff. now being replicated in North Central London.

2. NHS
NHS Improvement
Evidence is emerging that not all sites CASE STUDY • Nurses, whether in the acute setting
will be able to sustain a weekend service or in the community, are ideally placed
and alternative models need to be North Bristol NHS Trust provides to deliver the service
considered. Many of the sites currently the weekend high risk TIA service • There should be a clear rapid pathway
sustaining a weekend service cover for the Bristol, North Somerset back into the acute TIA service and to
populations of around 800,000 to one and South Gloucestershire health carotid intervention if required
million, although there are exceptions to community. • There should be a standard process
this. This suggests that many trusts will agreed locally with core content to be
need to work in partnership to deliver covered by all providers. This should
sustainable comprehensive weekend include:
services. Interest is also developing in the CASE STUDY • Secondary prevention – medicines
use of telemedicine to deliver weekend management, blood pressure,
services. Models emerging include: Northampton General Hospital lifestyle (diet, exercise, smoking)
NHS Trust provides the weekend • Education and information, including
• Stand alone one site serving their own service for Northampton, use of the FAST test
local population Kettering and Milton Keynes. • Clear instructions on driving
• Network wide solutions, where hyper • Point of contact and handover to
acute centres provide weekend the GP
services based on thrombolysis cover Develop a sustainable data and audit • Emotional and psychological
• Multi site trusts, where only one site system issues.
operates or the site rotates at
weekends • This is essential for taking the service The availability of a specialist follow up
• Partnership with neighbouring trusts forward, developing business cases, review following a TIA is an integral part
showing outcomes and return on of the best practice tariff for TIA.
investment
CASE STUDY
• Electronic audit tools standardise note
keeping and letters to GPs, and gather CASE STUDY
University Hospitals of Leicester
NHS Trust and University audit data that is reliable and easy to
use Oxford Radcliffe Hospitals NHS
Hospitals Coventry and Trust and The Royal Bournemouth
Warwickshire NHS Trust provide • Robust data collection and continuous
ongoing audit enables the service to and Christchurch Hospitals NHS
comprehensive seven day services Foundation Trust both provide
for local catchment areas. be altered quickly when problems arise.
follow up within the acute setting
by a nurse specialist.
CASE STUDY
CASE STUDY
University Hospitals of Leicester
North West London NHS Trust, Surrey and Sussex CASE STUDY
Cardiovascular and Stroke Healthcare NHS Trust, North
Network, the two hyper acute Bristol NHS Trust and Lancashire Avon, Gloucestershire, Wiltshire
stroke centres in north west Teaching Hospitals NHS and Somerset Cardiac and Stroke
London provide the weekend TIA Foundation Trust have all Network have developed
service which is provided by six developed robust data and audit standards for TIA follow up in
sites Monday to Friday systems primary care.
CASE STUDY Provide access to specialist follow up CASE STUDY
for all TIA patients
East Kent Hospitals University
The Royal Wolverhampton
NHS Foundation Trust based on • This can be provided in various settings Hospitals NHS Trust use band 7
three sites delivers a TIA service and by various professionals but community stroke coordinators to
Monday to Friday on each site should have a specialist element based deliver one month TIA reviews in
with the weekend service on clinical knowledge and agreed a community setting.
delivered at one site on a rotating competencies
basis.

