Download CAT TIA Stroke

CLINICAL AUDIT TOOL:
Initial Assessment and
Management of
Transient Ischaemic
Attack / Stroke
Introduction
This clinical audit tool addresses the initial assessment and management of transient
ischaemic attack (TIA) by an individual GP in the primary care setting.
It draws on best practice guidance summarised in the New Zealand Primary Care Handbook
2102 from the following source guidelines:

New Zealand Guideline for the Assessment and Management of People with Recent
Transient Ischaemic Attack (2008)

New Zealand Guidelines for Stroke Management (2010).
See http://www.health.govt.nz/publication/new-zealand-primary-care-handbook-2012 for
further content from the Handbook.
TOPIC
Initial Assessment and Management of TIA / Stroke
Why is this topic of interest or concern?
 Stroke is a major cause of disability.
 Urgent assessment and intervention reduces the risk of
stroke after TIA.
Key data reported in the New Zealand Guidelines for Stroke Management (2010):

Stroke is the third greatest cause of death in New Zealand after cancer and
heart disease.

Most strokes are not fatal and the major burden of stroke is chronic
disability. There are about 32000 people currently living in New Zealand
with stroke; only 30% of them are independent in activities of daily living.

Most of the burden of stroke in Māori and Pacific people in New Zealand is
in the under 65 year age group.

Mean age at first stroke is 61 years for Māori, 65 years for Pacific people
and 76 years for New Zealand Europeans.
The New Zealand Guideline for the Assessment and Management of People with
Recent Transient Ischaemic Attack (2008) emphasises:

TIA should be managed as a medical emergency

all people with suspected TIA should be assessed at initial point of health
care contact for their risk of stroke

the risk of stroke can be as high as 12% at 7 days and 20% at 90 days;
about half of these strokes will occur within the first 48 hours after TIA.

