Stroke and TIA Care Pathways

1
Stroke and TIA Care Pathways

• Martyn Wake
• Joint Medical Director
• Sutton Merton PCT

2
Stroke in the community

• 2.4 per 1000 have new stroke annually
• 2 per thousand new strokes age 55-64
• 20 per thousand have aged over 85
• 5-7 per thousand have had a stroke
• In a PCT covering population of 380,000 there
  will be 900 strokes per year
• Stroke consumes 5 of NHS resources

3
Older peoples NSF

• Identify those at greatest risk of stroke
• Improve identification of those at risk
• Intervene effectively to reduce risks
• Agree protocols for rapid referral after TIA
• Review hospital stroke services
• Establish integrated stroke care services.

4
NSF Milestones April 2004PCTs

• PCTs ensure that GPs,using protocols can identify
  and treat those at high risk of stroke
• GPs use locally agreed protocol for rapid
  referral of patients with TIA
• Every General Practice able to identify stroke
  patients and ensure their treatment according to
  locally agreed protocols
• GPs have established clinical audit sytems for
  stroke

5
Clinical Areas of Quality and Outcomes Framework

• Epilepsy-16
• Asthma-72
• COPD-45
• Mental health-41
• Cancer-12

• CHD and LVD-121
• Hypertension-105
• DM-99
• Stroke or TIA-31
• Hypothyroidism-8

6
Indicators common to CHD,Stroke,hypertension,
diabetes

• Smoking status and cessation advice(all)
• Blood pressure recorded (all)
• Target BP achieved 150/90 (145/85 in diabetics)
• Total cholesterol measured(except hypertension)
• Total cholesterol 5.0 mmol/l or less (except
  hypertension)

7
Primary prevention

• Lifestyle factors such as weight and diet
• Exercise promotion
• Smoking cessation support
• Salt intake
• Alcohol consumption
• Diabetic control
• Anticoagulate in atrial fibrillation whenever
  possible (and consider cardioversion)

8
Blood pressure control

• Identify hypertension and treat according to
  guidelines
• Diastolic reduction of 5mm Hg reduces risk by 34
• Systolic reduction of 10 mm Hg reduces risk by 28

9
Stroke management in primary care

• Initial assessment and decision to admit or not
• FBC,ESR,BS,EU,LFTs,Lipids,MSU,ECG,CXR
• CT scan (via neuro-vascular clinic)
• Carotid US (via neuro-vascular clinic)
• Echo-if associated heart disease

10
Admission

• All stroke patients who have not made good
  recovery in community
• Multiple TIAs
• Urgent investigation required for some patients
  e.g. haemorrhage
• Significant disability
• Complicating medical problems
• Home care difficult

11
Non admission

• Some TIAs and strokes can be managed without
  admission
• All TIAs and nearly all strokes require
  assessment in neuro-vascular clinic within one
  week
• Patients with terminal prognosis may prefer home
  management

12
Rehabilitation

• Through integrated specialised multidisciplinary
  teams in hospital and in community
• Increasing integration with social services
• Growing emphasis on services closer to home
• Involvement of carers
• Involvement of expert patients