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


Type of study

Cluster randomised feasibility trial


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?



Health and Care Research Wales

Total grant value


Amount accruing to your group (if different)


Start date


End date


Related links

ISRCTN registry: http://www.isrctn.com/ISRCTN85516498