rapid access to appropriate specialist assessment and investigations is
needed to reduce the risk of subsequent stroke. This should be urgent
(within 24 hours) for those at high risk and within 7 days for those at low
risk. If the treating doctor is confident of the diagnosis of TIA, has ready
access to brain and carotid imaging and can initiate treatment, specialist
review may not be required.
2
PLAN
Indicators
(elements of practice performance to be measured)
The practice effectively manages patients with suspected TIA when first seen in
primary care
1.
Assessment of stroke risk: patients with suspected TIA are assessed at initial
point of health care contact for their risk of stroke.
2.
Referral for specialist assessment or investigations is made within appropriate
timelines and with appropriate urgency.
3.
Initial assessment at first health care contact includes a thorough history and
clinical, prognostic and investigative tests.
4.
Patients with residual neurological symptoms at time of first contact are
managed for acute stroke.
5.
Secondary prevention measures are initiated at first health care contact as
appropriate.
6.
Follow-up occurs within 1 month (in primary or secondary care) to review
secondary prevention measures.
Criteria
1.
(how the indicator will be measured)
Stroke risk is assessed in a patient presenting with a TIA.
Patients are categorised as high risk or low risk of stroke.
High risk: ABCD2 score of 4 or more; crescendo TIAs; atrial fibrillation;
taking anticoagulants.
Low risk: ABCD2 score of less than 4; present more than 1 week after TIA
symptoms.
See Appendix for ABCD2 tool.
2.
Referral for specialist assessment or investigations is made for a person
presenting with TIA as appropriate according to stroke risk and clinical
assessment:
Urgent referral (within 24 hours) for those at high risk of stroke
Within 7 days for those at low risk of stroke.
If the treating doctor is confident of the diagnosis of TIA, has ready access
to brain and carotid imaging and can initiate treatment, specialist review
may not be required.
Note re. timeframes for brain and carotid imaging:
Brain imaging (preferably MRI) is arranged:
Urgently (immediately if available but within 24 hrs) for those classified as high risk
of stroke (see 1 above)
Within 7 days for those classified as low risk of stroke (see 1 above).
Carotid imaging is arranged:
Urgently (within 24 hrs) for those with carotid artery symptoms who would
potentially be candidates for carotid revascularisation
Within 7 days (if indicated) for those classified as low risk of stroke.
3.
Routine investigations are completed at initial point of health care contact
including: full blood count, electrolytes, ESR, renal function tests, lipid
profile, glucose level and ECG.
3
4.
Diagnosis of TIA confirmed by history and findings on initial assessment.
Rapid recovery of neurological symptoms, usually within 30 minutes, is
expected with TIA.
Manage for acute stroke if ANY residual symptoms or signs at time of
assessment.
Acute stroke management:
Urgent referral to specialist care. Same day admission to hospital
recommended for all patients. Possible exception where a palliative
approach deemed appropriate for the individual patient.
Immediate transfer to hospital for patients seen within 4.5 hours of
symptom onset as may be candidates for stroke thrombolysis.
Brain imaging (urgent CT or MRI) immediately if available but within 24
hrs.
5.
Stroke secondary prevention medications commenced immediately in all
patients who have fully recovered.
Treatment addresses risk factors: antiplatelet agent/s, blood pressure
lowering therapy, statin, nicotine replacement therapy or other smoking
cessation aid.
Exception is anticoagulation therapy (requires brain imaging prior to
commencement).
[Note – brain imaging and initiation of anticoagulation therapy is often
undertaken in the secondary care setting.]
6.
Follow-up 1 month after initial health care contact is arranged for review
of medication and other risk factor modification.
Standards
(the standards to be achieved)
Note that the focus is on improving standards of clinical practice, with 80%
achievement identified by the RNZCGP as an appropriate target and 100% as an
ideal. Individual GPs and practices may choose to set a differing target for a first or
subsequent audit/s, with a view to increasing standards over time.
1.
Patients are assessed for stroke risk (standard: 80%). Patient notes record
assessed risk of stroke and reason for risk category (80% of records).
2.
Need for referral is considered (standard: 80%) Patient notes record why
referral not indicated if not made (80% of records). Referral is made within
the recommended timeframe for patients referred (standard: 80%)
3.
Routine investigations completed [(or arranged) at first contact for 80% of
patients.
4.
Patients with residual neurological symptoms managed for acute stroke
(standard: 80%).
5.
Clinical records indicate secondary prevention measures commenced: 1) at
time of initial assessment (80%); 2) take into account individual risk factors
(80%).
6.
Patients are seen for follow-up in 1 month (80% of patients). (This may be
in secondary care.)
4
DO
Discover what you are doing now

(collect data)
Identify patients with a diagnosis of TIA/stroke in a specific (selected) time
period (in a smaller practice a longer time period will be needed to obtain
sufficient cases).

Select all cases where initial history or symptoms documented is consistent
with suspected TIA – aim for at least 10 cases.

Review patient notes using Case Review: Individual Patient Record Sheet
(following page).
STUDY
Next steps: what do the results tell you

(interpret the data)
Collate the data from individual patients according to the standards set and
compile a brief summary for each indicator
ACT

What are you doing well?

What needs improving?

What gaps between standards and performance do you want to close?

Identify possible solutions
Make changes – what changes can be made to
improve patient care?
Write an action plan

Choose one or two achievable goals

Identify any barriers and enablers to change e.g. resources, skills, IT

Decide what needs to be done and by when

Plan a review date to follow up on changes
Implement changes
Monitor change and progress

Review your action plan to see if you are keeping to timeline for implementing
change

