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NHS
NHS Improvement
CANCER
Heart and Stroke Improvement

DIAGNOSTICS
HEART
Atrial fibrillation in primary care: making an impact on stroke prevention

National priority project final summaries
October 2009
LUNG
STROKE
Contents
Foreword Introduction Project Summaries Incentivised detection and management of Atrial Fibrillation North Somerset PCT Atrial Fibrillation Screening Project - Bedford Atrial Fibrillation in Primary Care - Dudley Health Economy Atrial Fibrillation in Primary Care - Walsall Health Economy To standardise and develop an information package that supports patients along the referral pathway - Northamptonshire Primary Care Arrhythmia Service - Eastern and Coastal Kent PCT Primary Care Arrhythmia Service - Medway PCT Atrial Fibrillation Opportunistic Screening and Patient Review Pilot West Kent PCT Management of Atrial Fibrillation in Primary Care Lancaster and Morecambe Atrial Fibrillation in Primary Care - Rotherham Atrial Fibrillation in Primary Care Project - Sheffield Near Patient INR Testing Project - Whitby Group Practice Atrial Fibrillation in Primary Care - Woking and West Byfleet GRASP-AF (Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation) - West Yorkshire A sector wide approach to optimising therapy for Atrial Fibrillation patients in Primary Care - South West London Project Team Leads, Cardiac and Stroke Networks and Participating Sites 8 4 5
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www.improvement.nhs.uk
Foreword
Atrial fibrillation (AF) is the most common sustained dysrhythmia, affecting at least 600,000 (1.2%) people in England alone. It is also a major cause of stroke. Uniquely it also is an eminently preventable cause of stroke with a simple highly effective treatment. This treatment is also highly cost effective. These facts underpinned the first phase of the Heart and Stroke Improvement Programmes work on stroke prevention and atrial fibrillation. Fifteen cardiac and stroke networks participated in the national programme working with primary care trusts (PCTs), general practices, practice based consortia (PBC) and acute trusts. Projects were undertaken addressing the detection of atrial fibrillation, whether patients are appropriately treated with anti-coagulants and considering the best pathways for managing atrial fibrillation in primary care. The major outcomes of this work continue to demonstrate: A clear variation in identification rates for atrial fibrillation That opportunistic screening can significantly increase detection rates That many individuals who have already been identified to have atrial fibrillation and with known risk factors putting them at high risk of stroke, are not being treated with anticoagulants That the management of AF in primary care is both practical and a necessity. It is clear that improving identification of people with atrial fibrillation and inducing better intervention could prevent many thousands of strokes each year. The personal cost of a stroke to an individual is incalculable. To be aware that in many cases this was an identifiable and potentially avoidable situation can only increase the anxieties to the sufferer and their carers. The identification of those at risk and appropriate treatment offers a real opportunity for achieving cost effective, high quality care, with the goal of preventing avoidable mortality and morbidity.
Dr Campbell Cowan Consultant Cardiologist National Clinical Lead Heart Improvement Programme Dr Matt Fay GP with Special Interest National Clinical Lead Stroke Improvement Programme
Introduction
These national priority projects were established in 2007 in response to Chapter Eight of the National Framework for Coronary Heart Disease; Arrhythmias and Sudden Cardiac Death, published in March 2005, which set out the quality requirements for the prevention and treatment of patients with cardiac arrhythmias. This is underpinned by the publication by NICE in 2006 of Atrial Fibrillation. The management of atrial fibrillation costing report which highlighted that amongst patients with recognised AF, 46% of those who would benefit from warfarin are not receiving it. Out of an estimated 355,000, only 189,000 were actually receiving warfarin. In December 2008 the publication of the National Stroke Strategy affirmed the importance of this work for stroke prevention. Quality Marker 2 states: Markers of a quality service: Risk factors, including hypertension, obesity, high cholesterol, atrial fibrillation (irregular heartbeats) and diabetes, are managed according to clinical guidelines, and appropriate action is taken to reduce overall vascular risk Action needed: Commissioners and providers use ASSET to establish baseline and to ensure that there are systems in place locally for the following key prevention measures: warfarin for individuals with atrial fibrillation Measuring success: Greater proportion of individuals who have a history of stroke or cardiovascular disease or who are at a high risk who have had advice and/or are receiving treatment. Atrial fibrillation is a major predisposing factor to stroke, with 16,000 strokes annually in patients with AF of which approximately 12,500 are thought to be directly attributable to AF. The annual risk of stroke is five to six times greater in AF patients than in people with normal heart rhythm and is therefore a major risk factor for stroke. Appropriate anti-coagulation of all patients with recognised AF would prevent approximately 4,500 strokes per year and prevent 3,000 deaths. A recent Department of Health1 cost benefit analysis suggests that for stroke patients with AF there are around: 4,300 deaths in hospital 3,200 discharges to residential care 8,500 deaths within the first year. However, The treatment of AF with warfarin reduces risk of stroke by 50-70% The estimated total cost of maintaining one patient on warfarin for one year, including monitoring, is 383 The cost per stroke due to AF is estimated to be 11,900 in the first year after stroke occurrence. The early learning from the eighteen individual projects established was first published in May 2008 Atrial Fibrillation in Primary Care: National Priority Project (www.heart.nhs.uk/priority_projects /summary_documents/af_summary.pdf). This document aims to capture the final summary of their individual approach, lessons learned, improvements to practice and quality outcomes, also sharing tools and resources developed to enable other health communities to drive this agenda forward.
Department of Health Atrial Fibrillation cost benefit analysis. Marion Kerr, 2008.
Key learning A variety of approaches were undertaken responding to the needs of the local health communities; however each project sought to establish a baseline to demonstrate improvements to changes in practice against: Numbers of new patients with AF identified, and their subsequent treatment Numbers of existing AF patients reviewed and, where necessary, subject to optimal therapy Establishment of a clear and agreed patient pathway for AF patients. Innovation Key areas for the piloting new approaches centred on: Detection of AF though opportunistic screening at flu clinics Local enhanced service (LES) schemes for detection, screening and review of AF New models for anticoagulation services in primary and community settings Development of tools to support the review of patients with AF, risk stratify for stroke and consider optimal therapy: The Guidance on Risk Assessment for Stroke Prevention in AF (GRASP-AF) tool now available for use across all GP clinical systems via www.improvement.nhs.uk/graspaf Decision support tool the Auricle www.theauricle.co.uk Guidelines for primary to secondary care referral. Education All projects found the need to include education for professional and patients around: Pulse palpation Barriers to anti-coagulation in primary care ECG training and interpretation Patient awareness. Partnership working Opportunities have been sought both nationally and within local projects to work with the third sector and professional health organisations to develop supporting resources, tools and educational information to meet the continuous requirement for ongoing and relevant information for both the professional and the patient.
These have included: Department of Health (DH) National Institute for Clinical Excellence (NICE) Primary Care Cardiovascular Society (PCCS) Atrial Fibrillation Association (AFA) British Heart Foundation (BHF) Heart Rhythm UK (HRUK) The Stroke Association (SA) Primary Care Information Management Service (PRIMIS) Ambulance services. Quality outcomes Many of the approaches have already begun to spread across the network of priority projects and through sharing the work nationally through NHS Improvement national learning events. In particular we have seen: 1. The early piloting of opportunistic screening through pulse palpation at flu clinics by Bedfordshire and Hertfordshire Heart and Stroke Network which has led to this initiative being replicated in other areas. For example: The Colchester Practice Based Commissioning Group incentivised 37 practices out of 43 to undertake this approach enabling: 34,201patients to be screened in six weeks 189 patients found with AF (0.55%) Estimated numbers of strokes prevented next year = 5 At an estimated annual cost saving of 220,000 this represented 322% return on investment in addition to improved quality outcomes for patients. 2. The GRASP-AF tool developed and piloted by the West Yorkshire Cardiovascular Network in collaboration with their BHF Arrhythmia nurses and PRIMIS for use on GP clinical systems to identify for review AF patients with high risk of stroke, not on warfarin, has now been made available for use across England.
The York Health Group PBC cluster used GRASP-AF across their 24 practices with a total population of 228,651 patients of which 3,613 patients with AF were identified. By June 2009: The total number of reviews undertaken 716 Of which face-to-face reviews 110 New warfarin prescription 41(6%) Awaiting further review including consultant referral 37. Access to the GRASP-AF tool is through www.improvement.nhs.uk/graspaf and has already been downloaded by over 100 practices in the first couple of months of release. Summary It is clear that tools and resources are only part of the process; it requires a whole system approach to make significant and sustainable change across the whole pathway of care for patients with AF if we are to dramatically reduce their risk of stroke. This will require collaborative working across the whole health system between cardiac and stroke networks, clinicians, commissioners, public health and third sector organisations, in particular, to maximise benefit. Action was sought with key stakeholders to bring together a consensus approach across England to address the key factors in influencing, educating and encouraging change in the identification and management of these patients culminating in the publication in June 2009 Commissioning for Stroke Prevention in Primary Care - The role of Atrial Fibrillation (www.improvement.nhs.uk/ heart/Portals/0/documents2009/AF_Commissioning _Guide_v2.pdf). The next stage of this work will commence with a further nine projects from October 2009, building from this platform of evidence based learning and demonstrable outcomes for the improvement of the identification, diagnosis and optimal therapy for AF patients.
