WALES CENTRE FOR HEALTH



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|DRAFT: Proposed TIA minimum dataset |

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|TIA intelligent targets subgroup |

|Title: TIA minimum dataset |

|Authors: Gemma Northey, Specialty Registrar (Public Health Wales) and Michelle Price (National Leadership and Innovation |

|Agency for Healthcare) |

|Date: 28st March 2011 |

|Version: 0i |

|Purpose of paper: To provide a structure and format for the TIA intelligent targets minimum dataset |

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|Recommendation: For information |

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Purpose of document

This document proposes a structure for the minimum dataset for TIA intelligent targets updated from discussions at the TIA Intelligent Target Subgroup Meeting on 22 November 2010 and at further Web Exs on 20th and 30th December. There were also additional meetings with primary care colleagues and the dataset has been circulated by e-mails and comments received.

1 Background

Purpose of minimum dataset: The primary purpose of a minimum dataset is to enable the same health information to be generated, independent of the system that captures it. In achieving this, it will enable healthcare professionals to measure and compare the delivery and quality of care provided and support them in sharing information with other health professionals.

This document presents a revised minimum dataset, with clear relationships between the data items proposed in the ‘How to Guide’ and the interventions specified, and a clear definition and rationale for each data item.

Minimum dataset specification

Table 1 outlines the specification for the minimum dataset required in order to measure compliance with the TIA bundles. The table identifies the following:

• bundle each data item relates to

• intervention each data item relates to

• data item name

• definition

• rationale for collection

• related evidence (where applicable),

• data format (this specifies the input options for this data item, for example if format is ‘0,1,2,3’, it means that you can ONLY enter 0, 1, 2 or 3 for this data item)

• source of data (note: some data items will not be inputted manually by staff, but will be calculated automatically – where this is the case it is made explicit)

During the development of the minimum dataset, some data items were identified as process measures and are therefore not needed as part of the minimum dataset. However, they may provide valuable information on local processes and inform audit of services, so have been included in table 2 on page [12].

TABLE 1. MINIMUM DATASET

BundleInterventionData item nameDefinitionRationale for data itemRelated evidenceFormatData source----ID numberUnique hospital IDTo identify patients uniquely--NumberSecondary care (Hospital administrative system)1: First point of contact – symptom recognition and referral--Date first contact with health serviceDate first seen by a health professional for suspected TIA.

First contact is the time that TIA is identified as a possible diagnosis. It may be with a GP, A&E Doctor or ambulance service clinician- it has to be someone who is able to do all the elements of bundle

To establish the date the patient made initial contact with the health service for TIA. Will be used to calculate compliance with further interventions in bundles two, three and four.--dd/mm/yyyyTIA referral formUse ABCD2 to stratify riskABCD2 score calculated at first contact?Whether the health professional that saw the patient at first contact performed an ABCD2 screen at that time

Included to record whether intervention was undertaken at appropriate timeAny patient who presents with transient neurological symptoms suggestive of a cerebrovascular event should be considered to have had a transient ischaemic attack (TIA) (RCP, 4.2.1 A)

People who have had a suspected TIA, that is, they have no neurological symptoms at the time of assessment (within 24 hours), should be assessed as soon as possible for their risk of subsequent stroke using a validated scoring system, such as ABCD2 (RCP, 4.2.1 B)Yes, noTIA referral formUse ABCD2 to stratify riskABCD2 scoreA numeric score to show stroke risk level for patientABCD2 score required to indicate whether patient receives interventions in driver bundles two or three. As above0,1,2,3,4,

5,6,7TIA referral formGive aspirin immediatelyAspirin given at first contact?Whether the patient was given aspirin (or where aspirin is inappropriate, alternative antiplatelet drugs) at first contact

Data item required to determine whether aspirin was given at first contact. As aspirin may not be appropriate treatment for some patients, other options are given, such as ‘alternative antiplatelet drugs given’. If alternative treatment is given or it is considered inappropriate to give aspirin, this will be interpreted as the intervention having being achieved for the patient.