Monitor to see if actions are taking place

Solve problems as they arise

Obtain qualitative feedback from staff and patient about the improvement/s

Consider whether you need to develop new strategies to achieve the goals you
have set
5
APPENDIX
Table 1: ABCD2 score: assessment of stroke risk
HIGH RISK: Scores ≥4
LOW RISK: Scores <4
ABCD2 items (score 0-7)
Points
A
Age: ≥60 years
1
B
Blood pressure: ≥140/90 mm Hg
1
C
Clinical features:
D
D
Unilateral weakness; or
2
Speech impairment without weakness
1
Duration of symptoms:
≥60 minutes; or
2
10-59 minutes
1
Diabetes: (on medication/insulin)
1
Source: Johnston SC et al. Lancet 2007:369:283-292. Reproduced from the New
Zealand Primary Care Handbook 2012.
6
Clinical Audit Tool: Initial Assessment and
Management of TIA/Stroke
Patient Record Review Sheet
Date:_______
Patient 1 (add initials/NHI):
1.
Stroke risk assessed
Clinical notes
Clinical notes record assessed risk
state/suggest stroke
for stroke and reason for risk
risk assessed?
category (high risk vs low risk)?
Yes/No/Don’t know
Yes/No
2.
Referral
Clinical notes
Referral (if made)
Clinical notes
state/suggest
is within
record why referral
referral considered?
recommended
not indicated (if
timeframe?
not made)?
Yes/No
Yes/No
Yes/No/Don’t know
3.
Comments
Routine investigations completed?
Circle if done:
Comments
FBC electrolytes ESR RFTs lipid profile glucose level
4.
Comments
ECG
Residual symptoms
Patient had residual
If yes, patient was managed for
symptoms on initial
acute stroke?
Comments
assessment?
Yes/No
5.
Yes/No
Secondary prevention measures
Secondary
Secondary prevention measures initiated at
prevention
time of assessment address all relevant risk
measures
factors:
initiated at
Antiplatelet agent/s
time of
Blood pressure lowering therapy Yes/No/NA
assessment?
Statin Yes/No/NA
Comments
Yes/No/NA
NRT or other smoking cessation aid
Yes/No
Yes/No/NA
Anticoagulation therapy - if indicated (see
p.75 of Primary Care Handbook 2012)and
following brain imaging Yes/No/NA
If commenced in secondary care, ‘handover’
of treatment appropriate Yes/No/NA
6.
Follow up
Seen for follow-up in 1 month?
Comments
Yes/No
7
Patient 2 (add initials/NHI):
7.
Stroke risk assessed
Clinical notes
Clinical notes record assessed risk for
state/suggest stroke
stroke and reason for risk category
risk assessed?
(high risk vs low risk)?
Yes/No/Don’t know
Yes/No
8.
Referral
Clinical notes
Referral (if made)
Clinical notes
state/suggest
is within
record why referral
referral considered?
recommended
not indicated (if
timeframe?
not made)?
Yes/No
Yes/No
Yes/No/Don’t know
9.
Comments
Comments
Routine investigations completed?
Circle if done:
Comments
FBC electrolytes ESR RFTs lipid profile glucose level
ECG
10. Residual symptoms
Patient had residual
If yes, patient was managed for
symptoms on initial
acute stroke?
Comments
assessment?
Yes/No
Yes/No
11. Secondary prevention measures
Secondary
Secondary prevention measures initiated at
prevention
time of assessment address all relevant risk
measures
factors:
initiated at
Antiplatelet agent/s
time of
Blood pressure lowering therapy Yes/No/NA
assessment?
Statin Yes/No/NA
Comments
Yes/No/NA
NRT or other smoking cessation aid
Yes/No
Yes/No/NA
Anticoagulation therapy - if indicated (see pg
75 of Primary Care Handbook 2012)and
following brain imaging Yes/No/NA
If commenced in secondary care, ‘handover’
of treatment appropriate Yes/No/NA
12. Follow up
Seen for follow-up in 1 month?
Comments
Yes/No
8
Patient 3 (add initials/NHI):
13. Stroke risk assessed
Clinical notes
Clinical notes record assessed risk
state/suggest stroke
for stroke and reason for risk
risk assessed?
category (high risk vs low risk)?
Yes/No/Don’t know
Yes/No
Comments
14. Referral
