Alternative care pathways for patients with low risk tia attended by emergency ambulance: a national survey

Abstract

Abstract Background Patients presenting to emergency ambulance services with TIA are usually conveyed to the nearest Emergency Department (ED) with subsequent referral to specialist assessment at a TIA clinic within one week if at low risk of stroke. There is the opportunity for paramedics to refer patients with TIA at low risk of recurrent stroke directly to specialist TIA clinic, if such protocols can be shown to be safe and cost effective. We aimed to describe current service developments across the UK for the pre-hospital emergency care of patients with TIA, to inform the development of an intervention for testing. Methods We surveyed all UK Ambulance Trusts (n=13) by email, asking them to identify initiatives related to the management of TIA, and followed up services reporting an alternative TIA pathway by telephone to gather further details. Results Twelve ambulance services responded to our survey. Nine reported that they had no current TIA referral pathway; of these, one had a pathway which was discontinued due to service reconfiguration. Three reported currently using a TIA referral pathway. All (4/4) pathways which had been introduced used the FAST test and ABCD2 tool to screen patients, in line with national guidelines, and classified patients as low risk if the ABCD2 score was 3 or below. All pathways indicated that eligible low-risk TIA patients should be referred by paramedics to specialist care, 2/4 by telephone, and 2/4 by fax. Non-conveyance exclusion criteria varied. Although protocol compliance was audited in an initial pilot in one service, no formal evaluation of effectiveness was reported. Conclusion Several UK ambulance services have introduced referral pathways for low risk TIA patients, avoiding the ED. None have evaluated the safety (subsequent stroke or serious misdiagnosis) or cost effectiveness. A clinical trial to evaluate the safety and effectiveness of alternative care pathways for patients with suspected TIA presenting to emergency ambulance services is indicated. https://emj.bmj.com/content/34/10/e8.1 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/ DOI http://dx.doi.org/10.1136/openhrt-2015-000281