For optimal stroke prevention following transient ischemic attack or minor stroke, international best practice guidelines recommend carotid endarterectomy for appropriate candidates as soon possible, with a target of less than two weeks. Research has demonstrated however, that delays to surgery occur frequently, in part due to complex clinical care processes. The goal of our study was to identify modifiable factors which could improve timely access to urgent carotid endarterectomy.
A retrospective chart review was competed, examining transient ischemic attack /stroke patients assessed in four regional Stroke Prevention Clinics between 2011 and 2014, who subsequently underwent carotid endarterectomy. Descriptive statistics were used to examine patient characteristics and time points to carotid surgery. A thematic analysis was performed to identify key factors which enhanced or delayed timelines to carotid endarterectomy. These themes were further analyzed to determine avoidable delays and key success factors.
Seventy-five records were eligible for study inclusion. Completion of carotid endarterectomy within two weeks was achieved for 21% of patients. Six key themes were identified including patient response to stroke, first health care contact, surgical fitness, resource capacity and physician availability (neurology or surgery). Forty four percent of patients did not present to medical attention the day of symptom onset contributing substantially to avoidable delays in care. Furthermore, 79% of patients experienced delays in access to vascular imaging, neurologist assessment and surgical bookings. Success was influenced by distinct triage, rapid diagnostic testing, and physician accessibility strategies. This often required divergence from standard clinical practices and interdepartmental collaboration.
Delayed patient presentation was the most common reason for delayed carotid endarterectomy which highlights the importance of ongoing public awareness strategies. Significant clinical delays were also noted at each step where patients required imaging or consultation. In order to reach carotid endarterectomy benchmarks, quality enhancement approaches will require coordinated, multifaceted care innovations.