Further pilots will also be undertaken to: understand the issues and potential solutions for the management and optimal therapy for stroke and TIA patients with AF to model the potential impact on current services of new drugs for patients with AF. In addition, to support communities that have added pulse palpation as part of their NHS Health Check Programme, to have access to the learning for the management in primary care for patients with AF. The work of this national priority stroke prevention in primary care: addressing atrial fibrillation supports the national drive for: Quality outcomes through addressing optimal therapy for AF patients Innovative approaches to access and management in primary care for AF patients Productivity through reducing inappropriate referrals to secondary care and bed days saved Prevention by reducing risk of stroke. Many of these project sites are continuing to take this work further into implementation, with the aim to embed into core practice and continue to share their learning both nationally and locally through the cardiac and stroke networks and national learning events. The following case study summaries represent an overview of their work achieved by the end of April 2009 and the tools and resources they have generously made available to share can be accessed from the NHS Improvement website at: www.improvement.nhs.uk/afprojectsummaries
Incentivised detection and management of Atrial Fibrillation Avon, Gloucestershire, Wiltshire and Somerset Cardiac and Stroke Network, Nine GP Practices in North Somerset PCT
Duration of project January 2008 - December 2008 Scope of project To increase the detection rate of patients over the age of 65 with atrial fibrillation through opportunistic screening, with incentives paid for each new diagnosis made and confirmed on ECG To improve the management of known AF patients over the age of 65 by reviewing their management and optimising it where appropriate. Baseline position Nine practices completed the project The combined over 65 population for these nine practices was 16,062 (representing 19% of the registered population for these practices) 1,421 of these patients were known to have AF, giving an over 65 AF prevalence of 8.8%. What we did Opportunistic screening was undertaken in the nine practices, either in chronic disease clinics, on GP visits or practice nurse visits. A code was entered on to the computer system to capture this activity. Any suspected AF cases went on to have an ECG performed. For all confirmed cases a proforma was completed, outlining their risk score, management and any other relevant details. All new cases were validated by the lead clinician to ensure that they were truly opportunistic. An incentive payment was made for each new diagnosis. All known AF patients were entered onto a database and reviewed using the CHADS2 risk tool. Where patients were not managed as per the guidelines, they were reviewed to ascertain if medication could be optimised. Incentives were paid for each patient audited, with an enhanced level of payment for each payment where a medication change was made. Key challenges One of the key challenges at the outset was the definition of opportunistic, and thus ascertaining who was eligible for payment or not. Patients were excluded from the project if they presented with symptoms where it would be reasonable to expect the clinician to check their pulse. The time taken to review a large number of known AF patients also proved a challenge, and the
incentives for this work to be done had to be increased to reflect the labour-intensive nature of this task. There seems to be poor communication and cohesion between GPs and secondary care clinicians when it comes to management of AF. GPs have expressed a reluctance to change medication that was initially prescribed or recommended by cardiologists, but admit little dialogue about the most appropriate management of these patients. What went well Practices were very positive about the benefits associated with this project and involved most GPs, nurses and health care assistants. Many were also proactive in promoting the project to patients. All but one of the practices reported that whilst the incentives helped engage people, they believed it was a very worthwhile project and that they would have taken part anyway. There was strong clinical leadership and close working relations with the participating practices. Key learning from work The change in project manager mid way through the project proved a challenge. However, the network deputy director and one of the practice managers helped minimise the impact of this change. There was a feeling that the GP practices werent entirely clear of the aims of the project at the outset, and that the goal posts moved. There is a need when offering incentive payments that they reflect the labour intensity of the work. Outcomes Opportunistic screening 7,089 pulses were taken in the year period, which assuming patients only had their pulse taken once, represents 45% of the over 65 population in the nine participating practices 66 new diagnoses were made, which were truly opportunistic This equates to one new diagnosis for every 107 pulses taken. The range of new diagnosis per number of pulses taken was considerable (25 560), which raises questions about the reliability of the data and the methodology used
Over 70% of the new diagnoses had a CHADS2 score of two or more and were therefore considered high risk. However, only half of these were prescribed warfarin, with the majority of the remaining patients either refusing warfarin or being contraindicated. Review of known AF patients 1,075 patients with known AF over the age of 65 were reviewed, which was over 75% of the total known AF population in that age group across the nine practices Approximately 80% were reported to have permanent AF, and 20% paroxysmal AF The male:female split was approximately 54% male, 46% female for both types of AF 20% of the known AF patients scored as low risk on the CHADS2 tool (score 0-1), with 80% considered high risk according to the tool. Patients with permanent AF tended to have a higher CHADS2 risk than those with paroxysmal AF. Taking account of documented contraindications and patients refusing medication, 80% of patients with paroxysmal AF in the low risk category (a CHADS2 score of 0-1) were found to be on appropriate medication, compared to over 90% of those with permanent AF. In the high risk group (patients with a CHADS2 score of two or more), 49% of those with paroxysmal AF were treated according to the guidelines, compared to 73% of those with permanent AF. This demonstrates that patients with paroxysmal AF tend to be undertreated compared to those with permanent AF. In total 288 patients were identified as appropriate for a medication change, but only 16 actually went on to have a change in medication. This represents just 1.5% of the 1,075 patients audited. Given the number needed to treat with warfarin to prevent one stroke is 24, if the results from this project were applied to the whole PCT population, four strokes could be avoided in a population of approximately 200,000. Challenges for sustainability The review of known AF patients proved to be very time consuming, with small numbers of patients changed. The clinicians generally felt that the opportunistic screening was more beneficial and
more sustainable, with a focus on treating new diagnoses appropriately in the first place. Costs incurred The spend for this incentivised project was approximately 15,000 against an initial projection of 20,000. The cost not reflected in this is the project management time. Patient, carer and staff involvement Preliminary results were presented to the networks patient, carer and public involvement group, who showed keen interest in the project. They have strongly expressed a wish that a pulse check be mandatory in the vascular checks screen. Feedback from staff involved in the project has been very positive, with most reporting that it has raised the profile of AF in their practices and improved the way in which AF patients are managed, as well as improving attitudes to warfarin prescription. Resources and tools developed to support the changes Available for sharing via the Avon, Gloucestershire, Wiltshire and Somerset (AGWS) Cardiac and Stroke Network website (www.agwscs.nhs.uk) and the NHS Improvement website (www.improvement. nhs.uk/afprojectsummaries): AGWS North Somerset final report and appendices, including guidelines and proformas. Future plans Eight of the nine participating practices plan to continue opportunistic screening The results of this project are currently being disseminated across the PCT to decided how this can be rolled out to other practices Practices feel that a yearly pulse check should be added to Quality Outcomes Framework (QOF) for high risk groups Some practices have added a pulse check to their chronic disease templates There is a strong feeling that a public awareness campaign about AF would be beneficial, as well as training to GPs on warfarin initiation. Contact details Network Administrator: Email: AGWSCSnetwork@UHBristol.nhs.uk Clinical lead: Dr Martin Hime
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Atrial Fibrillation Screening Project Bedfordshire and Hertfordshire Heart and Stroke Network, Bedfordshire Primary Care Trust, 23 GP Practices
Duration of project October 2008 Scope of project Opportunistic pulse screening at flu clincs What we did One practice originally targeted for pulse screening patients during flu clinics Oct 2007. (see publication Heart Improvement: Atrial Fibrillation in Primary Care - National Priority Project (www.heart.nhs.uk/priority_projects /summary_documents/af_summary.pdf) Subsequently a local enhanced service (LES) was developed to encourage wider uptake One primary care trust (PCT) implemented this during the flu season of 2008 Currently working with the three other PCTs in the network through local implementation groups and practice based commissioning groups (PBC) to role out the LES for the 2009 flu season. Key challenges Engaging PBC groups. What went well AF registers significantly improved in practices that took up the LES. Key learning from work Communication is essential Posters and leaflets developed for patients Ensure district general hospital (DGH) services are aware of this initiative, as this can increase referrals into the cardiology department significantly Important to have AF management pathways in place to support initiative. Outcomes 23 practices used the LES 6,000 patients screened 122 new patients added to the AF register.
Costs incurred Payment to practices - 10p per patient screened, 60 per patient added to AF register. Patient, carer and staff involvement Patients, clinicians and practice staff all felt the project was worthwhile and caused very little disruption to the flu clinic. The patients in particular were very pleased with the extra service when they understood the importance of the screening. Resources and tools developed to support the changes Available for sharing by contacting project lead Local enhanced service. Future plans Continued expansion of the pulse screening in GP practices across Bedfordshire and Hertfordshire and improve AF awareness in relation to stroke prevention Offer regular training on the management of AF. Sites outside your network where your approach has been adopted by others North Yorkshire Essex. Contact details Project and clinical lead: Delyth Williams Email: Delyth.Williams@bedfordshire.nhs.uk
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Atrial Fibrillation in Primary Care - Dudley Health Economy Black Country Cardiovascular Network, Dudley PCT, Dudley Group of Hospitals Foundation Trust, Worcester Street Commissioning Cluster, Wychbury Medical Centre
Duration of project September 2007 - ongoing Scope of project Streamlining pathways and guidance for patients with AF by development of a AF primary care pathway Training and development of primary care practices to improve AF screening, detection and management within the primary care setting Improving access to diagnostics - ECG Improving access to anticoagulation services. Baseline position Full review and audit carried out at Worcester Street Commissioning Cluster against NICE guidance July-September 2007. Investigation of Quality and Outcomes Framework (QOF) data - July 2007. Baseline assessment of hospital admissions at Russells Hall Hospital. What we did Baseline investigation at Worcester Street Practice against NICE guidance Formation of project group as sub-group of the Coronary Heart Disease (CHD) Local Implementation Team Action planning at pilot practice following baseline assessment Searches at Worcester Street Practice to identify further potential patients Review of patients identified by searches for potential AF Draft AF guidelines developed Development of outreach anticoagulation clinic at Worcester Street Practice ECG provision training at Worcester Street Practice for health care assistants (HCAs) Pulse checking for irregular rhythms added to all templates at pilot practice Finalisation of draft AF guidelines prior to pilot Carried out a borough wide primary care antiplatelet/anticoagulant audit in atrial fibrillation in conjunction with the practice based pharmacy team Identification of second pilot practice Wychbury Medical Centre Action planning at practice following baseline assessment
Searches at Wychbury Medical Centre to identify further potential patients Review of patients identified by searches for potential AF and anticoagulation treatment Training and development sessions around the screening, detection and management of AF for all GPs, practice nurses, health visitors and district nurses attached to the practice Pulse checking for irregular rhythms added to all templates at pilot practice Integration with the Dudley stroke steering group to develop a plan for roll out of the project borough wide. Key challenges Practice engagement - our original pilot practice received all of the training but then would not engage in the screening process due to priorities around moving to a new practice premises in the near future. We decided to abandon work with this practice and move on to another site for pilot purposes. What went well Engagement between primary care practitioners and the cardiologists during training sessions. Key learning from work It is difficult to engage primary care to complete this work with their busy schedules unless funding is available to incentivise. Outcomes Establishment of the AF pathway is still in development but this will be available when completed and launched to the wider health economy. Challenges for sustainability To spread this health economy wide it may need to be incorporated into a local enhanced service. Pulse checking has been incorporated locally into the NHS Health Check Programme. Costs incurred Only staff time which for this pilot was given free of charge.
