Referral pathways for TIA patients avoiding hospital admission : a scoping review

Objective: To identify the features and effects of a pathway for emergency assessment and referral of patients with suspected transient ischaemic attack (TIA) in order to avoid admission to hospital.Design: Scoping review.Data sources: PubMed, CINAHL Web of Science, Scopus.Study selection: Reports of primary research on referral of patients with suspected TIA directly to specialist outpatient services.Data extraction: We screened studies for eligibility and extracted data from relevant studies. Data were analysed to describe setting, assessment and referral processes, treatment, implementation and outcomes.Results: 8 international studies were identified, mostly cohort designs. 4 pathways were used by family doctors and 3 pathways by emergency department physicians. No pathways used by paramedics were found. Referrals were made to specialist clinic either directly or via a 24-hour helpline. Practitioners identified TIA symptoms and risk of further events using a checklist including the ABCD2 tool or clinical assessment. Antiplatelet medication was often given, usually aspirin unless contraindicated. Some patients underwent tests before referral and discharge. 5 studies reported reduced incident of stroke at 90 days, from 6–10% predicted rate to 1.3–2.1% actual rate. Between 44% and 83% of suspected TIA cases in these studies were referred through the pathways.Conclusions: Research literature has focused on assessment and referral by family doctors and ED physicians to reduce hospitalisation of patients with TIA. No pathways for paramedical use were reported. We will use results of this scoping review to inform development of a paramedical referral pathway to be tested in a feasibility trial

The transient ischaemic attack 999 emergency referral (tier) feasibility trial: development of a complex intervention

Background Transient Ischaemic Attack (TIA) is a neurologic event with symptom resolution within 24 hours. Early specialist assessment of TIA reduces risk of stroke and death. NICE (2008) recommends patients with TIA are seen in specialist clinics within 24 hours (if high risk) and seven days (if low risk). We aimed to develop a complex intervention for patients with low risk TIA presenting to the emergency ambulance service. The intervention was then to be used in the TIER feasibility trial, in line with the MRC guidance on staged development and evaluation of complex interventions. Methods We conducted three interrelated activities to produce the TIER intervention: • Survey of UK Ambulance Services (n=13) to gather information about TIA pathways already in use • Scoping review of literature describing prehospital care of patients with TIA • Synthesis of data and definition of the intervention by specialist panel of: paramedics; ED and stroke consultants; service users; ambulance service managers. Results The panel defined the TIER intervention to include: 1. Protocol for paramedics to assess patients presenting with TIA and identify and refer low risk patients for prompt (<7 day) specialist review at TIA clinic 2. Patient Group Directive and information pack to allow paramedic administration of aspirin to patients left at home with referral to TIA clinic 3. Referral process via clinical desk in ambulance control room 4. Training package for paramedics 5. Agreement with TIA clinic service provider to ensure rapid review of referred patients Conclusion We followed MRC guidance to develop a clinical intervention which assesses and refers low risk TIA patients requesting 999 care. We will test feasibility of implementing and evaluating this in the TIER feasibility trial. We will then develop a fully powered randomised multicentre trial, if findings indicate this is appropriate. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0