Patient flow to carotid endarterectomy: hastening the patient journey Manar Khashram,* Justin A. Roake*† and David R. Lewis*† *University of Otago, Christchurch School of Medicine and †Department of Vascular, Endovascular and Transplant Surgery. Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand Key words audit, carotid endarterectomy (CEA), delay, guideline, timing. Abbreviations CEA, Carotid Endarterectomy; TIA, transient ischaemic attack; US, ultrasound. Correspondence Dr Manar Khashram, University of Otago, Christchurch School of Medicine, PO Box 4345, Christchurch 8013, New Zealand. Email: manar.khashram@gmail.com M. Khashram MbChB; J. A. Roake MbChB, DPhil, FRCS, FRACS; D. R. Lewis MBChB MD EBSQ(vasc) FRACS, FRCS Accepted for publication 23 August 2009. doi: 10.1111/j.1445-2197.2010.05308.x Abstract Background: Early carotid endarterectomy (CEA) after stroke or transient ischaemic attack is the proposed standard of care to prevent recurrent ischaemic events in selected patients. The aim of this study was to investigate if this standard is achieved in a tertiary vascular unit. Methods: This was a clinical audit. CEAs performed from 1 January 2006 to 31 December 2008 at Christchurch hospital were identified. The value stream from initial presentation to surgery was mapped in two phases (phase 1; 2006–2007 and phase 2; 2008). Patients who had carotid intervention for asymptomatic carotid lesions were excluded. Results: The relevant patient journey was documented in 81 patients (55 phase 1; 26 phase 2). Median time from initial presentation to carotid ultrasound was 5 days in phase 1 and 6 days in phase 2. Time from presentation to vascular surgery review was 22 days in phase 1 and 13 days in phase 2. Time from presentation to CEA significantly reduced from 83 to 32 days between phases (P < 0.005). Conclusions: There has been a significant decrease in time from presentation to operation between phase 1 and 2. The most significant change is reduced delay between vascular surgery review and CEA. There has been no improvement in urgency of referral for imaging or surgical review. This part of the patient journey is a target for improvement. Introduction The risk of recurrent stroke after a minor stroke or a transient ischaemic stroke is highest in the first 90 days. Urgent carotid endarterectomy (CEA) for transient ischaemic attacks (TIA)/minor strokes has been accepted as standard practice to prevent the maximum number of strokes in selected patients. The Carotid Endar- terectomy Trial Collaborators (CETC) published the pooled analysis from the three randomized controlled trials (VeteransAffairs (VA) study, North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST)) showing that CEA generated the lowest numbers needed to prevent strokes when surgery was performed within 2 weeks from the neurological event compared to over 12 weeks. 1 Up to 15% of ischaemic strokes are associated with significant (>50%) ipsilateral carotid stenosis and the risk of recurrent events is higher in patients with carotid atherosclerotic disease. 2 Several trials have shown a substantial reduction in stroke risk when TIA/minor strokes are managed acutely (medically and surgically) compared to outpatient or ‘standard’ treatment. 3–5 Despite this, published evidence also shows that urgent CEA practice is only being offered in a few institutes. Reasons for delays are multifactorial and include lack of education, a possible increase in operative risk with early CEA, lower priority compared to other conditions such as heart disease and cancer and reduced research funding. 6 Recently, observational studies from Canada, United Kingdom, Australia and New Zealand showed discrepancy in TIA management and, subsequently, delays in performing CEA. 7–10 Most of the barriers to urgent management have been attributed to delays in referrals and access to resources. Knowing these benefits, the question arises: How could symptomatic patients be diagnosed, have appropriate investigations and management in this small window of opportunity? In January 2008, the Department of Vascular Surgery at Christchurch Hospital adopted an informally agreed policy to SPECIAL ARTICLE ANZJSurg.com © 2010 The Authors Journal compilation © 2010 Royal Australasian College of Surgeons ANZ J Surg 80 (2010) 406–410