3. NHS
NHS Improvement
Agree a pathway for timely access to
carotid intervention
• Agree and communicate a pathway
between the stroke team, imaging and
vascular team that covers seven days a
week
• Understand where delays are in the
pathway from symptom onset to
intervention
• An intensive therapy unit or high
dependency unit bed is not an
essential requirement for undertaking
carotid endarterectomy. Handover of
the patient from theatre to recovery to
a ward with appropriately skilled staff
is the key
• It is important to have an anaesthetist
who is familiar with the procedure and
has experience and expertise in
anaesthesia for vascular surgery
• Good information for the patient
should be available explaining risks,
CASE STUDY
side effects and benefits.
East Kent Hospitals University
All patients requiring carotid intervention NHS Foundation Trust
following a TIA should have the implemented the Rapid Access
procedure within 14 days of onset as an Carotid Endarterectomy (RACE)
absolute maximum as detailed in the programme in 2008 which takes
NICE guidelines1, with providers working referrals direct from the seven
towards the 48 hours ideal as stated in day TIA clinics.
the National Stroke Strategy. Further
work to support services in providing
timely access to carotid intervention is
ongoing and updates will be available on
the NHS Improvement website. Data on high risk TIA patients is
collected by all trusts as a DH
Integrated Performance
CASE STUDY Measure (IPMR). There is a new
treatment function code for TIA
University College London that supports the best practice
Hospitals NHS Foundation Trust tariff for TIA.
has written a protocol for the
management of chronic stenosis
in patients with TIA or minor For more information and case
stroke with a clear pathway for studies, please visit the NHS
weekday and weekend referrals. Improvement website:
www.improvement.nhs.uk/stroke
1 Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA),
National Institute for Health and Clinical Excellence clinical guideline 68, 2008

4. NHS
NHS Improvement
PRACTICAL PRINCIPLES
focus on TIA imaging
1. Review and streamline the existing imaging pathway
2. Involve all members of the team
3. Train imaging staff in imaging for TIA
4. Introduce simple changes in imaging departments to ensure
best practice
Review and streamline the existing Involve all members of the team CASE STUDY
imaging pathway
• Involve all members of the team who Royal Devon and Exeter NHS
• Review working patterns for imaging have input into the TIA pathway as Foundation Trust have trained
teams, including extended days and often you are not aware of how the their stroke nurse practitioners to
weekend working pathway works outside of your own undertake carotid screening.
• In areas where there are significant department (stroke unit or radiology
capacity/staffing issues look at department)
alternative examinations where slots • Encourage attendance at
are more readily available i.e. MRA or multidisciplinary meetings so all staff CASE STUDY
CTA working within the pathway can raise
• Due to capacity issues within the MRI and discuss issues and look at new University Hospitals of Leicester
department, short sequence MRI scans ways of working. NHS Trust introduced a specialist
have been developed TIA service with access to both
• MRI questionnaires and cannulation (if carotid doppler and MRI.
required) can be carried out by CASE STUDY
departmental assistants prior to
scanning The Great Western Hospitals NHS
• The introduction of a dedicated TIA Foundation Trust implemented a Introduce simple changes in imaging
service with linked appointments will new TIA imaging booking system departments to ensure best practice
significantly reduce the patient to complement the new TIA
pathway. service. • Review the booking process –
appointments linked to clinic times can
significantly reduce the patient
CASE STUDY pathway
Train imaging staff in imaging for TIA • Sign up to a digital image transfer
Salford Royal NHS Foundation system so diagnostic information can
Trust implemented a seven day • Review the skill mix available and be shared effectively and safely
TIA service using ultrasound identify areas for training between trusts
Monday to Friday, and MRI at • Due to the shortage of sonographers, • Use the best practice tariff for TIA.
weekends. many trusts are looking to other health
care professionals to undertake Two publications are available to
scanning. This can include vascular support access to imaging for TIA:
technicians, nurse practitioners and
CASE STUDY stroke doctors • ‘Why treat stroke and transient
• Review other areas of ultrasound. For
ischaemic attacks (TIAs) as
Central Manchester University example, can obstetrics be run by
emergencies?’
Hospitals NHS Foundation Trust midwives, which frees up
• ‘A guide to achieving changes in
has introduced short sequence sonographers for more complex
examinations? imaging services to support new
MRI scans, with the total scan
stroke pathways’
time reduced to three minutes.
To access the above publication
and for more information and case
studies, please visit the NHS
Improvement website:
ACCELERATING
www.improvement.nhs.ukdiagnostics
STROKE IMPROVEMENT