People who have had a suspected TIA should have aspirin (300 mg daily) started immediately (RCP, 4.2.1 C, E), unless there are contraindications when alternative antiplatelet drugs such as clopidogrel should be started (RCP, 4.4.1 B)

EXPRESS study recommendations:

Give aspirin 300mg as a loading dose

If not on any anti-platelets then continue with 75mg once a day (consider adding a PPI if aspirin GI intolerant: use Clopidogrel 300mg loading and 75 mg maintenance if truly aspirin allergic)

Add dipyridamole MR 200 bd

Prescribe a statin (simvastatin 40mg)

Optimise BP control if systolic > 130mmHG by using existing medication or starting an ACE/ thiazide combinationYes, noTIA referral formBundleInterventionData item nameDefinitionRationale for data itemRelated evidenceFormatData source1: First point of contact – symptom recognition and referralRefer immediately onto appropriate pathway, electronically or by telephone and faxPatient referred?Date the patient was referred to TIA service at first point of contact and on to the appropriate pathway (either high or low risk). This could be by fax, telephone or electronically.

The referral must be a completed referral form as per local protocol and must include the date of onset of symptoms, date of first contact, ABCD2 score, whether or not aspirin was given, and what advice and information was given.

This data item records whether the patient has had immediate referral to specialist services, as outlined in bundle one.People who have had a suspected TIA who are at high risk of stroke (that is, with an ABCD2 score of 4 or above) should have specialist assessment and investigation within 24 hours of onset of symptoms (MPS, 4.2.1 C)

All higher-risk patients with TIA and minor stroke need to be assessed by a specialist and treated within 24 hours (DH, QM5 Rationale 5)

People with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke even though they may have an ABCD2 score of 3 or below (MPS, 4.2.1 D)

People who have had a suspected TIA who are at lower risk of stroke (that is, with an ABCD2 score of 3 or below) should have specialist assessment and investigation as soon as possible, but definitely within one week of onset of symptoms (RCP, 4.2.1 E)

People who have had a TIA but who present late (more than one week after their last symptom has resolved) should be treated as though they are at lower risk of stroke (RCP, 4.2.1 F)

dd/mm/yyyyTIA referral formGive patient information in appropriate formatInformation given at first contact?Whether patient was provided with all relevant information in a format appropriate to that patient.

Information to include:

That they must not drive/fly/operate heavy machinery for a minimum of four weeks

Advice on taking aspirin

Medical emergency

What to do if experience re-occurring symptoms

This records whether patient has received the appropriate information at the appropriate time and measures compliance with intervention four in bundle one.Every person who has a stroke or a TIA should be told that they must not drive for a minimum of four weeks (RCP, 6.48.1 E)

Every healthcare professional giving advice on driving should ensure that it is accurate and up to date (RCP, 6.48.1 C)

For those individuals attending primary care, advice needs to be given about taking aspirin and avoiding driving (DH, QM5 Rationale 4)

For each patient, information about stroke and risk factors should be reinforced at every opportunity by all health professionals involved in the care of the patient (RCP, 5.1.2 B)

Yes, noTIA referral formBundleInterventionData item nameDefinitionRationale for data itemRelated evidenceFormatData source2 and 3: Timely specialist managementSpecialist assessment and commence investigations within one day of first contact (or 7 days for low risk patients)High Risk/ Low RiskIs the patient high risk or low risk of having a stroke based on the ABCD2 score and additional clinical information within the referral or gained by triage This allows consultant physicians to re-categorise patients, for example a person with a high ABCD2 score who had there symptoms more than 2 weeks previously should be categorised as a low risk or a patient with a low ABCD2 score with considerable vascular risk factors may be categorised as a high risk.

People who have had a TIA but who present late (more than one week after their last symptom has resolved) should be treated as though they are at lower risk of stroke (RCP, 4.2.1 F)

High risk / low riskSecondary care (Hospital administrative system)Specialist assessment and commence investigations within one day of first contact (or 7 days for low risk patients)Date first assessed by specialistDate that patient was both first seen and assessed by a specialist within the TIA service. Specialist assessment is defined here as either a Consultant Physician or a Specialty Registrar in Stroke Medicine.

Specialist assessment entails clinical history and examination, screening of medical and lifestyle risk factors, referral for further investigation.

The date is recorded specifically, because intervention for high and low risk patients is subject to different timescales. Therefore to avoid unnecessary data entry, date of assessment is taken and used to calculate whether this intervention has been achieved, as outlined below.All higher-risk patients with TIA and minor stroke need to be assessed by a specialist and treated within 24 hours (DH, QM5 Rationale 5)

People who have had a suspected TIA should be assessed by a specialist before a decision on brain imaging is made (RCP, 4.3.1 A)

People who have had a suspected TIA who are at high risk of stroke in whom the vascular territory or pathology is uncertain should undergo urgent brain imaging- defined as ‘within 24 hours of onset of symptoms’ (RCP, 4.3.1 C).

