TIER

Title

Transient Ischaemic Attack 999 Emergency Referral (TIER)

Principal / Lead Investigator

Mr Nigel Rees, Head of Research & Innovation Welsh Ambulance Service NHS Trust (WAST)

Co-Investigators / Research team

Prof Helen Snooks, Swansea University
Dr Richard Dewar, Cwm Taf Health Board
Prof Adrian Edwards, Cardiff University
Chris Moore, Welsh Ambulance Services NHS Trust
Dr Alison Porter, Swansea University
Dr Bernadette Sewell, Swansea University
Prof Alan Watkins, Swansea University
Shirley Whitman (Patient representative)
Dr Anne Seagrove (Trial Manager), Swansea University
Dr Jenna Bulger (Trial Manager), Swansea University

Collaborators:

Dr Khalid Ali, Brighton &Sussex Medical School
Dr Bridie Evans, Swansea University
Prof Gary Ford, Oxford Academic Health Science Network
Mr Martin Heaven, Swansea University
Alan Pryce (Patient representative),
Prof Tom Quinn, Joint Faculty of Health, Social Care and Education, Kingston University and St. George's, University of London

Type of study

Cluster randomised feasibility trial

Summary

This trial addresses a problem in the care of patients with suspected TIA presenting to the ambulance service, where delays in the processes of care may have consequences for health and satisfaction of patients. Although our feasibility trial may result in some patients waiting longer for their initial assessment by a doctor, that initial assessment would be carried out by a specialist rather than an emergency care doctor, who would eventually need to refer the patient to a specialist anyway. Developing and testing an alternative care pathway based on initial assessment by paramedics and referral of eligible patients directly to specialist care, without conveyance and assessment at Emergency Department (ED) demonstrates prudent healthcare.

To develop and assess the feasibility of paramedic referral of patients with low-risk suspected TIA directly to TIA clinic for early review, without going to the emergency department (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 unnecessary cost to the NHS. If the intervention is found to be acceptable and practical to implement, we will develop our methods for a full randomised controlled trial (RCT). We will collect data on a number of outcomes to help us assess the feasibility of conducting such a trial.

How could this study benefit patients?

The feasibility trial will provide the basis for a rigorous trial to assess the risks and benefits of the new model of care for patients with suspected TIA attended by paramedics. Such systems are in place in parts of England at present without underpinning evidence of effectiveness and safety, underlining the need for this research for clinical practice and policy development. Our trial will be an important step towards a definitive trial, the outcome of which could pave the way to truly prudent healthcare for patients with suspected TIA.

Who is the study sponsor?

Welsh Ambulance Service NHS Trust

Does the study involve commercial partnership activity?

Funder

Health and Care Research Wales

Total grant value

£238,139

Amount accruing to your group (if different)

£229,819

Start date

01/10/2015

End date

30/09/2017

Outputs

Poster presentation: Rees N, Bulger J, Dewar R, et al. TRANSIENT ISCHAEMIC ATTACK 999 EMERGENCY REFERRAL (TIER): FEASIBILITY TRIAL. Emergency Medicine Journal 2016;33:e13.
Publication: Seagrove A, Bulger J, Snooks HA, Rees N, Heaven M. Transient Ischaemic Attack 999 Emergency Referral (TIER): a cluster randomised feasibility trial facilitated by data linkage. IJPDS (2017) Issue 1, Vol 1:326 Proceedings of the IPDLN Conference (August 2016)
Publication: Rees N, Ali K, Dewar R, Evans L, Ford G, John R, Moore C, Obiako M, Porter A, Quinn T, Bulger J, Jones C, Seagrove A, Snooks H, Hampton C. VP88 Transient Ischaemic Attack Referral (TIER) Intervention Development. January 2017 International Journal of Technology Assessment in Health Care 33(S1):189-190 DOI: 10.1017/S0266462317003555
Abstract presentation: Evans BA, Ali K, Bulger J, Ford GA, Jones M, Moore C, Porter A, Pryce AD, Quinn T, Seagrove AC, Snooks H, Whitman S, Rees N, on behalf of the TIER Trial Research Management Group. Referral pathways for patients with TIA avoiding hospital admission: a scoping review. BMJ Open 2017;7:e013443. doi:10.1136/bmjopen-2016-013443
Poster presentation: 'Transient Ischaemic Attack 999 Emergency Referralfeasibility trial (TIER): Recruitment and intervention usage' presented at 999 EMS Conference, 26th & 27th March 2018, Stirling.