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Patient, carer and staff involvement Positive feedback was received from the practice regarding the training they received. Resources and tools developed to support the changes Available for sharing from the Dudley PCT website (www.dudley.nhs.uk) and the NHS Improvement website (www.improvement.nhs.uk/ afprojectsummaries): AF primary care pathway. Future plans Currently planning how to spread the work economy wide once the electronic version of AF primary care pathway is complete including integrated work with the Dudley stroke steering group. Contact details Project lead: Joanne Gutteridge Email: joanne.gutteridge@dudley.nhs.uk Clinical lead: Dr Craig Barr/Dr Joe Martins Email: craig.barr@dgoh.nhs.uk Email: joe.martins@dgoh.nhs.uk
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Atrial Fibrillation in Primary Care Walsall Health Economy Black Country Cardiovascular Network, NHS Walsall, Walsall Hospitals NHS Trust, Lichfield Street Surgery
Duration of project September 2007 - ongoing Scope of project To deliver high quality care in line with Chapter Eight of the National Service Framework (NSF) To reduce emergency admissions for arrhythmia To develop streamlined whole pathways of care to reduce bed days and outpatient visits for this group of patients Develop an arrhythmia care pathway Improve access to anti-coagulation services in primary care Improve access to ECGs in primary care. Baseline position Baseline investigation at Lichfield Street Surgery against NICE guidance Baseline assessment of hospital admissions at Walsall Manor Hospital Baseline assessment antiplatelet/anticoagulant audit in atrial fibrillation across all practices in Walsall, in conjunction with the practice based pharmacy teams. What we did An audit was undertaken to look at 60 patients coded with a primary diagnosis of AF, how they were admitted and their length of stay. In conjunction with this a specialist registrar in public health has completed the report on the review undertaken on behalf of the group The medicines management team ran an IMPACT educational campaign on the management of atrial fibrillation and secondary prevention of stroke. The IMPACT campaign was developed to encourage a more structured and evidence-based approach to patient management. IMPACT pharmacists carried out face-to-face meetings with practices during the period of the campaign and all practices have now been completed. The IMPACT presentation was also delivered to year two doctors at the Manor Hospital as part of their ongoing educational programme, Heart Care Rehabilitation Centre clinicians and hospital pharmacy staff Formation of project group as sub-group of the CHD local implementation team reporting also to the long term conditions group Searches on systems at pilot practice to identify further potential patients and review of patients identified from search
AF guidelines to support the diagnosis and treatment of AF in primary care and a referral pathway from primary care into secondary care has now been agreed and the documentation disseminated to all GP practices to allow for further guidance Pulse checking for irregular rhythms has been added to all templates following IMPACT education sessions As part of the IMPACT campaign, practice pharmacists identified the proportion of AF patients currently prescribed anticoagulant/ antiplatelet therapy Using the CHADS2 scoring system, an audit of the practice population at Lichfield Street Surgery was carried out. Those on the practice AF register were identified using EMIS software. Patients not documented as receiving warfarin were identified as possible candidates for therapy. Patients were excluded from risk stratification if they had: 1. Documented return to sinus rhythm but remained on the AF register 2. Contraindications to warfarin therapy 3. Declined warfarin therapy in the last 12 months 4. A forthcoming appointment with their GP about commencing warfarin. Using medical records a CHADS2 score was calculated for each patient. Those with a CHADS2 score 2 were sent a letter to their home address explaining that they may benefit from warfarin therapy. They were invited to the surgery for a non-urgent consultation with a general practitioner of their choice to discuss starting warfarin. Four weeks after letters had been sent, the practice population was reaudited to determine the impact of the intervention Piloted AF screening at flu clinics at pilot practice from 28 September 2008 to 4 December 2008. Clinical staff felt the radial pulse of all patients having influenza vaccine. In a practice population of 7,504 a total of 1,324 pulses were recorded. Of those recorded 1,262 were found to be regular and 62 were found to be irregular. Of the 62 irregular pulses, 33 were known to have AF, seven were found to have AF following an ECG and seven are awaiting an ECG. Fifteen were found to have an ECG sinus rhythm with other causes of irregular pulse. These results show it was a worthwhile initiative that hopefully other practices take up next year. Seven new cases of AF were identified and seven more sent off for ECGs.
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It is worth using the services of the cardiac arrhythmia nurse as putting older people with AF on warfarin is much more effective in preventing strokes and has proved to be as safe (BAFTA study Lancet 2007) if regular INR monitoring is adhered to Arrhythmia clinic referrals at two pilot practices has been working well and has now been extended to all GP practices in Walsall. This clinic has 12 slots per week and is receiving regular appropriate referrals Integration with the Walsall Stroke Operational Group Presentation to the local medical committee (LMC) on the arrhythmia pathway. Teaching and education sessions to nurses from primary and secondary care have evaluated well Measures for AF will be monitored using Chronic Disease Register (CDR) Intell. Key challenges Engaging other practices still remains an issue. Not all practices are using the referral guidelines as intended and are still referring to cardiologists. What went well Engagement at pilot practice was very encouraging with links to secondary care and cardiologists. Key learning from work Getting practices to engage without additional funding remains an issue. Outcomes The referral pathway to the cardiac arrhythmia service works well with those GP practices engaged but still some work to be done. Pulse checking has been incorporated into the core set of checks for the NHS Health Check Programme in Walsall. Costs incurred Only staff time. Patient, carer and staff involvement Positive feedback has been received from the practices involved and the cardiac arrhythmia nurse.
Resources and tools developed to support the changes Available for sharing on the NHS Improvement website (www.improvement.nhs.uk/ afprojectsummaries): Impact campaign AF guidelines AF referral form. Future plans Looking to integrate more with the Walsall Stroke Operational Group Engaging remaining practices to refer to the cardiac arrhythmia service using the AF guidelines. Contact details Project lead: Angela Nelson Email: Angela.nelson@walsall.nhs.uk Clinical lead: Dr Rumi Jaumdally Email: Rumi.jaumdally@walsallhospitals.nhs.uk
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To standardise and develop an information package that supports patients along the referral pathway East Midlands Cardiac and Stroke Network (formerly Leicestershire Northamptonshire & Rutland Cardiac Network), GP Practices, Northamptonshire PCT
Duration of project 10 August 2007 - 01 August 2008 Scope of project To standardise and develop an information package that supports patients along the referral pathway. Process map the patient pathway Identify key information points Evaluate available information Identify who gives what to whom Survey users on information and its benefit (quality, clarity and timeliness) Develop a pathway with clear information indicators. Baseline position Information taken from QOF across sample of GP practices. Base line questionnaire on needs and pathways. What we did Evaluated feedback from questionnaire Assessed outcome from a data quality audit on 25 practices Brought together all evidence from NICE etc. including QOF and how to build a register Developed a folder of pathways and evidence including the use of CHADS2 scoring and ECG recognition Delivered ECG basic skills training for GP practices Distributed folder across Northamptonshire Asked for data quality team to run audit across Northamptonshire to assess impact of project Planned roll out of project across East Midlands in 2009/10. Key challenges Engagement from GPs ECG awareness skills in taking and reading Anticoagulation services access Audit time in data quality team programme. What went well Basic ECG skills evaluated well CHADS2 postcard evaluated well Pathway evaluated well Initial finding and feedback from audit.
Key learning from work Open project up to more GP practices at an earlier stage. This might be time consuming but it would ensure take up. Outcomes QOF indicators not yet available for project period. Challenges for sustainability The data quality team has been disbanded so can no longer carry out the audit. Costs incurred ECG training across county Printing cost for folder Both funded from network resources. Patient, carer and staff involvement Staff have found CHADS2 and ECG information useful and ECG training has evaluated well. Future plans Planned further training on ECG skills Include AF management in stroke workplan Anticoagulation baseline across East Midlands and project planned for 2009/10 Audit of QOF data to see if prevalence and lower indicators changes. Contact details Project lead: Ben Knight Email: benknight@nhs.net Clinical lead: Dr Shribman Email: jonathan@shribman.co.uk
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Primary Care Arrhythmia Service - Eastern and Coastal Kent PCT Kent Cardiovascular Network, Eastern and Coastal Kent PCT, East Kent Hospitals University NHS Foundation Trust
Duration of project November 2008 - ongoing Scope of project To develop a primary care arrhythmia service which will: Help GP practices identify AF and other arrhythmia patients by encouraging opportunistic screening Ensure existing AF patients are on optimal therapy (searches undertaken by use of GRASP-AF tool) Provide nurse-led primary care arrhythmia clinics Undertake and co-ordinate the patients diagnostic investigations Where necessary, refer patients to secondary care clinic for further management Manage appropriate patients within the arrhythmia service, or Refer patients back to the GP for management within primary care The service will act as the point of contact for sudden cardiac death, ensuring families have access to screening tests and information where appropriate. The three arrhythmia nurses are already in post and visiting practices. What we did A business case was prepared and submitted to the PCT. This was approved and recruitment began in summer 2008 for three arrhythmia nurses the last of which was in post by the end of November 2008. Key challenges Not all practices have welcomed the arrhythmia nurses and see them as an interference Conversely, others have been very supportive. There are only three arrhythmia nurses to cover a population of 710,000 and 115 GP practices. What went well Rapid approval of the business case by the PCT.
Key learning from work For a primary care arrhythmia service to be successful, it needs support from the neighbouring acute trusts consultant cardiologists Concentrate your initial efforts on those practices which can see the benefit of what you are doing. Outcomes It is too early to say what the outcomes are as the arrhythmia nurses have only started helping practices identify new patients and review existing ones. Challenges for sustainability Having permanently employed arrhythmia nurses will ensure sustainability. Resources and tools developed to support the changes All available for sharing by contacting the project lead: Business case Draft primary care education plan Arrhythmia nurse job description. Contact details Project lead: Tim Waite Email: tim.waite@nhs.net Clinical leads: Dr Mark Fenton Consultant Cardiologist East Kent Hospitals University NHS Foundation Trust Email: mark.fenton@nhs.net Shelley Sage Head of Community Cardiology Nurses Eastern and Coastal Kent PCT Email: shelley.sage@eastcoastkent.nhs.uk
www.improvement.nhs.uk/heart
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Primary Care Arrhythmia Service - Medway PCT Kent Cardiovascular Network, Medway PCT, Medway NHS Foundation Trust, Medway Maritime Hospital
Duration of project September 2007 - ongoing Scope of project Develop a primary care arrhythmia service which will: Help GP practices identify AF and other arrhythmia patients by encouraging opportunistic screening Ensure existing AF patients are on optimal therapy (searches undertaken by use of GRASP-AF tool) Provide nurse led primary care arrhythmia clinics Undertake and co-ordinate the patients diagnostic investigations Where necessary, refer patients to secondary care clinic for further management Manage appropriate patients within the arrhythmia service, or Refer patients back to the GP for management within primary care The service will act as the point of contact for sudden cardiac death ensuring families have access to screening tests and information where appropriate. Business case for two primary care arrhythmia nurses has been approved by the PCT Board with the aim of having the nurses in post by late summer 2009. Baseline position QOF data for Medway PCT suggests an under identification of approximately 1,300 AF patients. Key challenges Length of time it has taken to get approval for the business case. Challenges for sustainability Having permanently employed arrhythmia nurses will ensure sustainability.