People who have had a suspected TIA who are at lower risk of stroke (that is, with an ABCD2 score of 3 or below) should have specialist assessment and investigation as soon as possible, but definitely within 1 week of onset of symptoms (RCP, 4.2.1 E)

People who have had a suspected TIA who are at lower risk of stroke in whom the vascular territory or pathology is uncertain should undergo brain imaging - defined as ‘within one week of onset of symptoms’ (RCP, 4.3.1 D).

All patients with a TIA or stroke that resolves completely affecting the carotid circulation should have investigation for carotid stenosis as soon as possible and no later than seven days after the event by screening using Doppler ultrasound or other non-invasive test (RCP, 4.4.1 C)

In any patient where no common cause is identified, fuller investigation for other rare causes should be undertaken (RCP 5.1.1 C)

dd/mm/yyyySecondary care (Hospital administrative system)BundleInterventionData item nameDefinitionRationale for data itemRelated evidenceFormatData source2 and 3: Timely specialist managementSpecialist assessment and commence investigations within one day of first contact (or 7 days for low risk patients)Patient seen and assessed by specialistWhether the patient was seen and assessed by specialist within the required time.

Specialist is defined here as either a Consultant Physician or a Specialty Registrar in Stroke medicine.This will be calculated automatically by calculating the difference between the date of first contact and date first seen by specialist.As aboveYes, noCalculated automatically from datasetSpecialist assessment and commence investigations within one day of first contact (or 7 days for low risk patients)TIA confirmedTIA confirmed at initial specialist assessment by specialist.

This would be based on clinical history and examination and available test results.

Specialist is defined here as a Consultant Physician or a Specialty Registrar in Stroke medicine.If the patient is not considered at specialist assessment to have had a TIA the other interventions in the bundle and the later bundle 4 are not relevant.

Patients categorised as probable are included in bundles 2,3 and 4 and should be treated as a confirmed TIA.[--]Yes, no, probableSecondary care (Hospital administrative system)Specialist assessment and commence investigations within one day of first contact (or 7 days for low risk patients)Carotid Duplex RequestedWas the patient referred for a carotid duplex scan or similar investigation?

Required to establish denominator for carotid investigation within two daysYes, noSecondary care (Hospital administrative system)Specialist assessment and commence investigations within one day of first contact (or 7 days for low risk patients)Date CT/ MRIDate that CT or MRI was performed (if done; if not done, leave this blank).Recorded to be able to calculate whether high and low risk patients received investigations in appropriate timescale. The four investigations listed will be aggregated to form another data item, which indicates whether ANY investigations were commenced within one day of first contact (see below)As abovedd/mm/yyyySecondary care (Hospital administrative system)Specialist assessment and commence investigations within one day of first contact (or 7 days for low risk patients)Date ECGDate that ECG was performed (if done; if not done, leave this blank).Recorded to be able to calculate whether high and low risk patients received investigations in appropriate timescale. The four investigations listed will be aggregated to form another data item, which indicates whether ANY investigations were commenced within one day of first contact (see below)As abovedd/mm/yyyySecondary care (Hospital administrative system)BundleInterventionData item nameDefinitionRationale for data itemRelated evidenceFormatData source2 and 3: Timely specialist managementCarotid investigation within 2 days of first contact (or within 7 days for low risk patients)Date Carotid DuplexDate that carotid duplex was performed (if done; if not done, leave this blank).Recorded to be able to calculate whether high and low risk patients received investigations in appropriate timescale. The four investigations listed will be aggregated to form another data item, which indicates whether ANY investigations were commenced within one day of first contact (see below)As above, plus:

All people with suspected non-disabling stroke or TIA who after specialist assessment are considered as candidates for carotid endarterectomy should have carotid imaging within one week of onset (MPS, 4.4.1 C)

People with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of 50-99% according to NASCET criteria or 70-99% according to ESCT criteria should undergo endarterectomy within a maximum of two weeks of onset of symptoms (MPS, 4.4.1 E)dd/mm/yyyySecondary care (Hospital administrative system)Specialist assessment and commence investigations within one day of first contact (or 7 days for low risk patients)Investigations commenced in appropriate timescaleWhether any investigation was commenced within appropriate timescaleThis will be calculated using the difference between date of first contact and the earliest recorded date of any investigation.

