NHS                                             NHS ImprovementCANCER              Heart and Stroke ImprovementDIAGNOSTICS...
Atrial fibrillation in primary care: making an impact on stroke prevention    3ContentsForeword                           ...
4       Atrial fibrillation in primary care: making an impact on stroke prevention        Foreword        Atrial fibrillat...
Atrial fibrillation in primary care: making an impact on stroke prevention                     5IntroductionThese national...
6       Atrial fibrillation in primary care: making an impact on stroke prevention        Key learning                    ...
Atrial fibrillation in primary care: making an impact on stroke prevention                7The York Health Group PBC clust...
8       Atrial fibrillation in primary care: making an impact on stroke prevention        Incentivised detection and manag...
Atrial fibrillation in primary care: making an impact on stroke prevention             9• Over 70% of the new diagnoses ha...
10      Atrial fibrillation in primary care: making an impact on stroke prevention        Atrial Fibrillation Screening Pr...
Atrial fibrillation in primary care: making an impact on stroke prevention             11Atrial Fibrillation in Primary Ca...
12      Atrial fibrillation in primary care: making an impact on stroke prevention        Patient, carer and staff involve...
Atrial fibrillation in primary care: making an impact on stroke prevention              13Atrial Fibrillation in Primary C...
14      Atrial fibrillation in primary care: making an impact on stroke prevention        • It is worth using the services...
Atrial fibrillation in primary care: making an impact on stroke prevention         15To standardise and develop an informa...
16      Atrial fibrillation in primary care: making an impact on stroke prevention        Primary Care Arrhythmia Service ...
Atrial fibrillation in primary care: making an impact on stroke prevention         17Primary Care Arrhythmia Service - Med...
18      Atrial fibrillation in primary care: making an impact on stroke prevention        Atrial Fibrillation Opportunisti...
Atrial fibrillation in primary care: making an impact on stroke prevention             19Management of Atrial Fibrillation...
20      Atrial fibrillation in primary care: making an impact on stroke prevention        • Following analysis of the pres...
Atrial fibrillation in primary care: making an impact on stroke prevention             21Telemedicine pilot               ...
22      Atrial fibrillation in primary care: making an impact on stroke prevention        Challenges for sustainability   ...
Atrial fibrillation in primary care: making an impact on stroke prevention            23Atrial Fibrillation in Primary Car...
24      Atrial fibrillation in primary care: making an impact on stroke prevention        What went well                  ...
Atrial fibrillation in primary care: making an impact on stroke prevention             25Atrial Fibrillation in Primary Ca...
26      Atrial fibrillation in primary care: making an impact on stroke prevention        What we did                     ...
Atrial fibrillation in primary care: making an impact on stroke prevention   27Costs incurredNonePatient, carer and staff ...
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
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Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.


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Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.
The 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.
(Published October 2009).

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Atrial fibrillation in primary care: making an impact on stroke prevention National priority project final summaries.