Resources and tools developed to support the changes Available to share by contacting project lead Business case. Future plans The same model is already in operation in Eastern and Coastal Kent PCT. Contact details Project lead: Tim Waite Email: tim.waite@nhs.net Clinical leads: Dr Adrian Stewart Consultant Cardiologist Medway NHS Foundation Trust Email: adrian.stewart@medway.nhs.uk Mary Kirk BHF Consultant Nurse Medway PCT Email: mary.kirk@medwaypct.nhs.uk
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Atrial Fibrillation Opportunistic Screening and Patient Review Pilot South of West Kent - West Kent PCT Kent Cardiovascular Network, West Kent PCT
Duration of project 1 July 2009 - 31 February 2010 Scope of project The project has two aims: first to pilot the efficacy of opportunistic screening for atrial fibrillation within general practice of patients aged >65 years. This is in order to identify undiagnosed patients and ensure that they are added to practice registers and rapidly gain access to the appropriate treatment pathway (opportunistic screening has been shown to increase detection of AF by 60%). The purpose is to make opportunistic pulse checks a matter of routine. Second to review existing AF patients to ensure they are on optimal therapy using the GRASP-AF tool. Nine to ten GP practices in the South of West Kent are going to be involved in the project. Baseline position The detailed planning of the project has just been completed and practices are now being recruited to join the project. What we did The Kent Cardiovascular Network has provided funding to support the project Baseline data will be collected before the start of the project. Progress will be reported every two months and reviewed. Payments to practices are contingent on receipt of the bi-monthly data. Key learning from work Unable to report any key learning at the moment as project not due to start in earnest until July 2009.
Outcomes Unable to report outcomes at the moment as project not due to start in earnest until July 2009. Resources and tools developed to support the changes All available for sharing through contacting the project lead: Project proposal Project process Data collection forms GP agreement to join the project. Contact details Project lead: Tim Waite Email: tim.waite@nhs.net Clinical lead: Dr Paul Goozee Email: pg@hmg.nhs.net
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Management of Atrial Fibrillation in Primary Care Cardiac and Stroke Networks in Lancashire and Cumbria, Six GP practices in Lancaster and Morecambe, Royal Lancaster Infirmary (University Hospitals of Morecambe Bay NHS Trust), North Lancashire Primary Care Trust, Lancaster, Morecambe, Carnforth and Garstang Practice Based Commissioning Consortia
Duration of project 17 December 2007 - 31 March 2009 Scope of project In May 2007, members of the network primary care group identified that the NICE clinical guideline 36 published in June 2006 contained a number of confusing algorithms, therefore unlikely to be effectively implemented by GPs in primary care. Previous work undertaken by Blackpool, Fylde and Wyre health economy had produced an algorithm and supporting guidance focused on management in primary care. This was shared and adapted for network wide use and assessment of its effectiveness formed the basis for this project (Appendix A). The following objectives were set to support this evaluation and to align with the recommendations of the National Heart Improvement Programme: Ensure that AF prevalence in the practices matches what is expected nationally Ensure that all diagnoses have been confirmed as per NICE guidelines Ensure that all patients are receiving antiplatelet/anticoagulation therapy as appropriate Review prescribing trends for AF patients against NICE/local guidelines Address training needs, in particular around ECG recording and interpretation Review local anticoagulant service and address service improvements. Baseline position According to Quality Management and Analysis System (QMAS) data, AF prevalence in all but one of the six pilot practice is above nationally expected levels taken as 1% of total population, 4% of over 65s and 10% of over 75s. However, some practices registers required validating in view of the high elderly population. King Street, as a university practice was identified as an outlier in relation to the expected prevalence, with a prevalence of 0.58%. Baseline prevalence data (Appendix B) QOF data suggests that confirmation of diagnosis is good. Baseline prescribing data (Appendix C) indicates that warfarin prescribing particularly in the >75s is lower than recommended. At the practice visits, training needs were identified in relation to ECG recording and interpretation. It was decided in view of the difficulties in
maintaining a rolling programme of ECG training and the subsequent resource implications that this would offer an ideal opportunity to pilot the role of telemedicine for the interpretation of ECGs in primary care. What we did Established a project steering group, with representation from all stakeholders, to agree aims and objectives, provide guidance and support to the project Developed a project guide to inform stakeholders of background detail (Appendix D) Developed a communication plan to ensure that stakeholders are kept informed of developments (Appendix E) Collated and analysed baseline and final data (working with network data analyst) Visited each practice team individually to outline project aims, request baseline data and disseminate and discuss management of AF in primary care guidelines Following feedback from clinicians on the guidelines it was agreed that acute presentation of AF needed to be addressed within the supporting guidance. Amendments were made and resubmission to clinical governance was undertaken A poster shared through the national team was disseminated to all practices for use in raising awareness of AF and pulse checking as a screening tool (Appendix F) A flyer was also produced by the network to explain to patients the importance of pulse checks in identifying patients with AF and the risks associated with the condition (Appendix G) Worked in collaboration with colleagues in secondary care in relation to the local anticoagulation service, including a process mapping event. A summary of the learning and service improvement ideas generated are detailed in Appendix H The use of telemedicine to support GPs in the interpretation of ECGs was piloted The use of a single lead event monitor within primary care was piloted Following consultation with lead GPs from each practice, the two pilot projects were initiated in four practices and evaluated through the analysis of audit forms completed by the GPs (Appendix I, J) The governance issues surrounding these pilots were addressed and supported by NHS North Lancashire (Appendix K, L)
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Following analysis of the prescribing trends by North Lancashire Medicines Management, recommendations were made that could be incorporated into patient individualised medicines reviews by either the practice pharmacist or GP Final sustainability score report was undertaken (Appendix M). Key challenges Maintaining engagement of the practice teams The challenges within the telemedicine pilot included full engagement of all practices and individual GPs and promoting use of the single lead diagnostic tool The evaluation of the ECG interpretation audit was time consuming and complex. What went well Enthusiasm from the project team was high and clinical leadership essential Involvement and support from the patient representative proved helpful, both with the mapping event of the local anticoagulation service, and also in relation to feedback on leaflets and posters used throughout the project The steering group meetings were infrequent but attendance from every stakeholder group was high (PBC, PCT, GP clinical lead, patient, network) Although the telemedicine pilot was seen as time consuming with a high administrative burden, out of all data entries the data was 98% complete. Key learning from work Recurring themes were identified in relation to the identification and management of patients with AF: Final data collection has illustrated an increase in prevalence in all age groups across all practices. This may be due to raising the profile of AF within the practice teams, through the adoption of the network guidelines, the initiation of opportunistic screening methods or register validation Practices need to ensure that manual pulse checks are inserted into all appropriate chronic disease templates. It was identified that since the increased use of digital blood pressure (BP) monitors, pulse palpation was being neglected, when in actual fact it was all the more important Alternative methods of opportunistic screening have been discussed and shared by all participating practices, focusing in particular on those at higher risk
All practitioners have concerns about warfarin prescribing in >75s Many GPs are accessing the local anticoagulant service differently and are not confident that this aspect of their AF management is being delivered effectively. Local service provision requires review and could be addressed through PBC. Telemedicine key learning Assessment of GP competency to interpret ECGs was complex The use of the single lead diagnostic tool in primary care was useful and quicker results were obtained than accessing secondary care for ambulatory monitoring Whilst this project assessed competency of GPs to interpret ECGs, it was highlighted that the quality of the ECG recording was equally important. Outcomes Practices have reported that as a result of validation work and opportunistic screening they have increased numbers on their AF register. Final prevalence data and comparisons (Appendix N). Discussions have begun with colleagues in secondary care in relation to some redesign of the anticoagulation service. A number of developments have been identified for discussion by the PBC consortia. Warfarin prescribing increased in half of the practices however, more guidance is being sought to support warfarin prescribing, particularly in >75s. Currently the NICE algorithm is still being used to support decision making, although the use of the CHADS2 tool has been considered. The opportunity to pilot the Auricle decision support tool was considered but declined on account of the decision to undertake a telemedicine pilot. The final data collection of prescribing trends in relation to rate control of AF was variable. However, there was a reduction in the use of digoxin in four out of six of the practices. It was concluded that the support of the PCT Medicines Management Team is key to the success of guideline implementation in relation to prescribing. Final prescribing data and comparisons (Appendix N).
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Telemedicine pilot The aims of the project were: To assess ease of use and the clinical and personal impact of technology for ECG interpretation and single lead diagnostic monitoring To assess the required capacity and also the outcomes of the interpretations for each of the referral criteria (clinical symptoms, long-term conditions monitoring, screening prior to referral) To assess GP competency levels in relation to ECG interpretation to inform GPs, secondary care and PCTs To share findings and support wider dissemination. Telemedicine results (Appendix 0) NB: All appendices A-O are available from the NHS Improvement System Summary and recommendations Validation of registers Practices need to have a register of patients with active disease, excluding patients who have been cured by cardioversion or ablative therapy. Whilst the QOF register should reflect this, the atrial fibrillation resolved codes are often not used (validation will in fact tend to make the registers smaller). Medication reviews Practices need to review patients medication annually and adherence to the guidelines can be supported through recommendations from medicines management. Opportunistic screening The recommendation from the guideline to opportunistic screening was adopted by the practices and resulted in more AF patients being identified. Practices should ensure that manual pulse palpation checks are embedded within the appropriate chronic disease management templates and that the whole primary care team are aware of their responsibilities for screening for AF in their practice population.