For high risk patients:

If the difference is zero or one days, this would comply with the intervention

For low risk patients:

If the difference is 7 days or fewer, this would comply with the interventionAs aboveYes, noCalculated automatically from datasetDate referred for carotid interventionsDate patient referred for a carotid interventionDate patient was referred for a carotid interventionDate the referral for carotid intervention was made- this assumes that the carotid investigation was positive. By recording a date in this box then this data item can be both a minimum data point and a process measure.Carotid imaging should ideally be performed at initial specialist assessment and should not be delayed more than 24 hours after first clinical assessment of higher-risk patients (DH, QM5 Rationale 9)

Carotid endarterectomy should be considered when carotid stenosis is measured at greater than 70% as measured using the ECST methods, or 50% as measured using the NASCET methods (RCP, 5.7.1 B)

Carotid intervention for recently symptomatic severe carotid stenosis should be regarded as an emergency procedure in patients who are neurologically stable, and should ideally be performed within 48 hours of a TIA or minor stroke (DH, QM6 Rationale 13)

People with significant carotid stenosis should (as above):

1. be assessed and referred for carotid endarterectomy within one week of onset of stroke or TIA symptoms

2. undergo surgery within a maximum of two weeks of onset of stroke or TIA symptoms (RCP, 4.4.1 E)

dd/mm/yyyySecondary care (Hospital administrative system)BundleInterventionData item nameDefinitionRationale for data itemRelated evidenceFormatData source2 and 3: Timely specialist managementCarotid intervention, if appropriate, within 7 days of first contact (or from positive carotid investigation for low risk patients)

Date of carotid interventionDate that carotid intervention was performed; if not done, leave this blank.Date of intervention will be used to calculate whether this intervention has been achieved

As abovedd/mm/yyyySecondary care (Hospital administrative system)Carotid intervention, if appropriate, within 7 days of first contact (or from positive carotid investigation for low risk patients)Carotid intervention within specified timeframe?Whether patient received carotid intervention if appropriate, within the timescale.Calculated from the time difference between date of first contact (for high-risk patients) or positive carotid investigation (for low-risk patients) and date of carotid intervention. If seven or fewer days, this is considered as having complied with the intervention.

Not applicable applies to patients who would not be referred for intervention.

As aboveYes, noCalculated automatically from datasetIndividualised secondary prevention strategy agreed with patient at specialist assessment by someone with appropriate training and supported with written informationPrevention prescribed to patientIndividualised secondary prevention strategy agreed with patient at initial specialist assessment.

Lifestyle measures to be assessed/discussed should include (but are not limited to):

Smoking cessation

Exercise

Diet

Weight control

Alcohol intake

Substance misuse

Where appropriate, refer patient on to relevant services for follow up. A list of locally available services should be available from your Local Public Health Team (Public Health Wales).

To ensure that appropriate lifestyle interventions, services and support options are communicated to the patient to most effectively influence behaviour/lifestyle changes.Identification of risk factors for stroke should be part of the assessment during the acute phase (RCP, 5.2.3)

People who have had a TIA need information and advice on smoking cessation, diet, exercise, alcohol, driving and what to do in the event of a recurrent TIA or stroke (DH, QM6 Rationale 16)

For each patient, an individualised and comprehensive strategy for stroke prevention should be implemented as soon as possible following a TIA or stroke (RCP, 5.2.1 A). This should include lifestyle measures: smoking cessation, exercise, diet, weight control, blood pressure, alcohol intake (RCP, 5.3.1)

For each patient, information about stroke and risk factors should be reinforced at every opportunity by all health professionals involved in the care of the patient (RCP, 5.1.2 B)

Yes, noSecondary care (Hospital administrative system)BundleInterventionData item nameDefinitionRationale for data itemRelated evidenceFormatData source2 and 3: Timely specialist managementIndividualised secondary prevention strategy agreed with patient at specialist assessment by someone with appropriate training and supported with written informationMedication advice given and risk factors addressedIndividualised secondary prevention strategy agreed with patient at initial specialist assessment.