Clinical notes
Referral (if made)
Clinical notes
state/suggest
is within
record why referral
referral considered?
recommended
not indicated (if
timeframe?
not made)?
Yes/No
Yes/No
Yes/No/Don’t know
Comments
15. Routine investigations completed?
Circle if done:
Comments
FBC electrolytes ESR RFTs lipid profile glucose level
ECG
16. Residual symptoms
Patient had residual
If yes, patient was managed for
symptoms on initial
acute stroke?
Comments
assessment?
Yes/No
Yes/No
17. Secondary prevention measures
Secondary
Secondary prevention measures initiated at
prevention
time of assessment address all relevant risk
measures
factors:
initiated at
Antiplatelet agent/s
time of
Blood pressure lowering therapy Yes/No/NA
assessment?
Statin Yes/No/NA
Comments
Yes/No/NA
NRT or other smoking cessation aid
Yes/No
Yes/No/NA
Anticoagulation therapy - if indicated (see pg
75 of Primary Care Handbook 2012)and
following brain imaging Yes/No/NA
If commenced in secondary care, ‘handover’
of treatment appropriate Yes/No/NA
18. Follow up
Seen for follow-up in 1 month?
Comments
Yes/No
9
Patient 4 (add initials/NHI):
19. Stroke risk assessed
Clinical notes
Clinical notes record assessed risk
state/suggest stroke
for stroke and reason for risk
risk assessed?
category (high risk vs low risk)?
Yes/No/Don’t know
Yes/No
Comments
20. Referral
Clinical notes
Referral (if
Clinical notes
state/suggest referral
made) is within
record why referral
considered?
recommended
not indicated (if
timeframe?
not made)?
Yes/No
Yes/No
Yes/No/Don’t know
Comments
21. Routine investigations completed?
Circle if done:
Comments
FBC electrolytes ESR RFTs lipid profile glucose level
ECG
22. Residual symptoms
Patient had residual
If yes, patient was managed for
symptoms on initial
acute stroke?
Comments
assessment?
Yes/No
Yes/No
23. Secondary prevention measures
Secondary
Secondary prevention measures initiated at
prevention
time of assessment address all relevant risk
measures
factors:
initiated at
Antiplatelet agent/s
time of
Blood pressure lowering therapy Yes/No/NA
assessment?
Statin Yes/No/NA
Comments
Yes/No/NA
NRT or other smoking cessation aid
Yes/No
Yes/No/NA
Anticoagulation therapy - if indicated (see pg
75 of Primary Care Handbook 2012)and
following brain imaging Yes/No/NA
If commenced in secondary care, ‘handover’
of treatment appropriate Yes/No/NA
24. Follow up
Seen for follow-up in 1 month?
Comments
Yes/No
10
Patient 5 (add initials/NHI):
25. Stroke risk assessed
Clinical notes
Clinical notes record assessed risk
state/suggest stroke
for stroke and reason for risk
risk assessed?
category (high risk vs low risk)?
Yes/No/Don’t know
Yes/No
Comments
26. Referral
Clinical notes
Referral (if
Clinical notes
state/suggest referral
made) is within
record why referral
considered?
recommended
not indicated (if
timeframe?
not made)?
Yes/No
Yes/No
Yes/No/Don’t know
Comments
27. Routine investigations completed?
Circle if done:
Comments
FBC electrolytes ESR RFTs lipid profile glucose level
ECG
28. Residual symptoms
Patient had residual
If yes, patient was managed for
symptoms on initial
acute stroke?
Comments
assessment?
Yes/No
Yes/No
29. Secondary prevention measures
Secondary
Secondary prevention measures initiated at
prevention
time of assessment address all relevant risk
measures
factors:
initiated at
Antiplatelet agent/s
time of
Blood pressure lowering therapy Yes/No/NA
assessment?
Statin Yes/No/NA
Comments
Yes/No/NA
NRT or other smoking cessation aid
Yes/No
Yes/No/NA
Anticoagulation therapy - if indicated (see pg
75 of Primary Care Handbook 2012)and
following brain imaging Yes/No/NA
If commenced in secondary care, ‘handover’
of treatment appropriate Yes/No/NA
30. Follow up
Seen for follow-up in 1 month?
