Reduce recurrent transient ischemic attacks

Takeaways:

• The study presented in this article determined that recurrent TIA was significantly reduced in rapid access transient ischemic attack and stroke clinics compared previous clinic operation within the general neurology clinics at the Seattle VA.
• Protected appointment times and stroke specialist may be key considerations when developing TIA and stroke clinics.
• Rapid access TIA and stroke clinics may reduce diagnostic testing and treatment costs associated with recurrent TIA.

At the Veterans Administration (VA) Hospital in Seattle, which is part of the VA Puget Sound Health Care System and serves five states (Alaska, Idaho, Montana, Oregon, and Washington), patients with suspected transient ischemic attack (TIA) or stroke enter the system through several avenues. Patients who present within 2 weeks of onset of TIA or stroke usually are seen through the emergency department (ED). Patients who delay seeking medical attention for 2 weeks or more frequently make the initial appointment with their primary care provider (PCP) in the VA system. In addition, some veterans may be evaluated and treated initially by medical facilities other than the VA, such as a non-VA hospital or a PCP in an outpatient clinic. Not all PCPs refer these patients to the VA neurology service, and many don’t possess the specialized training and education of a stroke specialist. Lack of or delayed neurology service consultation can lead to prevention treatments and management that aren’t evidence-based.

Rapid access TIA and stroke (RATS) outpatient clinics set aside protected appointments for these conditions so that patients can be seen quickly by specialty clinicians who can improve outcomes and reduce recurrent TIA and stroke. I conducted a quasi-experimental study to determine whether these clinics would be appropriate for patients served at the Seattle VA. 

What’s the background?

Merwick and Kelly found that when patients are rapidly assessed and treated by stroke specialists in outpatient TIA clinics, hospital admissions and costs can be reduced. TIA clinics use structured clinical assessment tools, such as the ABCD2, and select the most efficacious imaging technology to improve diagnosis. Merwick and Kelly found that the preventive treatment offered by these clinics reduces secondary TIA and stroke.

The goal of my study was to evaluate patient outcomes (hypertension, body weight, and the number of recurrent TIAs and strokes 90 days after the previous event) in a newly implemented RATS clinic compared with general neurology outpatient clinics. The project targeted patients at the Seattle VA with new diagnoses of TIA and stroke made at outside healthcare facilities and those diagnosed by VA providers. (See TIA and stroke stats.)

The Seattle VA treats nearly 100 patients diagnosed with TIA and acute ischemic stroke annually. In 2014, when my study began, of 118 patients examined (n = 64 in the RATS clinic, n = 54 in the conventional clinic),two in the RATS clinic had recurrent stroke within 90 days of the initial event; none in the comparison clinic did. The RATS clinic group had no patients with a recurrent TIA; the comparison group had five.

In the literature, I discovered that the Existing Preventive Strategies for Stroke (EXPRESS) study found an 80% reduction of recurrent stroke 90 days after the qualifying event for patients receiving urgent care through a TIA clinic. In the international prospective observational TIAregistry.org project concluded in July 2015, among 4,583 patients followed over a median of 27.2 months at 61 TIA clinics, 25 died from cardiovascular causes and 168 (3.7%) had a recurrent stroke or TIA within 90 days.

Based on my literature review, a TIA clinic decreases the time between the incident event and referral, and from referral to appointment, thus decreasing the wait time to specialist evaluation and appropriate treatment. Studies have shown that stroke or TIA clinics can reduce secondary TIA and stroke, hospital admissions, and costs.

How did it work?

I conducted this study from 2014 through 2016 while working as a neurology nurse practitioner (NP) at the Seattle VA hospital and receiving training in stroke care through a doctoral NP program at Seattle University. I implemented the RATS clinic and evaluated outcomes.

Initially, the RATS clinic opened for one half-day per week with four appointments available only for patients with recent TIA and stroke. I predicted that with the limited hours, the number of qualifying patients would exceed the available appointments.A clinic triage tool was developed to prioritize patients not yet diagnosed or at highest risk of TIA or stroke recurrence. The Seattle VA neurology team and ED providers also used the ABCD2 tool for the assessment of TIA, which allows for risk stratification of future stroke. (See Triage guidelines.)