Implementation of guidelines Since the inception of the project, map of medicine has been adopted in most PCTs across the network. It is recommended that formal links between map of medicine and the guidelines are established in order to support its implementation. Warfarin prescribing (particularly in >75yrs) An agreed decision making tool used both in primary and secondary care should be adopted to reduce many of the uncertainties around prescribing and increase uptake. Consistency is probably more important than which exact tool we use e.g: CHADS2, NICE or SIGN. Telemedicine It was difficult to assess ease of use and acceptability of the service by the practices as they found the audit process was time consuming and high levels of administration were required. This may have influenced the perception of the telemedicine service Interpretation skills amongst GPs vary and assessment would be best done individually rather than as part of a wider audit. Full participation from all GPs as individuals was not achieved and did not highlight any one particular practice with a training requirement or competency issue Assessment of the requirements for practical ECG recording training should be considered Some GPs felt that they would prefer to see the ECG at recording as opposed to only having sight of it when receiving the report The turnaround time from Broomwell was seen as a positive benefit of the service and the recommendation for practices to assess their own ECG interpretation processes should be implemented PCTs should assess both elements of the telemedicine service as an operational need prior to implementation. Assessment of need should be carried out on an individual practice basis Proposed telemetric links between primary and secondary care may well support GPs further and PCTs should horizon scan future developments The single lead diagnostic device may not have been fully utilised, but access to a mobile, easy to use and accessible diagnostic within primary care, specifically for arrhythmia patients was seen as effective and useful.
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Challenges for sustainability A sustainability score and report was undertaken derived from the NHS Sustainability Model and Guide, developed by the NHS Institute for Innovation and Improvement. The sustainability model is a diagnostic tool that is used to predict the likelihood of sustainability for improvement projects and this has been applied to our management of atrial fibrillation in primary care project. Recommendations Review the organisational link between the PCT and PBC to establish adequate quality metrics Staff training in relation to Atrial Fibrillation management Raise the profile of AF and review its management in primary care. Incentivisation may be required to sustain services for AF patients in general Links to the NHS Health Check Programme and the prevention of cardiovascular disease should incorporate the screening for AF. Sustainability score report (appendix M). Costs incurred Costings for the telemedicine pilot were 6,000 for a period of three months for the four participating practices. Broomwell contributed 2,000 to these costs with the network funding the balance A project manager was appointed and funded through Heart Improvement Programme monies for two days a week for the duration of the project The project lead was assigned to work one day a month on the project out of her three day working week as a service improvement manager for the network. Patient, carer and staff involvement Patients reported liking the use of the single lead device and found it easy to use Staff reported that they felt much more aware of atrial fibrillation and their role in screening and identifying patients with the condition Staff became more aware of the network and its role in supporting the management of heart disease.
Resources and tools developed to support the changes: Available for sharing from NHS Improvement website (www.improvement.nhs.uk/af /projectsummaries): Baseline prevalence data Baseline prescribing data Project guide Project communication plan Poster Stroke the Beat Flyer Why have your pulse checked Process map and action plan Audit form ECG interpretation Audit form One lead device Serious untoward incident reporting algorithm Patient consent Telemedicine pilot Sustainability score report Final prevalence/prescribing data Telemedicine powerpoint presentation. Future plans The network plans to share this report initially with the participating practices and the host PCT and thereafter to the other PCTs in the region It also intends to align the learning with future developments in relation to prevention and detection of cardiovascular disease. Sites outside of the network where the approach has been adopted Apart from sharing developments with other networks involved in the national priority project, the guideline has also been shared with a neighbouring network area at their annual educational event. Contact details Project leads: Lauren Butler and Jean Hayhurst Email: lauren.butler@csnlc.nhs.uk Email: jean.hayhurst@csnlc.nhs.uk Clinical lead: Dr Andrew Gallagher Email: andrew.gallagher@gp-P81056.nhs.uk
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Atrial Fibrillation in Primary Care in Rotherham North Trent Network of Cardiac Care, NHS Rotherham
Duration of project July 2007 - ongoing Scope of project The initial aim of the project was to address atrial fibrillation, to ensure correct diagnosis, appropriate treatment within primary care and referral to secondary care as required. As the project was progressing the PCT was in the process of introducing near patient testing for anticoagulation in primary care and the focus changed to concentrate on developing this service. An ongoing rolling program of training has been initiated for staff across primary care which includes ECG training (both undertaking and interpretation), hypertension updates, CHD updates, CHD diploma, heart failure (HF) updates, stroke study days and cardiovascular risk assessment days (with the opportunity of becoming accredited). Baseline position The population being reviewed was that within the Rotherham PCT sector. The aim was to review what services were available within both secondary and primary care for patients with atrial fibrillation or for those at risk of developing atrial fibrillation. This also covers the population affected by the development of the near patient testing service for anticoagulation. What we did Evaluated how many practices undertook ECGs: Who undertook the ECG Who interpreted the ECG What training they had received When had they received the training Did they refer the patient into the open access service in secondary care Scoping exercise to identify what training and competencies are available to support near patient testing for anticoagulation Developed a rolling program of training for staff across primary care including GPs, nurses, health care assistants and allied health professionals
Set up train the trainers for people working with the south asian population to advise about the risk and symptoms of cardiovascular disease and these are to be repeated and aimed at all BME populations Held public awareness sessions for people from the south asian population to raise awareness about cardiovascular disease and these are to be repeated and are open to the general population The Coronary Heart Disease Local Implementation Team (LIT) encompassed stroke and became the Cardiovascular Disease (CVD) LIT the lead physician for stroke and the PCT lead for stroke both sit on this group A stroke pathway group has been established which feeds into the CVD LIT A gap analysis on atrial fibrillation was undertaken and as a result of this a patient safety group for anticoagulation has been established to drive the work forward on near patient testing including developing service specifications, standard operating procedures and a programme of training Other areas of work relating to atrial fibrillation identified in the gap analysis will be picked up once the work around anticoagulation has been completed A review of admissions to secondary care in 2007 with a primary diagnosis of atrial fibrillation was undertaken, and also of those with a secondary diagnosis of atrial fibrillation/flutter several had a diagnosis of TIA, stroke or cerebral haemorrhage Reviewing how to introduce manual checking of pulse within primary care. Key challenges Getting manual pulse adopted by GP practices as a routine check Setting up the anticoagulation near patient testing service Getting atrial fibrillation on to the stroke agenda Reviewing the whole of the atrial fibrillation pathway Identifying training opportunities to support anticoagulation services Ensuring that other areas identified as needing attention within the gap analysis are targeted.
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What went well The training programme has been very successful and continues to be so. Staff within general practice including GPs, nurses and health care assistants have attended the study days and undertaken diploma courses. Much of the training is now being repeated, and we hope to offer diplomas in stroke and atrial fibrillation in the future Gap analysis identified that there were major issues in developing the work around near patient testing and anticoagulation and this led to the initiation of the patient safety group for anticoagulation and targeted work in this area The standard operating procedure and service specification are being developed for the near patient testing service for anticoagulation under locally enhanced services (LES) Meetings have been held to review what the educational needs for people who are initiating treatment are as against those who will be maintaining treatment, and how to link these in with the competencies. Training days are being developed for practice staff who will be maintaining patients for anticoagulation. Key learning from work Perseverance Linking atrial fibrillation in with the stroke agenda How to have manual pulse checking accepted as routine this is ongoing That although near patient testing is important there are still many other areas which need review as identified in the gap analysis for atrial fibrillation. The near patient testing service will also in some areas include initiation of the treatment and this will have an impact on the number of patients who currently have to be referred and seen in secondary care for this service.
Outcomes That a locally enhanced service (LES) will drive the work around near patient testing and anticoagulation within Rotherham That patients who would have had to attend secondary care for this service may now be able to access it at a local level Atrial fibrillation is rising up the stroke agenda. Challenges for sustainability There are issues around getting manual pulse checking accepted as a routine check Ensuring that staff attend regular updates regarding the near patient testing. Future plans To set up educational training days for staff within primary care both GP practices and provider services and also to link in with nursing and care homes and the housebound To have manual pulse checking adopted as routine. Contact details
Project lead:
Ann Baines Email: Ann.baines@rotherhampct.nhs.uk
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Atrial Fibrillation in Primary Care Project North Trent Network of Cardiac Care, Sheffield PCT, Sheffield Teaching Hospitals Foundation Trusts (Northern General Hospital), Six GP practices
Duration of project March 2008 - March 2009 Scope of project In Sheffield, there is considerable variation in diagnosis of AF across the city, demonstrated by the wide variation in QMAS (QOF) reporting for 2006/7. The percentage of patients with AF who are currently treated with warfarin therapy is also variable. A steering group was established with clinicians from general practice, the acute trust, public health and provider services. Sheffield Teaching Hospital Foundation Trust (STHFT) planned to pilot a fast track AF clinic alongside the AF primary care project, enabling pilot practices to fast track appropriate patients to secondary care (Appendix A). Ten practices were identified in
areas of high deprivation which also linked to the enhanced public health programmes. Six of the ten practices were invited and recruited between March 2008 and October 2008. Practices were asked to: Use opportunistic screening to identify patients with AF over the age of 65 Run a MIQUEST query which would risk stratify patients using the NICE algorithm and would assist practices in reviewing current management of patients with AF Refer appropriate patients to the enhanced public health programmes in their area (e.g. weight management programmes) Refer appropriate patients to the pilot fast track AF clinic at STHFT.
Baseline position Results of opportunistic screening for atrial fibrillation for patients over 65 in pilot GP practices
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What we did The project approach was to identify pilot practices through prevalence and individual practice data. Practices would be asked to screen patients using opportunistic screening of patients 65 and over (reference the SAFE Study. Health Technology Assessment 2005; 9:1-74). Support would be provided to enable practices to review current management of patients with a diagnosis of AF and to review their protocols to ensure they are evidenced based and consistent with current best practice. Support would be offered to practices to develop appropriate treatment services such as practiced based anticoagulation services. Six practices were recruited. All six practices agreed to use the opportunistic screening approach for the identification of AF in the over 65s. Two practices opted out of searching their system for unidentified patients and management review of current patients using the MIQUEST query, as the practices have systems in place to do this. Four practices were happy to discuss running the MIQUEST query once it had been developed and tested. The MIQUEST query risk stratified patients according to NICE stroke risk algorithm. All six practices welcomed the opportunity to refer to the enhanced public health programmes and the pilot fast track AF clinic. Key challenges Lengthy process developing MIQUEST query as the IT person was not given any dedicated time for the project. Different practice systems meant amendments to MIQUEST Actually getting appointments to visit practices. Difficulty getting everyone to meetings due to other commitments. Attendances at project meeting were good for the first six months but then began to tail off. What went well The practices visited were all very keen to participate in the opportunistic screening because there were no targets or extra workload involved. One practice contacted the enhanced public health programme and set up a weight management programme for their patients. Five patients were referred to the fast track AF clinic at the Northern General Hospital.