Comments
Yes/No
11
Patient 6 (add initials/NHI):
31. Stroke risk assessed
Clinical notes
Clinical notes record assessed risk
state/suggest stroke
for stroke and reason for risk
risk assessed?
category (high risk vs low risk)?
Yes/No/Don’t know
Yes/No
Comments
32. Referral
Clinical notes
Referral (if made)
Clinical notes
state/suggest
is within
record why referral
referral considered?
recommended
not indicated (if
timeframe?
not made)?
Yes/No
Yes/No
Yes/No/Don’t know
Comments
33. Routine investigations completed?
Circle if done:
Comments
FBC electrolytes ESR RFTs lipid profile glucose level
ECG
34. Residual symptoms
Patient had residual
If yes, patient was managed for
symptoms on initial
acute stroke?
Comments
assessment?
Yes/No
Yes/No
35. Secondary prevention measures
Secondary
Secondary prevention measures initiated at
prevention
time of assessment address all relevant risk
measures
factors:
initiated at
Antiplatelet agent/s
time of
Blood pressure lowering therapy Yes/No/NA
assessment?
Statin Yes/No/NA
Comments
Yes/No/NA
NRT or other smoking cessation aid
Yes/No
Yes/No/NA
Anticoagulation therapy - if indicated (see pg
75 of Primary Care Handbook 2012)and
following brain imaging Yes/No/NA
If commenced in secondary care, ‘handover’
of treatment appropriate Yes/No/NA
36. Follow up
Seen for follow-up in 1 month?
Comments
Yes/No
12
Patient 7 (add initials/NHI):
37. Stroke risk assessed
Clinical notes
Clinical notes record assessed risk
state/suggest stroke
for stroke and reason for risk
risk assessed?
category (high risk vs low risk)?
Yes/No/Don’t know
Yes/No
Comments
38. Referral
Clinical notes
Referral (if made)
Clinical notes
state/suggest
is within
record why referral
referral considered?
recommended
not indicated (if
timeframe?
not made)?
Yes/No
Yes/No
Yes/No/Don’t know
Comments
39. Routine investigations completed?
Circle if done:
Comments
FBC electrolytes ESR RFTs lipid profile glucose level
ECG
40. Residual symptoms
Patient had residual
If yes, patient was managed for
symptoms on initial
acute stroke?
Comments
assessment?
Yes/No
Yes/No
41. Secondary prevention measures
Secondary
Secondary prevention measures initiated at
prevention
time of assessment address all relevant risk
measures
factors:
initiated at
Antiplatelet agent/s
time of
Blood pressure lowering therapy Yes/No/NA
assessment?
Statin Yes/No/NA
Comments
Yes/No/NA
NRT or other smoking cessation aid
Yes/No
Yes/No/NA
Anticoagulation therapy - if indicated (see pg
75 of Primary Care Handbook 2012)and
following brain imaging Yes/No/NA
If commenced in secondary care, ‘handover’
of treatment appropriate Yes/No/NA
42. Follow up
Seen for follow-up in 1 month?
Comments
Yes/No
13
Patient 8 (add initials/NHI):
43. Stroke risk assessed
Clinical notes
Clinical notes record assessed risk
state/suggest stroke
for stroke and reason for risk
risk assessed?
category (high risk vs low risk)?
Yes/No/Don’t know
Yes/No
Comments
44. Referral
Clinical notes
Referral (if made)
Clinical notes
state/suggest
is within
record why referral
referral considered?
recommended
not indicated (if
timeframe?
not made)?
Yes/No
Yes/No
Yes/No/Don’t know
Comments
45. Routine investigations completed?
Circle if done:
Comments
FBC electrolytes ESR RFTs lipid profile glucose level
ECG
46. Residual symptoms
Patient had residual
If yes, patient was managed for
symptoms on initial
acute stroke?
Comments
assessment?
Yes/No
Yes/No
47. Secondary prevention measures
Secondary
Secondary prevention measures initiated at
prevention
time of assessment address all relevant risk
measures
factors:
initiated at
Antiplatelet agent/s
time of
Blood pressure lowering therapy Yes/No/NA
assessment?
Statin Yes/No/NA
Comments
Yes/No/NA
NRT or other smoking cessation aid
