Summary
Transient Ischaemic Attack 999 Emergency Referral (TIER)
Funder: HCRW
Background and study aims
This is a study of an alternative care pathway (that is, care plan to help patients with a specific condition or symptoms) for patients with low-risk suspected transient ischaemic attack (TIA). TIAs, sometimes referred to as a ‘mini stroke’, occur when there is a temporary interruption in the flow of blood to the brain. Symptoms may be similar to that of a stroke, for example, difficulty with talking, raising their arms or controlling facial muscles (causing, for example, the face to drop on one side or the patient not being able to smile). To be classed as a TIA, the symptoms must last less than 24 hours. Patients who have a TIA are at risk of having a stroke. How high this risk is depends on the ‘severity’ of the TIA, which can be assessed with a clinical scoring tool. Those at high-risk should be assessed by a specialist within 24 hours. Guidelines state, however, that patients with low-risk TIA do not require immediate assessment, and can be assessed by a specialist within one week of the TIA. Currently, if a patient calls 999 because they have symptoms of a TIA, paramedics are likely to take them to the emergency department (ED) to be assessed by a doctor. The patient may have to wait several hours to be seen. When the patient is seen by a doctor in the ED, that doctor may refer the patient to TIA clinic, or to the on-call medical doctor. This medical doctor will probably not be a TIA specialist. The outcome of the hospital assessment is, therefore, likely to be a referral to TIA clinic. The patient will have to attend this TIA clinic where a specialist doctor or nurse can assess them again. This duplication of assessment is inconvenient to the patient, and it also wastes NHS resources. This is particularly a problem now, when ED waiting times often exceed the government target of four hours. The aim of this study is to develop and assess the feasibility of paramedic referral pathway of patients with low-risk suspected TIA directly to a TIA clinic for early specialist review, without going to the ED. For those patients who do not require immediate hospital care, this will provide timely specialist review without: adverse consequences; the inconvenience of ED attendance; and cost to the NHS. Patients with high-risk TIA will still be taken to ED.
Who can participate?
All paramedics working in the area where the study is taking place can take part. Patients to be included are those considered to be suffering from a low-risk TIA.
What does the study involve?
Some areas of the UK already have pathways to allow paramedics to directly refer patients to TIA clinics. Interviews take place with some of the people involved in these pathways to discover how often they are used and if they seem to work well or are problematic. Service user (i.e. involving members of the public) workshops are run to discuss and develop the study with patients providing their perspectives on the problems of existing practice. A review of the literature concerning the prehospital care of patients with suspected TIA is also done. Paramedics are recruited to the study and attend focus groups. The results of the interviews and focus groups are used to help researchers to decide how the pathway tested in this study should work. Paramedics are then randomly allocated to either the intervention group (using the new pathway) or control group (continuing to provide current care). Training is given to the paramedics in the intervention group so that they can safely and appropriately assess and refer patients with suspected TIA. Patients are recruited to the study over the period of one year. An NHS researcher takes the patient’s consent to take part in research seven to ten days after their initial 999 call. During the period of patient recruitment, some of the clinicians and managers in the study area are interviewed to get their opinions and ensure there are no concerns with safety. Using the secure anonymised information linkage databank (SAIL), what happens to the participating patients (in either group) are tracked. Patients are contacted after 30 days and also at three months after their initial 999 calls to collect data about their state of health. At the end of the study, patients are interviewed about their experiences and further paramedic focus groups are run to see how their opinions have changed.
What are the possible benefits and risks of participating?
The main benefit for patients with low-risk TIA, is a direct referral to a TIA clinic thus avoiding a lengthy wait in ED to see a doctor unlikely to be a TIA specialist. There may be a risk found in leaving patients at home after they have called 999 without transferring them to ED. However, the National Institute for Health and Care Excellence (NICE) guidance states that patients with low-risk TIA do not require immediate assessment. Any low-risk patients with suspected TIA, assessed as suitable for direct referral to a TIA clinic and therefore left at home, will be appropriately informed of their health condition and the rationale for this clinical decision. They will be provided with a Patient Information Leaflet, including instructions that, should they experience another TIA, especially if it is within one week of the initial episode, that they should call 999 again. Any low-risk patient who wishes to attend hospital in preference to being referred directly to TIA clinic, will be taken to the ED. All high-risk patients will still be transferred to ED.
Where is the study run from?
Welsh Ambulance Services NHS Trust (UK)
When is the study starting and how long is it expected to run for?
October 2015 to September 2017
Contact Details
Trial Manager / Lead Contact: Nigel Rees
Email: nigel.rees5@wales.nhs.uk
ISCRTN Number: 85516498; IRAS ID: 190685;