Key learning from work The project practices may have been too small Perhaps recruit all interested practices not just those linked to enhanced public health programmes Identify resource needs prior to the project although we did this it was on an ad hoc basis which is why it took so long to develop the MIQUEST query Commitment needed from practices to review their patients when they have been identified. Outcomes Sixteen new patients were identified by four of the six pilot practices between April 2008 and February 2009. Extrapolating these results to the whole of Sheffield practices identifies 248 new patients Due to the lengthy process of developing the MIQUEST query and the availability of the IT specialist the query was not tested in a practice with live data until March 2009 The test resulted in the identification of: Seven patients risk stratified as high risk with a diagnosis of AF who are not on warfarin or asprin and have no contraindications recorded 38 patients at high risk with a diagnosis of AF were on asprin only with no contraindications recorded 23 patients did not have their diagnosis confirmed by ECG and other review diagnosis (2) The practice was given a report with named patient data and asked to consider reviewing these patients. The practice plan to review these patients These results should be viewed with caution as we were unable to access exception reporting information at the time. We plan to run the query in another pilot practice. GPs have been asked to comment on the accuracy and usefulness of the information provided and whether patients have been reviewed as a result of the information Quick reference AF management guidelines have been developed for GPs The guidance has been approved by the area prescribing committee and PEC and have been circulated to all GP practices in the city. Note: Anticoagulation in general practice is a separate PCT project.
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Costs incurred None Patient, carer and staff involvement Although the project has ended opportunistic screening and reviewing the management of patients with AF has now become part of the primary/secondary prevention phase of our stroke project. Practice staff and PBC through the stroke project have expressed an interest in the results of the project. Resources and tools developed to support the changes Available for sharing via NHS Improvement website (www.improvement.nhs.uk/afprojectsummaries): GP management guidelines Fast track AF clinic referral form and criteria Information pathway. Future plans Now part of the stroke project Work is currently underway with PBC to develop arrhythmia services and pathways in primary care Sheffield Teaching Hospital NHS Foundation Trust have developed a palpitations clinic which runs alongside the AF clinic Plans to develop the service further to include post ICD patients Palpitation service in primary care to commence from June 2009, followed by 24 hour ECG service in primary care. Contact details Project lead: Colette Longford Email: Colette.longford@sheffieldpct.nhs.uk Clinical lead: Dr Brian Hopkins Email: b.j.hopkins@sheffield.ac.uk
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Near Patient INR Testing Project - Whitby Group Practice North and East Yorkshire and Northern Lincolnshire (NEYNL) Cardiac and Stroke Network, Whitby Group Practice, Robin Hoods Bay Surgery (satellite surgery)
Duration of project August 2007 - March 2008 Scope of project The project aimed to: Reduce the number of INR tests required to maintain good control Improve patient convenience Improve efficiency in the use of GP/nurse time Reduce the potential for dosing error. Baseline position Current practice population 15,133 AF registers showed 229 patients in practice on warfarin from a possible 267. A case note review was performed to ensure patients were not inappropriately untreated A satisfaction survey was performed on staff and patients. Whilst staff were dissatisfied with the service, patients found the current service efficient and were generally satisfied Using lab-based testing at baseline position What we did Equipment purchased by practice manager including three Coagucheck XS plus monitoring machines, testing strips and INR star software All nursing staff trained in the use of equipment and the use of the software Appointment slots redesigned Mechanism of calibrating equipment and validating tests set up with lab System set up within the practice with GP who will check and advise on results if required. Key challenges Training delays due to staff sickness and cover meant there were some delays transferring to the new system Disseminating timetable of changing practice to the GP partners The district nursing team found the changes made them more involved in the dosing process which their PCT were unhappy with. This resulted in the practice nurses having to take over the dosing and informing patients once the INR result was obtained by the community nurses. Not ideal but not appropriate to have a two-tiered system with some patients on labbased testing and some patients on near patient testing.
What went well The patients adjusted very well to the change over The company we used to supply the equipment were easy to contact and gave us lots of support The support from the network was brilliant. Key learning from work Good planning makes all the difference Be aware that not all changes are positive for everyone. Outcomes Practice registers were audited and any patients not on warfarin with no coded contraindication were checked CSW time on telephone measured as 21 hours per week using the old system dramatically reduced as fewer lab tests required. Challenges for sustainability None that we are aware of, apart from the district nurse situation which is frustrating. Costs incurred Approximately 9,400 last year for testing strips and the quality control testers for the machines to Roche. Approximately 150 per machine for NEQAS testing. Pump priming costs were paid by NEYNL Cardiac and Stroke Network. Patient, carer and staff involvement All positive from patients. District nurse team found it challenging however since the practice nurses have taken over the dosing and informing patients once the INR result was obtained this has improved. Future plans No future plans to expand or apply elsewhere by this practice although learning shared withy other areas for their use. Sites outside the network where the approach has been adopted by others Jackie Edwards, Practice Pharmacist West Kirby Health Centre, Wirral PCT. Contact details Project and clinical lead: Melanie Dunwell Email: Melanie.dunwell@gp-b82017.nhs.uk
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Atrial Fibrillation in Primary Care Surrey Heart and Stroke Network, 13 GP practices in Woking and West Byfleet, Surrey PCT
Duration of project January 2008 - October 2008 Scope of project To improve detection and treatment of atrial fibrillation in a sample of practices in Woking and West Byfleet in order to make best practice recommendations for rollout across Surrey. Baseline position Thirteen practices with a combined population of 107,304. Of these patients, 1,346 were already registered by March 2007 as having AF, giving a prevalence of 1.25%. What we did A clinical lead was appointed for the project A project steering group that included a GPSI cardiology, PCT commissioning lead, consultant cardiologist, pharmacist and IT lead was established Thirteen out of 15 practices across three practice based commissioning groups were recruited. There were three stages to practice involvement in the project: Attendance at a lunchtime session practice update to be led by consultant cardiologist, covering primary care management of AF Opportunistic screening to detect people with atrial fibrillation twinned with piloting the use of a hand-held ECG machine Review of patients already diagnosed with AF to improve rates of anticoagulation (stroke prevention). Patient satisfaction was sought on information that they receive about AF through a targeted questionnaire and a focus group. Opportunistic screening Practices were given a care pathway to follow for three months requiring patients aged over 64 years who were not on the AF register to have their pulse taken when presenting for an appointment at the practice. A basic care pathway with READ codes was given to all GPs in the pilot practices, along with various reminder posters and flyers for both clinicians and patients. In addition, practices were given a hand-held ECG monitoring device called the Omron Heart Scan and corresponding software.
Review of patients Practices were asked to use MIQUEST (GRASPAF) search and spreadsheet being developed by West Yorkshire Cardiovascular Network with PRIMIS+ to identify AF patients, risk stratify for stroke using CHADS2 and review for prescribing warfarin as part of an incentivised scheme. Key challenges Maintaining momentum in wide range of practices Getting information back from practices. What went well Most were happy to do the opportunistic screening without payment and continue to take pulses now opportunistically, although not routinely recorded. Key learning from work The MIQUEST search identified patients who had AF in the past but no longer did, generating unneeded patient reviews CHADS2 was welcomed by the majority of practices as an easily administered stroke risk decision making tool There is a wide variety of practice with respect to who to prescribe warfarin to for AF. Outcomes Practice updates 34 clinicians, mostly GPs, attended two sessions. Overall evaluation was excellent; GPs really welcomed local educational updates of such a high quality and indicated a preference for such updates in the future. However, it was difficult to arrange mutually convenient dates and times in outer Woking, the largest area with most of the pilot practices. Opportunistic screening Three practices out of a potential 13 returned information on numbers of people newly diagnosed with AF following opportunistic pulse palpation.
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407 patients out of 3,000 patients over the age of 65 years, who attended the three practices over the three month period were READ coded for pulse palpation (13.6%). 11.5% of these 407 patients had an irregular pulse (47) 18 went on to be diagnosed with atrial fibrillation (4.4% of those READ coded for pulse palpation). There was a wide variance in use and acceptability of the Omron Heart Scan. The majority of practices did not find it useful. There were issues with downloading the software that allowed clinicians to view the ECG trace in greater magnification and a single-trace ECG was not clinically acceptable for most GPs when investigating possible AF. One GP who found it very useful was one with a special interest in cardiology. Review of patients 56% of all AF patients had a CHADS2 score of two or more i.e. were high risk for stroke 41% (378) of these high risk for stroke patients were not being prescribed warfarin; aspirin was the most common antithrombotic alternative with a small number being prescribed clopidogrel Nine out of the 13 practices that were sent reports that highlighted these patients carried out patient reviews. The remaining four did not return audit forms 178 (71%) patients in these nine practices had their notes reviewed to see if they could be safely switched to warfarin 41 patients attended for medication review (the remainder was ruled out as being unsuitable for warfarin following a review of their notes) Eight patients were switched to warfarin amounting to 2% of the total number of patients in these nine practices who were highlighted as being at high risk of stroke. The overall conversion rate to warfarin is very low, certainly in comparison to Leeds where the same exercise was carried out but patients notes were initially reviewed by arrhythmia nurse specialist with 50% being tagged as appropriate for warfarin. The main reason given for patients not being switched to warfarin was not suitable. AF guidelines were circulated to all practices in Surrey in June 2008. This includes a care pathway.
A service specification is being written for atrial fibrillation. All practices are to be sent very clear information about warfarin and stroke; practice-based pharmacists have agreed to talk to all practices about GRASP-AF and CHADS2, the aim being to review all patients in Surrey to see if more could be converted from aspirin to warfarin to prevent stroke. Acute trust cardiology departments are to write to GPs whenever they refer patients for AF investigation/management asking them to CHADS2 score where appropriate. Challenges for sustainability If we utilise practice-based pharmacists to continue spreading the word about AF, ensuring that it is in their work plan, it could be sustained quite well. They are already planning to review beta blockers which will include some AF patients as well as hand delivering the AF and warfarin flyer that we are currently developing. The best way to make sustainable changes though is via contracts i.e. QOF. Including CHADS2 scoring in QOF for AF patients would make a big impact on awareness. Costs incurred Summary To trial use in primary care to see if they reduce need for 12-lead ECGs 5,872.06 To trial use in community to see if they improve detection of AF 2,998.00 To encourage practitioners to follow NICE guidance when managing AF 165.00 To attract clinicians to education session with Vince Paul 56.68 To carry out a focus group with AF patients to better understand their experiences of having AF 171.66 To encourage review of patients from MIQUEST search 1,139.00 Feedback from practices - cancelled due to lack of interest 235.00 Arrhythmia and SCD masterclass 1330.00. NB. Full budget is available through the NHS Improvement System.
