Transient Ischaemic Attacks: “Mini-strokes”
e-learning to support training in TIA and TIA-like presentations

Welcome to TIA Clinic e-learning

Narrowed neck artery, angiogramThis e-learning is life-like and interactive. You have 8 clinics of 3-5 patients each (see links on the right). For each case-presentation, there are questions with feedback. Research evidence-based, current NHS guidelines and clinical expertise inform diagnosis and management in these clinics. This resource will help you develop your knowledge and skills if you have just started in this clinical area or refresh/extend your learning as part of continued professional development.

We have identified three levels of competence within TIA clinic work:

Level 1:

Physician new to TIA Clinic. All work (patient consultations, management and the clinic letter) checked in clinic by the consultant.

Level 2:

Physician knowledgeable and skilled in common TIA clinic presentations. Can stratify clinic referrals. The physician has peer review of some but not all patients. The physician selects appropriate investigations and management. The physician teaches medical students in the clinic and independently writes the letter.

Level 3:

The physician works independently in the clinic, only referring to experts/colleagues to discuss challenging cases. The TIA Clinic physician teaches medical students and doctors in training.
Our first 8 e-clinics are pitched at a competency level of Levels 1 and 2. You need to be seeing sufficient numbers of real-life patients in TIA Clinic hence regular participation in a local clinic is essential to develop competence.

Setting the scene

TIA clinics were created to improve access to investigations and treatment. This was successful, but UK audits demonstrated only 30-50% of clinic patients were diagnosed with TIA. Diagnosis is now a key role of these clinics. There is no point carrying out an ABCD2 score or prescribing anti-platelets and statins if a patient does not have a TIA.

Strive to be an excellent physician

Transient events can be harder to diagnose. More work is required to make an accurate diagnosis. Contacting a witness, when they are not in clinic is an example. Do you label the event as a TIA based on an incomplete patient history? No, with patient permission, you telephone the collateral for example, and may find not the TIA story, but a description of a seizure. Seeking medical notes/GP records for diagnostic evidence are further examples of striving required in enhancing diagnostic accuracy.

Consultation skills

The clinic requires multiple steps:

  • diagnostic process
  • selecting investigations and their interpretation
  • explaining diagnosis and treatment to the patient and family member
  • writing a high quality letter for the GP and patient

Ability to communicate effectively is key. We cannot assess that here but as you are learning, why not gain feedback from patients/carers through use of a feedback clinic questionnaire or have a peer observe your consultation skills and provide constructive feedback. The GMC website has a feedback questionnaire you could ask a member of your team to send out to patients with the clinic letter.

History

History taking is taught to medical students as taking place at 1-point in a consultation. This is true for a simple problem. For a transient/complex problem, information can come out at multiple points during the consultation. Furthermore, the transient nature means no physical signs when seen hence the history is so vital to diagnosis and decision-making. Different stages of the consultation seem to trigger the patient or doctor to provide/prompt more information. The process of listening, prompting and checking as a repeated cycle is necessary in many patients. Your hypothesis for a diagnosis can change during a consultation as more information becomes available.

Examination

Make sure you collect the patient from the waiting room. Observe how they mobilise, their co-ordination and arm swing. During history-taking, observe posture, facial expression and symmetry of voluntary movements. Listen for speech impairment and get a feel for their mood. Undertake examination open to different diagnoses, the main focus is CVS and NS, but do not forget other systems – they may have an abdominal aneurysm!

Investigations

Select investigations appropriately. Avoid a ‘scan-all’ approach, not just because of radiation from CT, any test is stressful for the patient, be cost-considerate and make requests tailored to the individual patient.

The patient: Rounding the consultation up

Communication with the patient: Patients can feel overwhelmed at TIA Clinic because of the diagnosis, consultations, tests and new treatment-it is like an obstacle race! Consequently retention of information can be lacking. Audit in our service in 2013 indicated that GPs felt only 50% of patients understood their diagnosis after TIA clinic attendance –not good enough! Explain diagnosis and treatment and provide back-up written information including the clinic letter.
Early follow up with the GP is essential and a telephone follow-up consultation/hospital appointment as appropriate.
Focus on drugs and targets for lifestyle changes. Smoking cessation is the most important change. Nurse-led smoking cessation clinic and started on NRT increases success rates.
Driving: Explain restrictions -no driving for one month (UK). Heavy goods or public vehicle drivers need to inform the DVLA for further evaluation and advice
Holiday and travel (flying): The patient should contact holiday companies and airlines and avoid going away internationally for a period of time. Six weeks avoidance of flying is usually the requirement.
All advice needs documentation in the medical records and GP letter.

The role of other experts

Patients attending TIA Clinic can have a range of cardiovascular, neurological and ophthalmological pathology. Advice from colleagues in these fields may be required. For our clinic, radiology and the eye clinic, followed by vascular surgery are the experts we work most closely with. A significant number of patients with TIAs are known to specialists in diabetes and/or renal disease.

Communication with the GP (and the referrer if not the GP)

It is your responsibility to decide about the urgency for communication to referrer. Many clinics use same-day communication. Safety and quality is key. Some patients will be started on new anticoagulation. Communicating this (preferably same-day) with their GP is essential. It may be necessary to re-calculate risks, taking into account other relevant history. Do not be afraid to state what might be obvious to you but not to others. For example, when commencing new anticoagulation, aspirin should be stopped. If communication is unclear, the patient may continue to take aspirin and risk a serious GIT bleed.

References

Intercollegiate Stroke Working Party National Clinical Guidelines for Stroke 4th Edition, London: Royal College of Physicians, 2012
Stroke: Diagnosis and Initial Management of Stroke and TIA. NICE Clinical Guideline 68 London: Royal College of Physicians, 2008

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