Specifying a service for the diagnosis and initial management of transient ischaemic attack and non-disabling stroke

Service components

The key components of a service for the diagnosis and initial management of transient ischaemic attack (TIA) and non-disabling stroke are:

• prompt recognition and diagnosis of TIA and non-disabling stroke
• specialist assessment and investigation
• developing a high-quality service for the diagnosis and initial management of TIA and non-disabling stroke.

Prompt recognition and diagnosis of TIA and non-disabling stroke

The recognition and diagnosis of TIA and stroke is described in NICE clinical guideline CG68 on stroke. Commissioners will need to work in partnership with ambulance trusts and across primary and secondary care, and be assured that:

• all front-line staff are competent to identify people with suspected TIA or stroke outside hospital using a validated tool such as FAST (Face Arm Speech Test)
• accident and emergency staff are able to establish a diagnosis rapidly, using a validated tool such as ROSIER (Recognition of Stroke in the Emergency Room).

Commissioners may also wish to make resources available to raise awareness of the symptoms of TIA and stroke among the public, and make it known that TIA and stroke need to be treated as a medical emergency.

Commissioners should ensure that locally agreed care pathways, systems and protocols are in place, so that people with TIA and non-disabling stroke can access and receive appropriate immediate treatment, and/or referral for urgent specialist assessment and investigation.

Specialist assessment and investigation

NICE clinical guideline CG68 on stroke makes recommendations about which people with suspected TIA need brain imaging and includes the type of imaging that is helpful, and the timescales in which it should be delivered. Commissioners may also wish to refer to Implementing the National Stroke Strategy - an imaging guide for its recommendations on imaging for TIA. Commissioners will wish to ensure that there is capacity in secondary care to enable all people at high or low risk of stroke to receive specialist assessment and investigation in an appropriate timescale following the onset of symptoms. This is important both in terms of reducing long-term disability and preventing possible death, and also in managing service demand.

Commissioners may also wish to review access to carotid imaging and surgery and estimate the likely demand for these services. Use the TIA service commissioning and benchmarking tool to determine the level of service that might be needed locally for carotid endarterectomy procedures and to calculate the cost of commissioning the service using the indicative benchmark and/or your own local data.

Developing a high-quality service for the diagnosis and initial management of TIA and non-disabling stroke

NICE clinical guideline CG68 on stroke recommends that people with stable neurological symptoms from an acute non-disabling stroke or TIA who have symptomatic carotid stenosis of 50-99% according to the NASCET (North American Symptomatic Carotid Endarterectomy Trial) criteria, or 70-99% according to the ECST (European Carotid Surgery Trialists' Collaborative Group) criteria, should:

• be assessed and referred for carotid endarterectomy within 1 week of onset of stroke or TIA symptoms
• undergo surgery within a maximum of 2 weeks of onset of stroke or TIA symptoms
• receive best medical treatment (control of blood pressure antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice).

People with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of less than 50% according to the NASCET criteria, or less that 70% according to the ECST criteria, should:

• not undergo surgery
• receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice).

Commissioners may wish to work collaboratively with other primary care trusts (PCTs) and the local stroke network when reviewing TIA services and/or considering service redesign. Stroke networks should include all healthcare organisations involved in providing services, for example acute trusts, ambulance trusts, PCTs and social care services. Stroke Improvement, part of NHS Improvement, provides guidance and support for stroke networks.

Commissioners may wish to consider delivering a service for the diagnosis and initial management of TIA and non-disabling stroke in a number of different ways, and mixed models of provision may be appropriate across a local health economy. General examples include:

• an urgent assessment and investigation service provided by secondary care that allows same-day access for high-risk patients; this may be achieved by allowing open access for GPs, accident and emergency department staff, paramedics and other providers
• daily open-access, nurse-led TIA clinics with access to specialist services 7 days a week
• immediate access to a specialist stroke team 24 hours a day, 7 days a week using telemedicine solutions to enable access to specialist assessment.

Local stakeholders, including service users and carers, should be involved in determining what is needed from a service for the diagnosis and initial management of TIA and non-disabling stroke in order to meet local needs. The service should be patient-centred and integrated with other elements of care for people with TIA and non-disabling stroke.

The service specification needs to consider:

• the required competencies of, and training for, front-line staff and staff responsible for providing the service
• the expected number of patients (this should take into account how quickly any changes in service provision are likely to take place) and the likely proportion of non-disabling TIA diagnoses requiring initial access to a TIA service
• ease of access and service location; commissioners should engage with service users and other relevant individuals and organisations locally
• care and referral pathways
• information and audit requirements, including IT support and infrastructure
• service monitoring criteria.

Useful sources of information may include:

• The Map of medicine provides an information resource that visually organises the care pathway.
• The NICE shared learning database offers examples of how organisations have implemented NICE guidance locally.
• Implementing the National Stroke Strategy - an imaging guide sets out best practice and provides guidance on how imaging services may develop to provide gold-standard TIA and stroke care.
• Workforce planning resource supports stroke-related workforce planning alongside the National Stroke Strategy.
• Heart Improvement ­- rapid access models.
• NICE costing report on Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack.
• Providers guidance for stroke services - ASSET(1) ‘Action on stroke services: an evaluation toolkit' (ASSET) was created to help healthcare organisations improve and transform stroke services for patients.
• Commissioning guidance for stroke services - ASSET (2) provides advice to commissioners on good practice on improving stroke services and highlights key issues to consider.
• Mending hearts and brains - a clinical case for change. Report by Professor Roger Boyle, National Director for heart disease and stroke.