2023-11-17 00:05:13
(By Luu-Ly DO-QUANG, at the annual day of stroke sector representatives and facilitators)
LILLE, November 16, 2023 (APMnews) – The management of transient ischemic attacks (TIA) in France is still provided mainly by neurovascular units (UNV) and to a reduced extent, in “AIT clinics”, according to different models depending on the means available in particular, according to an inventory drawn up by the French Neurovascular Society (SFNV), presented Wednesday on the sidelines of its congress in Lille.
Dr Denis Sablot from the Perpignan Hospital presented the results of this survey during a session on TIAs as part of the national day for ARS (regional health agencies) referents and facilitators of the stroke care sectors. brain (stroke).
This involves relaunching the work initiated with the General Directorate for Healthcare Supply (DGOS) in 2017 on the organization of a sector for the treatment of TIAs (see dispatch from 11/16/2017 at 7:00 p.m.) but which were interrupted or suspended, he continued, adding that he did not know the reasons.
But the discussions seem to be resuming. “For this, it is important to have an inventory of the treatment of TIAs in France.” The SFNV sent a questionnaire to the 139 UNV managers in France between March and November and 123 (88.5%) responded.
Among them, two thirds (67%) declare that there is no specific reception structure for the management of TIAs within their establishment, 23% declare one in neurology including 18% within the ‘UNV and 5% within the day hospital (HDJ), 5% within the emergency reception service (SAU) and 5% elsewhere.
Concerning a specifically identified “TIA clinic”, 88% of respondents stated that there is no officially identified one in their establishment, with care mainly in UNV (67%) or in outside (15%) but in 6%, there is an organization that comes close.
Finally, 15 UNV managers (12%) declared a “TIA clinic” officially recognized by their establishment, having specific resources, staff and/or dedicated premises (6%), or without resources (3%), or recognized by a health authority, in particular the ARS (2%), or being in another situation (1%).
These 15 “AIT clinics” are distributed unevenly across the territory, with three notably in Ile-de-France and six in the South-West quarter, although “one of the first opened in Toulouse has been closed for a year “, some are open only during business hours, five days a week (53%) or even seven days a week (6%) and others 24 hours a day (41%).
All these structures have a referring doctor, 60% a coordinating nurse, 33% in particular a coordinating advanced practice nurse (APN) and 20% dedicated secretarial time. More than two thirds (37%) have a specific telephone line manned by the neurologist or nurse.
Asked how to promote this activity, UNV officials say they do so through day hospitalization at 62%, full hospitalization at 25% and consultation at 13%.
The applicants for the clinic are first of all other health professionals, the SAU (52.7%), the town doctor (23%), the Samu (17.8%), another establishment (16, 5%) and firefighters (2.7%); the patient or family calling directly in only 5.3%.
Excluding “AIT clinic”, however, there is a written procedure specific to the management of AIT within the establishment for 32% of 101 managers who answered this question and 5% for the entire health territory. So for the majority (53%), there is no specific written procedure.
Differences in support
The SFNV also asked about the management of these TIAs and the responses show differences, probably linked to habits and available resources.
For example, faced with a deficit which has completely regressed but occurred within six hours, 68% of the 116 managers who responded manage it “as an acute phase, day and night, but 20% during the day, 7% on a case by case basis but 5% do not support it. If a patient presents to the emergency room with a TIA that occurred between 6 and 24 hours before, only 46% treat it as an acute phase and 43% do not treat it and if it presents night 24 hours later, 67% still perform the imaging while 24% wait until the morning, 9% deciding on a case-by-case basis.
Dr Sablot further detailed responses showing variable practices on examinations and first-line exploration times, access to transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), with difficulties notably reported respectively by 58 % and 78% of respondents, on the treatments initiated, with in particular 48% who have integrated the systematic prescription of aspirin + clopidogrel but another 25% for whom they are not defined in advance.
Only 12% of UNV managers say they can access an endarterectomy in less than 24 hours in the event of asymptomatic stenosis and 35% have to wait between five and 10 days! “This figure of 12% is not very satisfactory,” he commented.
Finally, a post-stroke consultation is offered in 90% of cases among 106 respondents, most often within three to six months (70%).
The activity data were collected from the medical information department of 77 UNV, making it possible to count a total of 14,034 AITs taken care of by these structures, “which is relatively consistent with the number of AITs in France estimated at 54,000 per year from the Dijon stroke register”, commented the neurologist, recalling that “a good half do not go to the hospital”.
For these 77 UNV, the circuit probably varies according to local possibilities: in 13%, it is the UNV which takes care of the AIT and in 22%, the NICU (neurovascular intensive care unit), in 29% , the patient goes through the SAU then leaves the establishment and in the majority of cases, 36%, he goes to a service other than the UNV. The average length of stay is three days when the patient goes through the UNV and 3.6 days outside the UNV.
Overall, these results show a disparity in the treatment of TIA in France, according to habits and resources, except in particular for imaging carried out in the acute phase and post-stroke consultation, patients with TIA benefiting from the stroke sector, and point out some points for vigilance, in particular access to cardiac ultrasound and the time to access endarterectomy, concluded Dr Sablot.
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