This should include medication advice (where appropriate) as given in evidence column. Also to include investigation of risk factors (where preventative interventions would be appropriate), including as a minimum checking for and managing:

Raised blood pressure

Hyperlipidaemia

Diabetes mellitus

The following risk factors should also be checked for:

Atrial fibrillation and other arrythmias

Structural cardiac disease

Carotid artery stenosis (only for individuals with a non-disabling carotid territory event likely to benefit from surgery for stenosis)

To measure whether the patient has received the required risk factor assessment and appropriate medication adviceFor each patient, an individualised and comprehensive strategy for stroke prevention should be implemented as soon as possible following a TIA or stroke (RCP, 5.2.1 A) to include: lifestyle measures

Every patient who has had a stroke (including TIA and SAH) and in whom preventative interventions would be appropriate should be investigated for risk factors as soon as possible, certainly within one week of onset. At a minimum this includes checking for and managed:

raised blood pressure (sustained over 130/90 mmHg) (RCP, 5.4.1)

hyperlipidaemia (RCP, 5.5.1)

diabetes mellitus (RCP, 5.1.1 A)

For patients who have had an ischaemic stroke or TIA the following risk factors should also be checked for:

atrial fibrillation and other arrhythmias

structural cardiac disease

carotid artery stenosis (only for individuals with a non-disabling carotid territory event likely to benefit from surgery for stenosis) (RCP, 5.1.1 B)

All patients receiving medication for secondary prevention should:

1. be given information about the reason for the medication, how and when to take it and any possible common side effects

2. receive verbal and written information about their medicines in a format appropriate to their needs and abilities

3. have compliance aids such as large-print labels and non-childproof tops provided, according to their level of manual dexterity, cognitive impairment and personal preference and compatible with safety in the home environment

4. be aware how to obtain further supplies of medication (RCP, 5.2.1 D)

Yes, noSecondary care (Hospital administrative system)BundleInterventionData item nameDefinitionRationale for data itemRelated evidenceFormatData source2 and 3: Timely specialist managementIndividualised secondary prevention strategy agreed with patient at specialist assessment by someone with brief intervention training and supported with written information

Professional appropriately trainedWhether the health professional who is prescribing the prevention measures is appropriately trained.

Appropriately training may include accredited training in smoking cessation brief intervention.

To ascertain whether the information given is being delivered in the most effective way to influence behaviour/lifestyle change.[NICE 2006a. Brief interventions and referral for smoking cessation in primary care and other settings. PH001. London: NICE.

NICE. 2006b. Implementation advice. Brief interventions and referral for smoking cessation in primary care and other settings. London: NICE. ]Yes, noSecondary care (Hospital administrative system)Communicate treatment plan back to GP within one day of specialist assessmentDate of summary to GP Date the treatment plan communicated back to GP

The date is the day that the treatment plan was actually posted, e-mailed or faxed to the GP Practice. Date used to allow flexibility of data entry. Compliance with this intervention will be calculated from the difference between date of specialist assessment and date of GP referral.Patients should have their risk factors reviewed and monitored regularly in primary care, at a minimum on a yearly basis (RCP, 5.2.1 C)

All patients receiving medication for secondary prevention should have a regular review of their medication (RCP, 5.2.1 D)

dd/mm/yyyySecondary care (Hospital administrative system)4: Ongoing secondary prevention and risk management--Secondary care follow up neededWhether patient follow up in secondary care is needed, if not they should be followed up in primary careIncluded here as not all patients need follow up in secondary care, therefore acts as a prompt to seek further information from primary care records for patients followed up by their GP

--Yes, noSecondary care (Hospital administrative system)Review medical management of risk factorsReview of medical risk factorsDate of review to ensure all the medication prescribed at specialist assessment was being taken appropriately and tolerated wellTo identify whether the patient has had a medication review at one month follow up.All patients receiving medication for secondary prevention should have a regular review of their medication (RCP, 5.2.1 D)

Patients should have their risk factors reviewed and monitored regularly in primary care, at a minimum on a yearly basis (RCP, 5.2.1 C)

dd/mm/yyyySecondary care (Hospital administrative system) or Primary care (Audit plus software)BundleInterventionData item nameDefinitionRationale for data itemRelated evidenceFormatData source4: Ongoing secondary prevention and risk managementAdvice on lifestyle risk factors from someone with appropriate trainingPatient advised on lifestyle risk factors Date of review to ensure that each prevention measure is appropriate and to discuss an appropriate course of action.