Evidence-based standardized outpatient clinic practices for post TIA and stroke were replicated for the RATS clinic based on my literature review, as well as local and national practice. The clinic protocol begins with a full history and neurologic examination with vital signs and weight (and National Institute of Health Stroke Scale/Score if the patient had had a stroke) to confirm the diagnosis and etiology. Another key action is to ensure a complete work-up for TIA and stroke has been accomplished to determine vascular risk factors and the TIA or stroke etiology to produce an individualized treatment plan. An additional action step is to discuss other vascular risk factors, such as diabetes, hypertension, excessive body weight and sedentary lifestyle, with the patient and family.

We communicate all findings and the recommended treatment plan to the patient’s PCP and other consultants via the electronic health record (EHR). All clinic tasks are captured on a TIA and stroke outpatient algorithm in the EHR for easy access by other RATS clinic practitioners.

What did we learn?

In this study, recurrent TIA was significantly reduced in patients treated at the RATS clinic compared to the general neurology clinics (pre-2014). The Fisher’s exact test revealed a significant reduction in recurrent TIA for patients seen at the RATS clinic compared with the conventional clinic (p = .04); no significant differences were seen between the two groups in hypertension reduction, weight reduction, recurrent stroke (p = .50), or rehospitalization (p = .75).

With a qualified specialized provider available to develop, implement, and evaluate the new RATS clinic, no additional expense was incurred for staff or a data analyst. In addition, all of the necessary diagnostic equipment and ancillary departments were already in place. And when compared to the costs associated with a recurrent TIA admission or outpatient visit and accompanying diagnostic tests and treatments, the costs of the RATS clinic proved it to be a great investment for the VA neurology department.

Both ED and primary care staff noted that the clinic resulted in more satisfied patients because they were seen and treated sooner. The VA administrators were pleased to have improved access for patient appointments, which is the VA’s current quality improvement goal. The clinic’s positive impact and the predicted need for more appointment availability led to approval for another NP-led RATS clinic at the American Lake VA in southern Washington. Within months of the original RATS clinic start-up, a stroke physician was hired and is currently staffing three RATS clinics, seeing an average of seven new patients per week. In addition, I’m staffing three clinics, which also see an average of seven new patients each week.

Can you do this too?

The RATS clinic is replicable in both VA and civilian settings, especially if you have specialty-trained staff, the required ancillary departments for diagnostic testing, and the appropriate space. Start by getting key leadership support. You can have the greatest plan in the world, but without senior leadership and financial support, your chances for success are low. Next, get stakeholder buy-in. Healthcare is a team sport, so you need all the clinical players to support each component necessary for the new practice. Finally, secure space as soon as possible, which may be tough in a tight healthcare market. (See Steps for clinic development.)

Preventing recurrent TIA and stroke can reduce costs and improve outcomes, but it depends on early diagnosis and the appropriate treatment plan. A RATS clinic can help your organization achieve these goals.

Kim Veilleux is a nurse practitioner in neurology at the VA Puget Sound Health Care System in Seattle, Washington. 

Selected references

Amarenco P, Lavallée PC, Labreuche J, et al. One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med. 2016;374(16):1533-42.

Centers for Disease Control and Prevention. National Center for Health Statistics: Cerebrovascular disease and stroke. May 2017. cdc.gov/nchs/fastats/stroke.htm

Di Carlo A. Human and economic burden of stroke. Age Ageing. 2009;38(1):4-5.

Feigin VL, Krishnamurthi RV, Parmar P, et al. Update on the global burden of ischemic and hemorrhagic stroke in 1990-2013: The GBD 2013 Study. Neuroepidemiology.2015;45(3):161-76.

Luengo-Fernandez R, Gray AM, Rothwell PM. Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): A prospective population-based sequential comparison. Lancet Neurol. 2009;8(3):235-43.

Merwick A, Kelly PJ. Transient ischaemic attack clinics and management of transient ischaemic attacks. Curr Opin Neurol. 2011;24(1):50-8.

Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: A report from the American Heart Association.Circulation. 2015;131(4):e29-322.

Petkar S, Bell W, Rice N, et al. Initial experience with a rapid access blackouts triage clinic. Clin Med. 2011;11(1):11-6.