Stroke care seven days a week – improving outcomes for patients, co-ordinating the Stroke imaging pathway - 365 day rapid-access one-stop TIA clinic - Dr David Eveson - presentation from the seven day services in diagnostics event held on 4 March 2013 #7dayDiagnostics

1. Stroke care seven days a week – improving
outcomes for patients, co-ordinating the Stroke
imaging pathway
365 day rapid-access one-stop TIA clinic
“NHS Improvement - Equality for all.
Delivering safe care -seven days a week” - Sept 2011
Dr David Eveson
Consultant in Stroke Medicine
University Hospitals Leicester

2. What is a TIA and why is it important to manage
rapidly?
• ‘Heralding’ event
• Half of TIA patients have a
2-day stroke risk 6-10%
• Immediate versus late
treatment, reduction of
stroke recurrence by 80%
(EXPRESS Study)
Rothwell PM et al. Lancet 2007. 370, 1432-42

3. What is a TIA and why is it important to manage
rapidly?
• Specialist services:
– Confirm diagnosis
– Conduct full assessment of
stroke risk
• Carotid imaging (duplex US)
• Brain imaging (MRI)
– Initiate tailored treatment
• Antiplatelet / Anticoagulant
• Antihypertensive
• Lipid lowering
• Lifestyle intervention
• Carotid endarterectomy

4. Incentives for 7 day service provision
• Quality of care
– Improved patient outcomes
– What service would you or a relative wish to access?
– Two-tier services no longer acceptable (7-day society)
• Financial
– Best practice tariff
• Core
– access to a 7-day service - £477 (versus £133)
• Supplementary
– Investigate and treat higher-risk patients within 24 hours £97
– MRI for brain imaging - £72
– Every stroke prevented saves £23,315 (NAO 1st year costs)

5. The Leicester model
• <2007
– No system
– Imaging took several weeks
• >2007
– Combined business case for Acute Stroke and TIA services
– Capital – PCT (revenue funding support) and acute trust
– Local tariff negotiated (now superseded)
TIA Vital Sign (Integrated Performance Measure)
Percentage of Transient Ischaemic Attack (TIA) cases with a higher
risk of stroke who are treated within 24 hours
Q3 2008/9 Q4 2010/11
Leicester City 33% 70%
Leicester County 13% 70%

6. The Leicester model
• Imaging
– Brain
• Costing prepared by radiology department in accordance with National
Stroke Strategy – an imaging guide (2008)
• 3.5 wte Band 6 Radiographers
• 3.0 wte Band 3 RDA
• 1.0 wte Band 2 Porters
– 5-day MRI, 2-day CT initially, now 7-day MRI
– Carotid
• Vascular scientists attached to vascular surgery department
• Permanent weekend staffing (management of change, not overtime)
• Weekend pay enhancement plus time back during week
• Locate scanner in TIA clinic and use it for in-patient scans

7. Ongoing challenges
200
180
160
140
120
100
Number of patients
High-risk percentage
80
60
40
20
0
An ever increasing number of referrals to the TIA clinic?

8. Ongoing challenges and solutions
• Appointment saturation (Parkinson’s law?)
– Increase the number of appointments
– Utilise taxis instead of NHS transport
– Electronic referral system including ‘intelligent booking’ and user
feedback
• 7-day TIA services elsewhere
– Not a one size fits all solution
– TIA incidence 0.5/1000 per annum
– Combine populations
– Weekend ward rounds
– Tele-medicine/radiology