How do service factors contribute to delay in specialist assessment for TIA and minor stroke?

Problem

There is a high risk of major stroke following a transient ischaemic attack (TIA) or minor stroke but this can be substantially reduced by early assessment and management in a specialist clinic. Unfortunately most cases are not seen soon enough to fully benefit from this intervention, and service delays are important contributors.

Approach

We conducted semi structured interviews with 42 patients recently diagnosed at hospital with TIA or minor stroke to explore how service factors contributed to delay. We also interviewed 18 GPs who were involved in these patients’ care at the time. Interviews were transcribed and analysed using constant comparison.

Findings

The following categories of delay were identified. Firstly, delay in assessment in general practice following contact with the service; this related to availability of same day appointments and the role of the receptionist in identifying urgent cases. Secondly, delays in diagnosis by the healthcare practitioner first consulted, including the GP, optometrists, out of hours services, walk in centres and the Emergency Department. Thirdly, delays in referral after a suspected diagnosis; these included variable use of the ABCD2 risk stratification score and referral templates in general practice, and referral back to the patients’ GP in cases where he/she was not the first HCP consulted.

Consequences

Primary and emergency care providers need to review how they can best handle patients presenting with symptoms that could be due to stroke or TIA. In general practice this may include receptionist training and/or triage by a nurse or doctor. Mechanisms need to be established to enable direct referral to the TIA clinic when patients whose symptoms have resolved present to other agencies. Further work is needed to improve diagnostic accuracy by non-specialists.