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Patient, carer and staff involvement Patient satisfaction Two of the pilot practices posted out a questionnaire to all the patients on their AF registers: Information about AF was not routinely given out to these patients. Most reported that they felt alone at the time of diagnosis and had no one to ask questions Most were aware of the stroke risk concomitant with having AF, but the majority were much more concerned with controlling their AF symptoms e.g. palpitations They were not really sure what meaningful actions they could take to reduce their risk of stroke There were lots of questions about medication, surgical interventions, cardioversion, symptoms. It really felt as though there is a large unmet need in this patient group Developing a support group for people with AF was popular at the focus group session itself. All reported how good it was to talk to other people with the same condition and to swap tips and advice. Linking AF patients with existing cardiac support groups at the time of diagnosis would be the most efficient way of ensuring such patients received peer support. Resources and tools developed to support the changes Available for sharing through the NHS Improvement website (www.improvement.nhs.uk/ afprojectsummaries): Project budget Poster to remind clinicians to take pulse West Surrey AF in primary care final report Final protocol for AF in primary care project Project budget.
Future plans None at present Sites outside of the network where the approach has been adopted by others Contacted by networks in Kent and Sussex for details of the project and shared project protocols and other resources. Contact details Project lead: Liz Patroe Email: Liz.patroe@surreypct.nhs.uk Clinical lead: Dr. Vince Paul provided initial support.
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GRASP-AF (Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation) West Yorkshire Cardiovascular Network. Early stages of project Leeds PCT and Leeds Teaching Hospitals Trust. During development of tool test sites in Bradford and Airedale PCT, Kirklees PCT, Wakefield PCT. Completion of tool York Health Group participating in live project to demonstrate working of tool in practice
Duration of project September 2007 - January 2009 Scope of project To develop a MIQUEST IT based search tool to run on all GP practices covering all IT systems to risk assess for stroke and score all diagnosed AF patients using CHADS2 The tool will produce excel spreadsheet information on all AF patients allowing GP practices in order of risk score to review their patients and manage according to need The tool will also provide access to evidence based medicine within advice files and a pod cast. Baseline position Phase one (development stages): Six practices Population: 55,500 AF register: 722 Prevalence: 1.3% Number of patients CHADS2 score >1: 398 (55.1%) Number of patients CHADS2 score >1: not on warfarin: 176 (44.2%) The above pilot demonstrated potential numbers after running the tool. Phase two: Eight practices Population: 65,000 AF register: 981 Prevalence: 1.4% Number of patients CHADS2 score >1: 422 (43%) Number of patients CHADS2 score >1 not on warfarin: 221 (52%) (BHF Nurses undertook reviews) Number of patients reviewed: 168 Number of patients with no contraindication: 78 (46%) Number of patients with relative contraindications: 63 (38%) Number of patients with absolute contraindications: 27 (16%) The second pilot showed the first pilots estimations in terms of numbers expected were accurate.
Figures unknown as to how many patients were prescribed warfarin from reviews as GP would need to agree and prescribe following nurses recommendation. After tool completed and available for use: York Group Project: 24 practices Population: 230,960 AF register: 3678 Prevalence: 1.6% Number of patients CHADS2 score >1 not on warfarin (for review): 935 (25%) Estimated number of patients with no contraindications to warfarin: 473 (51%) Project due to complete June 2009. What we did The early stages of the project were spent engaging relevant people to commit to the project. Once agreement was reached on the scope of project, business cases were written for network funding to develop the tool. Meetings were arranged with PRIMIS+, cost agreed and commencement of writing the algorithms began. The tool had been produced in a pilot phase working only on EMIS based IT systems, the phase one calculations and findings were carried out to demonstrate the early workings of the tool, this contributed to the process of securing Network funds. Whilst the tool was being developed fully a phase two stage of using the EMIS based tool was carried out demonstrating further evidence for the work. During the later stages of the tool being finalised (2008) the network approached a PBC alliance in York (Network Primary Care Clinical Lead member of York Health Group) and meetings were arranged with PBC board to present the tool and gain agreement to participate in first live project of the GRASP-AF tool. Agreement was reached and presentations to the PBC practices took place in January 2009.
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Sign up completed by all 24 practices 30 January 2009. Project commenced 12/13 February with training for practice staff. The review completion date was the 30 April 09 with recording sheets returned by 7 May and the GRASP-AF tool re run to show a difference by 22 May. Full report available from June 2009. The network development manager (NDM) produced a toolkit that covers how to use the tool, what the tool can do, things to remember and examples of work carried out in West Yorkshire, including examples of business cases, sign up forms, invite letters, recording sheets, contraindication frameworks etc. A network approach to the roll out of the tool has been produced and during 2009 meetings have been arranged by the NDM of the West Yorkshire Cardiovascular Network (WYCN) to present the tool to PCTs and PBC alliances to encourage implementation. Support of the NDM and network team is available for any PCT/PBC alliance across the network wishing to undertake GRASP-AF. The WYCN website hosted the tool with access only allowed via the NDM. The tool has now been made available for use nationally via the NHS Improvement website at: www.imrovement.nhs.uk/graspaf. Key challenges Throughout the early stages of the project, engagement with the relevant people in the PCT was challenging. Identifying who had responsibility for cardiac work within the PCT was difficult, as this role was not one undertaken specifically by the PCT since Commissioning a Patient Led NHS (CPLNHS). The project did span across both the cardiac and stroke agenda but the stroke lead had a specific work programme already agreed for 2008 which left very little room for manoeuvre, therefore no support was available. However, a GP who sat on the PCT PEC did support the early stages of the project and offered his expertise and insights to primary care working on to developing a tool to run on primary care IT systems. Time was also a challenge whilst working with PRIMIS to develop the tool as the clinical workloads of the West Yorkshire HCP whilst developing the algorithms for the tool still took place. Clinics, interventions and patient diagnosis and
management were still the professionals day job and patients were their priority so making extra time to write the algorithms, advice and pod cast were difficult. Arranging for local sites to run the first test also proved a challenge, again trying to fit into the busy GP day. What went well Early discussions with PRIMIS+ on developing the tool. The clinicians and management at PRIMIS were very keen, excited and enthused by the idea of the tool. PRIMIS also supported the testing of the tool when time was against us by identifying and using established practices who regularly support PRIMIS work to test the tool. The presentation of the tool to the WYCN board full support and agreement that AF/stroke prevention would be a priority for 2009/10 and the vehicle to do this would be GRASP-AF. GRASP-AF is in our work programme and remains a priority. Local target events across Leeds the BHF arrhythmia nurses held many events raising the awareness of GRASP AF and educating practices in AF as a condition, warfarin as a drug and how to use the tool. They also offered their support in reviewing patients. The specific GP education sessions included in the York project pre-questionnaires were completed and post-questionnaires will also be completed to support the results of the project. The training was GP specific, covering not only the project and tool but clinical understanding of AF, warfarin as a prescription drug and the diagnosing and managing AF very GP focussed including case studies. The session evaluated excellently and discussions are ongoing to reproduce the training on a large scale to support the GRASP-AF. The support of the Atrial Fibrillation Alliance (AFA), Arrhythmia Alliance (AA) and British Heart Foundation (BHF) all who are keen to support the marketing of GRASP-AF. The WYCN purchased patient information from AFA for every GP practice to encourage a consistent approach and message to patients when it comes to AF and stroke prevention.
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Key learning from work A lot of preparatory work is required in order to set up a network roll out plan approximately 12 months Engaging with primary care is a challenge even though links were already established within the nnetwork Having a primary care GP clinical lead is vital in order to succeed a champion and advocate that will bridge the potential clinical gaps and demonstrate it is possible to implement within current working commitments A clinical AF lead, local cardiologists willing to support the networks activities Having a proven structure and plan for leading individual projects across a network managing your time is key as other areas of work as a network development manager do have an impact on this work and still require to be achieved Team spirit and support knowing that you can count on the support of your team. Outcomes Areas across West Yorkshire are beginning to embrace GRASP-AF with new projects commencing. All data from projects will be captured by WYCN and shared both locally, regionally and nationally. The York project, once completed will be able to share outcomes in terms of numbers of AF patients reviewed and, where necessary, optimal therapy. Number of strokes prevented will also be known. Individual practices who were test sites for the tool have demonstrated other benefits from implementing the tool including cleaned up AF registers (finding patients incorrectly coded for example and, patients that were being prescribed warfarin from the hospital but not known to the practice). AF annual reviews have also been set up to ensure year on year risk scoring takes place and best management continues. Warfarin has been prescribed to appropriate patients in these test sites (total ten across three practices).
Challenges for sustainability Hoping practices, whilst undertaking the work READ code accurately their findings, otherwise if the tool is repeated to show improvement or indeed annually, they will identify all the same people again That GRASP-AF does not drop off the radar other projects and areas of priority are always going to be introduced and efforts channelled into whatever is new next There is no element in the existing QOF to support practices to continue reviewing and stroke risk scoring their AF patients and worries that this will become a one off exercise patients stroke risk will change annually due to age and may change due to other contributing factors, meaning they need assessing annually. Costs incurred To develop the tool to work on all IT systems 12,000 (network funded) A total cost of hours by the clinical Lead, BHF arrhythmia nurses and NDM of the network has not been including in the above costing The clinical lead for Chapter Eight of the NSF is salaried for his agreed sessions for network activities The network has financially supported the York project to provide timely results in order to support implementation across West Yorkshire, provide results for national use, and to support the building of CHART ONLINE, a national data collection facility, total cost approximately 15,000. This includes practice payments to participating staff costs as well as lead GP and NDM time involved in project, the training sessions and all associated administrative work. Patient, carer and staff involvement The feedback from the GPs currently in the project has been excellent, all agree an area worthwhile undertaking and all very positive on the training received The final questionnaire will provide valuable feedback covering every aspect of the project. A number of local GPwSi involved in testing GRASP fed back how good the tool is and how easy it is to download and interpret the results; these GPs lead locally in the cardiac field but were noble enough to say even in their practice the tool found work to be done.
