A Streamlined Approach to Atrial Fibrillation Screening

Transcription

1 A Streamlined Approach to Atrial Fibrillation Screening Partnership between the Cardiac Rhythm Management Team & Department of Stroke Medicine 1 Dowds J, 1 Britton J, 1 McNair W, 1 Turkington L, 1 Curry L, 1 Williamson R, 2 Kinnaird M, 2 Scullion E. 2 Wiggam MI 2018 Northern Ireland Stroke Conference Tuesday 12 th June 2018

2 Background 15-20% of all strokes caused by Atrial Fibrillation (AF) [1] 25% Cryptogenic Strokes with no clear cause found [2] Significant proportion will have Paroxysmal AF (PAF), 24% [3] Role for Cardiac Monitoring? [1] World Health Organisation. The atlas of heart disease and stroke. [2] Kishore A, Vail A, Majid A, Dawson J, et al, Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke, 45, [3] Sposato LA, Cipriano LE, Saposnik G, Vargas ER, et al, Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and metaanalysis. Lancet Neurology.

3 Monitoring Duration period 2016 recommendations [4]: >12 hours, All patients >24 hours, no cause found Implications Increased burden on Cardiac monitoring services Challenge Are we screening enough? [4] National clinical guideline for stroke. Prepared by the Intercollegiate Stroke Working Party. Fifth Edition 2016

4 Tertiary Stroke Service Challenge Tertiary Cardiac Monitoring Service Capacity/Demand Issue 2453 new referrals 1452 Inpatients 839 Strokes/TIA s 800 Outpatients 263 Stroke Day Assessment Service [SDAS] (commenced June 2017) 2016 Guidelines 3000 Investigations 450 AF Screenings 234 Same day Holter = Resource intensive No weekend cover Supply/demand issue Limited availability Forced to be selective Prolonged waiting list Missed Hot period *2017 data from Sroke Dept, BHSCT **2016 Data from Cardiology, BHSCT

5 Our Solution Partnership Meetings Funding Targets Networking New Equipment 1-14 days duration AF detection AF >30sec Asymptomatic? New Workflow Fast Analysis Quick Turnaround Nurse-Led Service Empowerment Core Nurses Training Support Monitor hookup & removal

6 Monitors Holter ECG Event Monitor Full disclosure 24hr-72hr Resource intensive Slow analysis Cost Symptom activated Real-time snapshot Too short? Mobile Cardiac Telemetry Autodetection 1-30 days Remote Future? Implantable Loop Autodetection 2-3 years Invasive Cost Too long?

7 Novacor R.Test 4 AF detection algorithm, 91% sensitive 9x more likely to detect sustained PAF

8 Old New Service New Team Cardiac Ambulatory Monitoring team Cardiac Device Review Team Service General, Cardiology, GP, Stroke etc Stroke Only Monitor Holter Monitor, Continuous Automatic Event Recorders x18 Analysis Slow Fast Report Delays Same day O/P W/L 7-9 months? Availability Limited (I/P Mon-Thurs only) Good (18x monitors for Stroke) Staff Physiologist-led only Physiologist & Stroke Dept partnership *New - Nurse-led Inpatient Service *New Weekend service *New Lunchbox Transfer System

9 Walkthrough

10 Real Case Example 67 year old female Admitted with Cryptogenic Stroke AF Screening indicated Fitted with R.Test 4

11 Assessment of Service Primary outcome measures Number of patients who received screening Percentage of patients who accessed same day screening Waiting time for patient who did not receive same day screening Assessed over a comparable four month period Nov 2016 to Feb 2017 vs Nov 2017 to Feb 2018

12 No. of Patients Results The total number of patients accessing AF screening more than doubled after introduction of the new service (402 v 153) % increase Total Number of Patients Screened Old Service New Service

13 Results 28% increase of proportion screened on the day of referral from 51% (78/153) to 79% (318/402) 4x more Same-day screenings (78 vs 318) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Proportion of Same-day Referral & Screening 51% Old Service 79% New Service

14 Days Results Decrease from 144 days to 30 days in average wait for those not accessing same day investigation, p< % reduction Mean Outpatient Waiting time Old Service 30 New Sevice

15 Conclusion >1300 patients Screened, 11 months AF detection 5% Other arrhythmias VT, heart block, asystole Significantly improved AF Screening post Stroke New ECG monitoring system Empowerment of stroke unit staff Partnership between Stroke Unit & Cardiac Rhythm Management team

16 Discussion Longer monitoring duration? New or Alternative technology? ESUS (Embolic stroke of undetermined source )

17 John Dowds Chief Cardiac Physiologist Cardiac Device Clinic BHSCT E: John Britton Senior Cardiac Physiologist Cardiac Device Clinic BHSCT E: