A Streamlined Approach to Atrial Fibrillation Screening
Partnership between the Cardiac Rhythm Management Team & Department of Stroke Medicine
1Dowds J, 1Britton J, 1McNair W, 1Turkington L, 1Curry L, 1Williamson R, 2Kinnaird M, 2Scullion E. 2Wiggam MI
2018 Northern Ireland Stroke ConferenceTuesday 12th June 2018
Background
• 15-20% of all strokes caused by Atrial Fibrillation (AF) [1]
• 25% Cryptogenic Strokes with no clear cause found [2]
• Significant proportion will have Paroxysmal AF
(PAF), 24% [3]
[1] World Health Organisation. The atlas of heart disease and stroke. [2] Kishore A, Vail A, Majid A, Dawson J, et al, 2014. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke, 45, 520-6.[3] Sposato LA, Cipriano LE, Saposnik G, Vargas ER, et al, 2015. Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurology.
Role for Cardiac Monitoring?
Monitoring Duration period
• 2016 recommendations [4]:
– >12 hours, All patients
– >24 hours, no cause found
• Implications…
– Increased burden on Cardiac monitoring services
• Challenge… Are we screening enough?
[4] National clinical guideline for stroke. Prepared by the Intercollegiate Stroke Working Party. Fifth Edition 2016
ChallengeTertiary Stroke
Service
• 2453 new referrals
• 1452 Inpatients
• 839 Strokes/TIA’s
• 800 Outpatients
• 263 Stroke Day Assessment Service [SDAS] (commenced June
2017)
• 2016 Guidelines
Tertiary Cardiac Monitoring Service
• 3000 Investigations
• 450 AF Screenings
• 234 Same day
• Holter = Resource intensive
• No weekend cover
• Supply/demand issue
Capacity/Demand Issue
• Limited availability
• Forced to be selective
• Prolonged waiting list
• Missed ‘Hot’ period
*2017 data from Sroke Dept, BHSCT **2016 Data from Cardiology, BHSCT
Our Solution
Partnership
• Meetings
• Funding
• Targets
• Networking
New Equipment
• 1-14 days duration
• AF detection
• AF >30sec
• Asymptomatic?
New Workflow
• Fast Analysis
• Quick Turnaround
• Nurse-Led Service
Empowerment
• Core Nurses
• Training
• Support
• Monitor hook-up & removal
Monitors
• Symptom activated
• Real-time snapshot
• Too short?
Event Monitor
• Full disclosure
• 24hr-72hr
• Resource intensive
• Slow analysis
• Cost
Holter ECG
• Auto-detection
• 2-3 years
• Invasive
• Cost
• Too long?
Implantable Loop
• Auto-detection
• 1-30 days
• Remote
• Future?
Mobile Cardiac Telemetry
Novacor R.Test 4
AF detection algorithm, 91% sensitive 9x more likely to detect sustained PAF
New ServiceOld New
Team Cardiac Ambulatory Monitoring team Cardiac Device Review Team
Service General, Cardiology, GP, Stroke etc Stroke Only
Monitor Holter Monitor, Continuous Automatic Event Recorders x18
Analysis Slow Fast
Report Delays Same day
O/P W/L 7-9 months ?
Availability Limited (I/P Mon-Thurs only) Good (18x monitors for Stroke)
Staff Physiologist-led only Physiologist & Stroke Deptpartnership
*New - Nurse-led Inpatient Service
*New – Weekend service
*New – ‘Lunchbox’ Transfer System
Walkthrough
Real Case Example
• 67 year old female
• Admitted with Cryptogenic Stroke
• AF Screening indicated
• Fitted with R.Test 4
Assessment of Service
• Primary outcome measures• Number of patients who received screening
• Percentage of patients who accessed same day screening
• Waiting time for patient who did not receive same day screening
• Assessed over a comparable four month period
– Nov 2016 to Feb 2017 vs
– Nov 2017 to Feb 2018
Results
153
402
0
50
100
150
200
250
300
350
400
450
Old Service New Service
No
. of
Pat
ien
ts
Total Number of Patients Screened• The total number of patients accessing AF
screening more than doubled after introduction of the new
service (402 v 153).
• 162.7% increase
Results
• 28% increase of proportion screened on the day of referral from 51% (78/153) to 79% (318/402)
• 4x more Same-day screenings (78 vs 318)
51%
79%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Old Service New Service
Proportion of Same-day Referral & Screening
Results• Decrease from 144
days to 30 days in average wait for those not accessing same day investigation, p<0.001
• 80% reduction
144
30
0
20
40
60
80
100
120
140
160
Old Service New Sevice
Day
s
Mean Outpatient Waiting time
Conclusion
• >1300 patients Screened, 11 months
• AF detection 5%• Other arrhythmias… VT, heart block, asystole
• Significantly improved AF Screening post Stroke – New ECG monitoring system
– Empowerment of stroke unit staff
– Partnership between Stroke Unit & Cardiac Rhythm Management team
Discussion…
• Longer monitoring duration?
• New or Alternative technology?
• ESUS (Embolic stroke of undetermined source )
John DowdsChief Cardiac Physiologist
Cardiac Device Clinic |BHSCT |E: [email protected]
John BrittonSenior Cardiac Physiologist
Cardiac Device Clinic |BHSCT |E: [email protected]