Yes/No
Yes/No/NA
Anticoagulation therapy - if indicated (see pg
75 of Primary Care Handbook 2012)and
following brain imaging Yes/No/NA
If commenced in secondary care, ‘handover’
of treatment appropriate Yes/No/NA
48. Follow up
Seen for follow-up in 1 month?
Comments
Yes/No
14
Patient 9 (add initials/NHI):
49. Stroke risk assessed
Clinical notes
Clinical notes record assessed risk
state/suggest stroke
for stroke and reason for risk
risk assessed?
category (high risk vs low risk)?
Yes/No/Don’t know
Yes/No
Comments
50. Referral
Clinical notes
Referral (if made)
Clinical notes
state/suggest
is within
record why referral
referral considered?
recommended
not indicated (if
timeframe?
not made)?
Yes/No
Yes/No
Yes/No/Don’t know
Comments
51. Routine investigations completed?
Circle if done:
Comments
FBC electrolytes ESR RFTs lipid profile glucose level
ECG
52. Residual symptoms
Patient had residual
If yes, patient was managed for
symptoms on initial
acute stroke?
Comments
assessment?
Yes/No
Yes/No
53. Secondary prevention measures
Secondary
Secondary prevention measures initiated at
prevention
time of assessment address all relevant risk
measures
factors:
initiated at
Antiplatelet agent/s
time of
Blood pressure lowering therapy Yes/No/NA
assessment?
Statin Yes/No/NA
Comments
Yes/No/NA
NRT or other smoking cessation aid
Yes/No
Yes/No/NA
Anticoagulation therapy - if indicated (see pg
75 of Primary Care Handbook 2012)and
following brain imaging Yes/No/NA
If commenced in secondary care, ‘handover’
of treatment appropriate Yes/No/NA
54. Follow up
Seen for follow-up in 1 month?
Comments
Yes/No
15
Patient 10 (add initials/NHI):
55. Stroke risk assessed
Clinical notes
Clinical notes record assessed risk
state/suggest stroke
for stroke and reason for risk
risk assessed?
category (high risk vs low risk)?
Yes/No/Don’t know
Yes/No
Comments
56. Referral
Clinical notes
Referral (if made)
Clinical notes
state/suggest
is within
record why referral
referral considered?
recommended
not indicated (if
timeframe?
not made)?
Yes/No
Yes/No
Yes/No/Don’t know
Comments
57. Routine investigations completed?
Circle if done:
Comments
FBC electrolytes ESR RFTs lipid profile glucose level
ECG
58. Residual symptoms
Patient had residual
If yes, patient was managed for
symptoms on initial
acute stroke?
Comments
assessment?
Yes/No
Yes/No
59. Secondary prevention measures
Secondary
Secondary prevention measures initiated at
prevention
time of assessment address all relevant risk
measures
factors:
initiated at
Antiplatelet agent/s
time of
Blood pressure lowering therapy Yes/No/NA
assessment?
Statin Yes/No/NA
Comments
Yes/No/NA
NRT or other smoking cessation aid
Yes/No
Yes/No/NA
Anticoagulation therapy - if indicated (see pg
75 of Primary Care Handbook 2012)and
following brain imaging Yes/No/NA
If commenced in secondary care, ‘handover’
of treatment appropriate Yes/No/NA
60. Follow up
Seen for follow-up in 1 month?
Comments
Yes/No
16
RNZCGP Summary Sheet
Continuous Quality Improvement (CQI) Activity
Topic:
Initial Assessment and Management of
TIA/Stroke
Doctor's name:
_____________________________________________________________________
First cycle
Data: Date of data collection:
Check: Describe any areas targeted for improvement as a result of analysing the data
collected.
Action: Describe how these improvements will be implemented.
Monitor: Describe how well the process is working. When will you undertake a second
cycle?
17
Second cycle
Data: Date of data collection:
Check: Describe any areas targeted for improvement as a result of analysing the data
collected.
Action: Describe how these improvements will be implemented.
Monitor: Describe how well the process is working.
Comments:
18