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Type and Title of Submission


Title:

Nurse-led care for patients after a TIA

Description:

Specialist Transient Ischaemic Attack (TIA) clinics were set up following the publication of the National Stroke Strategy and NICE CG68 to provide specialist assessment of patients with a suspected TIA. This has led to much earlier diagnosis and initial management of TIAs. However, patients can be overwhelmed following the initial diagnosis with its significant implications on lifestyle. The National Stroke Strategy and national guidance (DH 2007; Intercollegiate Stroke Working Party 2008) recommend patients are followed up within 1 month of diagnosis either in primary or secondary care. Specialist Nurse-led TIA follow-up clinics are an effective way of delivering specialist advice, helping patients cope with their diagnosis and empowering them to manage their cerebrovascular risk factors.

Does the submission relate to the general implementation of all NICE guidance?

Yes

Does the submission relate to the implementation of a specific piece of NICE guidance?

No

Full title of NICE guidance:

CG68 - Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)

Is the submission industry-sponsored in any way?

No


Description of submission


Aims and objectives

In response to NICE CG68 and the National Stroke Strategy, specialist TIA assessment clinics have led to early diagnosis of TIAs. Patients with a diagnosis of a TIA benefit from specialist follow up with specific needs. In Nottingham University Hospitals (NUH), the TIA clinic sees around 35 patients a week with around 55% of patients being diagnosed with a TIA. In addition to patients seen in the Emergency Department and Acute Admission Units, this amounts to around 20 patients per week requiring follow up following their TIAs in addition to the patients treated in Stroke Outpatients. The main aim of the implementation initiative was to deliver specialist TIA follow-up via nurse-led clinics

Context

Patients with high risk TIAs and strokes are followed up in the Consultant-led Stroke Outpatient Clinics. There was limited excess capacity to follow-up all TIA patients within 1 month of their TIA in secondary care. The Stroke Service in NUH had an Advanced Nurse Practitioner (ANP) with independent prescribing and extensive experience managing patients following TIAs and strokes. Nurse-led clinics have already been in existence in other fields and the setting up of the Nurse-led TIA Follow-up Clinic was a logical extension of the role of the Stroke ANP.

Methods

Initial assessment of activity and capacity within the Stroke Service. Team building with key staff members to ensure close teamwork and support from the entire clinical team. Identify key skills required to run an independent nurse-led TIA follow-up clinic (e.g. extensive stroke/TIA experience, strong community links, independent prescribing). Clearly define sources of referrals for follow-up to the clinic. There were no significant additional costs incurred in implementing the clinics as the Stroke Advanced Nurse Practitioner role had already been funded to deliver comprehensive care for TIA patients as part of Commissioning for Best Practice Guidance.

Results and evaluation

Patient experience questionnaire - 96% of patients found the clinic helpful. Around 85% of patients felt that they understood their diagnosis and investigations, had all their concerns addressed and had enough information to empower them to improve their lifestyles. In the qualitative section, a significant proportion of patients felt they received more individualised care and were more reassured in the specialised clinic. In summary, the nurse-led clinic was well received by the patients. Retrospective audit of clinic activity - Around 50% of patients had medication issues addressed (e.g. side effects, compliance, dose titration). Around 21% of patients were signposted to services in the community (e.g. New Leaf, community exercise programmes, community matrons). Around 22% of patients had low mood or depression when screened by the PHQ-9 questionnaire for depression and a management plan formulated. All patients had a chance to discuss their diagnosis, investigations and concerns. They were all given positive lifestyle advice. Long term clinical outcome data (recurrent TIA or stroke)- ongoing data collection but not available as the clinic started less than a year ago in May 2011. Patients seen in the clinic has risen since it started in May 2011 from around 6 patients a week to around 15 patients a week. In summary, the Specialised Nurse-led TIA Follow-up Clinic is a successful and essential pillar in the care of patients following a TIA.

Key learning points

To develop Advanced Nurse Practitioner role early on within the service. Develop close links with clinical team to provide medical support and advice if needed for the clinic. Work with Outpatient Managers to provide sufficient administrative and clinical resources (e.g phlebotomy, clinical observations and ECGs) Forge links with local smoking cessation services, community-based stroke teams, cardiac rehabilitation and exercise programmes, community matrons and General Practitioners.

Contact Details

Name:Dr Kelvin Ng Kuan Huei
Job Title:SpR in Stroke Medicine/Clinical Pharmacology and Therapeutics/General Internal Medicine
Organisation:Nottingham University Hospitals NHS Trust
Address:Stroke Service, Nottingham City Hospital, Hucknall Road
Town:Nottingham
County:Nottinghamshire
Postcode:NG5 1PB
Phone:+44 7789760514
Email:kelvinng@nhs.net
Website:http://www.nuh.nhs.uk/

 

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This page was last updated: 31 January 2012

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.