Lifestyle measures to be discussed, as appropriate, should include (but are not limited to):

Smoking cessation

Exercise

Diet

Weight control

Blood pressure

Alcohol intake

Substance misuse

Driving

Where appropriate, refer patient on to relevant services for follow up, [for example, to Stop Smoking Wales]. A list of locally available services should be available from your Local Public Health Team (Public Health Wales).

Collected to discern whether the appropriate information on risk factors has been delivered effectively at every opportunity.For each patient, information about stroke and risk factors should be reinforced at every opportunity by all health professionals involved in the care of the patient (RCP, 5.1.2 B)

Patients should be encouraged to take responsibility for their own health and be supported to identify, prioritise and manage their risk factors (SIGN Guideline 12.1)

For each patient, information about stroke and risk factors should be provided in an appropriate format (RCP, 5.2.1 B)

Patients should have their risk factors reviewed and monitored regularly in primary care, at a minimum on a yearly basis (RCP, 5.2.1 C)

dd/mm/yyyy hypertensionSecondary care (Hospital administrative system) or Primary care (Audit plus software)Advice on lifestyle risk factors from someone with appropriate trainingPerson giving advice has appropriate trainingWhether the health professional who is prescribing the prevention measures is appropriately trained.

Appropriately training may include accredited training in smoking cessation brief intervention.

This is a measure to ascertain whether the information given is being delivered in the most effective way to influence behaviour/lifestyle change.For each patient, information about stroke and risk factors should be provided in an appropriate format (RCP, 5.2.1 B)

Yes, noSecondary care (Hospital administrative system) or Primary care (Audit plus software)Written personalised secondary prevention plan and information providedWas written personalised secondary prevention plan providedFollowing discussion and agreement with the patient, did they receive a personalised prevention plan, containing information on relevant risk factors and services available?To measure whether the patient is receiving the appropriate information and that the messages are reinforced at every opportunity.For each patient, information about stroke and risk factors should be provided in an appropriate format (RCP, 5.2.1 B)Yes, noSecondary care (Hospital administrative system) or Primary care (Audit plus software)

TABLE 2. ADDITIONAL PROCESS MEASURES

BundleData item nameDefinitionRationaleFormatData source1: first point of contactDate of onsetDate of onset of latest clinical symptoms of TIA that led the patient to seek medical adviceTo monitor delays in patients seeking medical advice which may be n indication to levels of public awarenessdd/mm/yyyyTIA referral formPlace of first contactPlace first seen by a health professional for suspected TIA.

First contact is the time that TIA is identified as a possible diagnosis. It may be with a GP, A&E Doctor or ambulance service clinician- it has to be someone who is able to do all the elements of bundle

To monitor where their referrals come from.stringTIA referral form2 and 3: Timely specialist managementDate referral received by specialist serviceDate referral received by TIA service

dd/mm/yyyySecondary care (Hospital administrative system)Date of first appointment offeredDate of first appointment offered, even if patient declines to attendSecondary care (Hospital administrative system)CT Requested Was a CT scan clinically indicated and requestedThis allows services to monitor the demand for CT scans for patients presenting with TIAYes, No

Secondary care (Hospital administrative system)MRI Requested Was a MRI scan clinically indicated and requestedThis allows services to monitor the demand for MRI scans for patients presenting with TIAYes, No

Secondary care (Hospital administrative system)ECG Requested Was an ECG clinically indicated

and requestedThis allows services to monitor the demand for ECG for patients presenting with TIAYes, No

Secondary care (Hospital administrative system)Carotid stenosis scoreNumeric score for carotid stenosis

Using European Carotid Stenosis Trial (ECST) scoring system0-100%Secondary care (Hospital administrative system)References

RCP – Royal College of Physicians (2008). National clinical guideline on the management of people with stroke. 3rd Edition. London. RCP Intercollegiate Stroke Working Party.

DH – Department of Health (2007). National stroke strategy. London. Department of Health

SIGN - Scottish Intercollegiate Guidelines Network (2008). Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention. A national clinical guideline. Edinburgh. Scottish Intercollegiate Guidelines Network

EXPRESS- Rothwell PM, Giles MF et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke

(EXPRESS study): a prospective population-based sequential comparison (2007); Lancet.370: 1432–1442

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