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Resources and tool developed to support the changes Available to share via the NHS Improvement website (www.improvement.nhs.uk/ afprojectsummaries): Toolkit to accompany GRASP-AF tool (www.improvement.nhs.uk/graspaf). Future plans As this is a network priority in 2009/10 the roll out and implementation has already begun in West Yorkshire. Sites outside of the network where the approach has been adopted by others Our neighbours North and East Yorkshire and North Lincolnshire (NEYNL) have access to the tool via the website (West Yorkshire and NEYNL share the same website). The NDM have supported and continue to support the lead in Hull to implement GRASP-AF. Contact details Project lead: Adele Graham Email: adele.graham@bradford.nhs.uk BHF Arrhythmia Nurse: Keith Tyndall Clinical lead: Dr Campbell Cowan Email: Campbell.cowan@leedsth.nhs.uk
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A sector wide approach to optimising therapy for Atrial Fibrillation patients in Primary Care
South West London Cardiac and Stroke Network, Richmond and Twickenham PCT, Wandsworth tPCT, Kingston PCT, Sutton and Merton PCT, Croydon PCT, St Georges Hospital, Kingston Hospital, Epsom and St Helier Hospitals, Mayday Hospital, Queen Marys Hospital, Roehampton
Duration of project June 2007 - still ongoing Scope of project The project planned to improve the quality of initial diagnosis and ongoing management of existing patients with atrial fibrillation through several different mechanisms: The agreement of sector wide guidelines, pathways and protocols for: the management of atrial fibrillation in primary care rapid access arrhythmia clinics cardioversion The development of an audit tool for use across the sector A coordinated approach to supporting practices to carry out the audit The delivery of an education event to support primary care. Baseline position A preliminary audit from one practice suggested that at least 30% of patients on the AF register could benefit from having their therapy optimised. What we did Sector wide guidelines for the management of atrial fibrillation in primary care were developed with the clinical lead and a GP lead for CHD from one PCT with input from the cardiac network. These were then launched at an educational event attended by over 50 GPs. The guidelines went to the prescribing committee of each PCT in the network. Through a sector wide team of BHF arrhythmia nurses, we worked with each individual PCT and acute trust to agree pathways and protocols for rapid access clinics to ensure timely and accurate assessment and diagnosis and also cardioversion services to ensure timely treatment where appropriate. We carried out the audit in two practices to develop and refine the audit tool. We then attended the relevant cardiac meetings in each PCT to discuss this work and offer support to targeting practices. The audit tool was also offered to each PCT. One PCT adopted the audit to investigate and address anticoagulation therapy as part of its prescribing incentive scheme with take up varying
across PBC clusters. A BHF arrhythmia nurse supported one practice to review and optimise all identified patients. An education event was organised, covering all aspects of arrhythmias but with a focus on the management of atrial fibrillation in primary care. 92 people attended and 98% of people completing evaluation forms said that they had learnt something that would change their current practice. As this work developed, we also had the opportunity to take part in a pilot for The Auricle, a web based tool that has been created by a GP in Suffolk to guide GPs through reviewing their AF patients CHADS2 score and their medication. The tool also has the capacity to send the information to a consultant in local hospital for additional comments and decision support via email (and for a small fee), potentially saving on unnecessary outpatient appointments. As this appeared to fit well with the aims of our project to improve diagnosis and management of patients with atrial fibrillation, we spent a significant amount of time developing links between one PCT and an acute trust and progressing a pilot project. However, the PCT then decided that they did not want to proceed with the pilot but wanted to develop a local algorithm to refer to the BHF arrhythmia nurse rapid access clinic at the acute trust. Key challenges The main challenge was competing workloads for network staff and BHF arrhythmia nurses. In the areas where we were most successful at progressing this project, it required significant input from network staff and a BHF arrhythmia nurse to keep the momentum going and make progress. Although PCTs expressed an interest in the audit tool, the take up was low. It may have been more appropriate to share this at PBC and/or individual practice level to ensure all practices were aware of this. Where we did share the audit tool, there was little feedback from practices as to how many patients had been identified and reviewed, despite requesting this information when the tool was shared. Changing priorities for PCTs also provided a challenge, especially for The Auricle element of this work.
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What went well The development of local pathways and protocols has ensured that there is a joined up approach to diagnosis and management of patients with atrial fibrillation. For example, patients who are sent by their GP for an ECG who are found to be in atrial fibrillation have their ECG report sent back to their GP together with a referral form for the rapid access arrhythmia clinic. Rapid access clinics are ensuring that patients are seen in a timely manner. The adoption of the AF pilot as part of the prescribing incentive scheme was a good mechanism to drive this work forward to a wider audience, although take up varied across PBC clusters in the PCT. The BHF arrhythmia nurse working with a practice to review all patients who had been optimised as on sub-optimal therapy ensured these patients were reviewed in an appropriate manner. The practice was very positive about this level of support and the additional informal learning that this method offered. The education events were extremely well received with positive feedback from attendees. Key learning from work It is important to have network staff to drive this work forward at PCT level as without it, this work slows down or stops BHF arrhythmia nurse services need to be linked into primary care to ensure there is an appropriate route for patients to receive fast and accurate diagnosis and ongoing management. Outcomes 200 existing AF patients were reviewed at three practices and where appropriate, their treatment was optimised Clear pathways have been agreed at five acute trusts and four PCTs, with 100 patients benefiting from the new AF pathway at one acute trust, with similar uptake across all trusts in the sector Over 200 patients benefited from faster access to cardioversion at one trust. Wait times were halved from 12 weeks to six weeks as part of the establishment of a clear and agreed pathway for AF patients Three out of 10 practices in one PBC cluster adopted the prescribing incentive scheme at one PCT 150 clinicians attended two educational events.
Challenges for sustainability As mentioned previously, it is important to ensure that this work remains a priority with cardiac and stroke networks to support and facilitate PCTs to drive this work forward. Costs incurred None, as this project was carried out using existing staff and resources. Patient, carer and staff involvement Patients have been very positive about the services provided by the BHF arrhythmia nurses and their ability to see patients in a timely manner. The practice who worked with a BHF arrhythmia nurse to review atrial patients was very positive about this level of support and the additional informal learning that this method offered. The networks patient and carer representative group is keen for this work to be extended to include identification of new cases of atrial fibrillation. Resources and tools developed to support the changes Available for sharing via the South West London Cardiac and Stroke Network website at: www.southwestlondoncardiacnetwork.nhs.uk AF audit tool for GP practice. Future plans The next stage of this work would be to develop and adopt a sector wide approach to the identification of new cases of atrial fibrillation and ensuring appropriate diagnosis and ongoing management for this group of patients. Contact details Project lead: Michelle Bull Email: Michelle.bull@stgeorges.nhs.uk Clinical lead: Professor John Camm Email: jcamm@sgul.ac.uk
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Project Team Leads, Cardiac and Stroke Networks and Participating Sites
Avon, Gloucestershire, Wiltshire and Somerset Cardiac and Stroke Network Angela Kell North Somerset PCT, nine GP practices. Bedfordshire and Hertfordshire Heart and Stroke Network Delyth Williams Primary Care Trust, 23 GP practices Black Country Cardiovascular Network Joanne Gutteridge, Angela Nelson Dudley PCT, Dudley Group of Hospitals Foundation Trust, Worcester Street Commissioning Cluster, Wychbury Medical Centre, Litchfield Street Surgery, NHS Walsall, Walsall Hospitals NHS Trust East Midlands Cardiac and Stroke Network (formerly Leicestershire, Northamptonshire & Rutland Cardiac Network) Ben Knight GP practices, Northamptonshire PCT Kent Cardiovascular Network Tim Waite Medway PCT, Medway NHS Foundation Trust (Medway Maritime Hospital) Eastern and Coastal Kent PCT, East Kent Hospitals University NHS Foundation Trust, West Kent PCT Cardiac and Stroke Networks in Lancashire and Cumbria Lauren Butler, Jeannie Hayhurst Six GP practices in Lancaster and Morecambe, Royal Lancaster Infirmary (University Hospitals of Morecambe Bay NHS Trust), North Lancashire Primary Care Trust, Lancaster, Morecambe, Carnforth and Garstang Practice Based Commissioning Consortia North Trent Network of Cardiac Care Ann Baines, Colette Longford NHS Rotherham, Sheffield PCT, Sheffield Teaching Hospital NHS Foundation Trust (Northern General Hospital), six GP practices North and East Yorkshire and Northern Lincolnshire Cardiac and Stroke Network Melanie Dunwell Whitby Group Practice, Robin Hoods Bay (satellite surgery) Surrey Heart and Stroke Network Liz Patroe, 13 General practices in Woking and West Byfleet, Surrey PCT West Yorkshire Cardiovascular Network Adele Graham, Keith Tyndall Leeds PCT, Leeds Teaching Hospitals NHS Trust, York Health Group, Bradford and Airedale PCT, Kirklees PCT, Wakefield PCT.
South West London Cardiac and Stroke Network Richmond and Twickenham PCT, Wandsworth PCT, Kingston PCT, Sutton and Merton PCT, Croydon PCT, St Georges Hospital, Kingston Hospital, Epsom and St Helier Hospitals, Mayday Hospital , Queen Marys Hospital, Roehampton
National Team Members

Dr Campbell Cowan National Clinical Lead, Consultant Cardiologist Dr Matt Fay National Clinical Lead, General Practitioner Sue Hall National Improvement Lead, NHS Improvement
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NHS Improvement With nearly ten years practical service improvement experience in cancer, diagnostics and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, share improvement resources and learning, increase impact and ensure value for money to improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements across the entire pathway of care in cancer, diagnostics, heart and stroke services.
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Delivering tomorrows improvement agenda for the NHS
NHS Improvement 2009 | All Rights Reserved - Publication Ref: IMP/heart09/01

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Heart and Stroke Improvement

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Ann Baines Email: Ann.baines@rotherhampct.nhs.uk

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation in primary care: making an impact on stroke prevention

National Team Members

Delivering tomorrows improvement agenda for the NHS

NHS Improvement 2009 | All Rights Reserved - Publication Ref: IMP/heart09/01

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