Background: With the purpose of identifying gaps as well as best practices in guideline-concordant TIA/minor stroke care in the Veterans Health Administration (VHA) system, we sought to elucidate the perceived challenges and facilitators of TIA care across clinical specialties and across settings of care.
Methods: We conducted a prospective, formative evaluation in 14 VHA hospitals across the US. We conducted 70 semi-structured interviews with front-line clinicians, leadership and quality managers. Interviews were audiorecorded, transcribed, and double coded in Nvivo 10 software using an emergent codebook. We analyzed the reported challenges and facilitators of TIA guideline care.
Results: Six of the fourteen sites reported the existence of a Stroke Nurse Coordinator to track the quality of stroke care and to minimize the gaps in services across inpatient and outpatient settings. Of the six, only one site had a defined algorithm for TIA care services specifically for and separate from their stroke protocols. A lack of care coordination for TIA patients across services and across the inpatient and outpatient settings were major reported challenges. Sites without a stroke coordinator often reported a lack of staff to reduce this service gap. Some provided outpatient follow-up as well as risk factor management at the inpatient bedside for all admitted TIA patients and this appeared to facilitate TIA care. Educating facility staff for stroke care was a common responsibility, but few stated they provided TIA-specific staff education. Stroke/TIA quality data collection was often performed by the Stroke Nurse Coordinator; however the data feedback process varied widely across facilities from none to a stroke team, and by schedule from weekly or, quarterly to occasionally. It is unclear how the Stroke Nurse Coordinator interacted with the neurology service from these data, but the six sites with a Stroke Nurse Coordinator had much lower rates of consulting the Neurology service.
Conclusions: Extending the role of the local Stroke Coordinator to include specifying a TIA protocol, assisting care coordination for patients with TIA, tracking and feeding quality data back to local providers may improve the quality of TIA care. SDP # 12-178.