  1. 1. NHS NHS ImprovementCANCER Heart and Stroke ImprovementDIAGNOSTICS Atrial fibrillation in primary care: making an impact on strokeHEART prevention National priority project final summariesLUNG October 2009STROKE
  2. 2. Atrial fibrillation in primary care: making an impact on stroke prevention 3ContentsForeword 4Introduction 5Project SummariesIncentivised detection and management of Atrial Fibrillation - 8North Somerset PCTAtrial Fibrillation Screening Project - Bedford 10Atrial Fibrillation in Primary Care - Dudley Health Economy 11Atrial Fibrillation in Primary Care - Walsall Health Economy 13To standardise and develop an information package that supports 15patients along the referral pathway - NorthamptonshirePrimary Care Arrhythmia Service - Eastern and Coastal Kent PCT 16Primary Care Arrhythmia Service - Medway PCT 17Atrial Fibrillation Opportunistic Screening and Patient Review Pilot - 18West Kent PCTManagement of Atrial Fibrillation in Primary Care - 19Lancaster and MorecambeAtrial Fibrillation in Primary Care - Rotherham 23Atrial Fibrillation in Primary Care Project - Sheffield 25Near Patient INR Testing Project - Whitby Group Practice 28Atrial Fibrillation in Primary Care - Woking and West Byfleet 29GRASP-AF (Guidance on Risk Assessment for Stroke Prevention in Atrial 32Fibrillation) - West YorkshireA sector wide approach to optimising therapy for Atrial Fibrillation 36patients in Primary Care - South West LondonProject Team Leads, Cardiac and Stroke Networks and Participating Sites 38 www.improvement.nhs.uk
  3. 3. 4 Atrial fibrillation in primary care: making an impact on stroke prevention Foreword Atrial fibrillation (AF) is the most common It is clear that improving identification of people sustained dysrhythmia, affecting at least 600,000 with atrial fibrillation and inducing better (1.2%) people in England alone. It is also a major intervention could prevent many thousands of cause of stroke. strokes each year. The personal cost of a stroke to an individual is incalculable. To be aware that in Uniquely it also is an eminently preventable cause many cases this was an identifiable and potentially of stroke with a simple highly effective treatment. avoidable situation can only increase the anxieties This treatment is also highly cost effective. to the sufferer and their carers. These facts underpinned the first phase of the The identification of those at risk and appropriate Heart and Stroke Improvement Programmes’ work treatment offers a real opportunity for achieving on stroke prevention and atrial fibrillation. Fifteen cost effective, high quality care, with the goal of cardiac and stroke networks participated in the preventing avoidable mortality and morbidity. 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 Dr Campbell Cowan treated with anti-coagulants and considering the Consultant Cardiologist best pathways for managing atrial fibrillation in National Clinical Lead primary care. Heart Improvement Programme The major outcomes of this work continue to Dr Matt Fay demonstrate: GP with Special Interest National Clinical Lead • A clear variation in identification rates for atrial Stroke Improvement Programme 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 anti- coagulants • That the management of AF in primary care is both practical and a necessity.www.improvement.nhs.uk
  4. 4. Atrial fibrillation in primary care: making an impact on stroke prevention 5IntroductionThese national priority projects were established Appropriate anti-coagulation of all patients within 2007 in response to Chapter Eight of the recognised AF would prevent approximately 4,500National Framework for Coronary Heart Disease; strokes per year and prevent 3,000 deaths.Arrhythmias and Sudden Cardiac Death, publishedin March 2005, which set out the quality A recent Department of Health1 cost benefitrequirements for the prevention and treatment of analysis suggests that for stroke patients withpatients with cardiac arrhythmias. AF there are around: • 4,300 deaths in hospitalThis is underpinned by the publication by NICE in • 3,200 discharges to residential care2006 of ‘Atrial Fibrillation. The management of • 8,500 deaths within the first year.atrial fibrillation costing report’ which highlighted However,that amongst patients with recognised AF, 46% of • The treatment of AF with warfarin reduces riskthose who would benefit from warfarin are not of stroke by 50-70%receiving it. Out of an estimated 355,000, only • The estimated total cost of maintaining one189,000 were actually receiving warfarin. patient on warfarin for one year, including monitoring, is £383In December 2008 the publication of the National • The cost per stroke due to AF is estimated to beStroke Strategy affirmed the importance of this £11,900 in the first year after stroke occurrence.work for stroke prevention. Quality Marker 2states: The early learning from the eighteen individual• ‘Markers of a quality service: Risk factors, projects established was first published in May 2008 including hypertension, obesity, high cholesterol, ‘Atrial Fibrillation in Primary Care: atrial fibrillation (irregular heartbeats) and National Priority Project‘ diabetes, are managed according to clinical (www.heart.nhs.uk/priority_projects guidelines, and appropriate action is taken to /summary_documents/af_summary.pdf). reduce overall vascular risk This document aims to capture• Action needed: Commissioners and providers use the final summary of ASSET to establish baseline and to ensure that their individual there are systems in place locally for the approach, lessons following key prevention measures: warfarin for learned, individuals with atrial fibrillation improvements• Measuring success: Greater proportion of to practice and individuals who have a history of stroke or quality cardiovascular disease or who are at a high risk outcomes, also who have had advice and/or are receiving sharing tools and treatment’. resources developed toAtrial fibrillation is a major predisposing factor to enable other healthstroke, with 16,000 strokes annually in patients communities towith AF of which approximately 12,500 are drive this agendathought to be directly attributable to AF. The forward.annual risk of stroke is five to six times greater inAF patients than in people with normal heartrhythm and is therefore a major risk factor forstroke.1 Department of Health Atrial Fibrillation cost benefit analysis. Marion Kerr, 2008. www.improvement.nhs.uk
  5. 5. 6 Atrial fibrillation in primary care: making an impact on stroke prevention Key learning These have included: A variety of approaches were undertaken • Department of Health (DH) responding to the needs of the local health • National Institute for Clinical Excellence (NICE) communities; however each project sought to • Primary Care Cardiovascular Society (PCCS) establish a baseline to demonstrate improvements • Atrial Fibrillation Association (AFA) to changes in practice against: • British Heart Foundation (BHF) • Numbers of new patients with AF identified, and • Heart Rhythm UK (HRUK) their subsequent treatment • The Stroke Association (SA) • Numbers of existing AF patients reviewed and, • Primary Care Information Management where necessary, subject to optimal therapy Service (PRIMIS) • Establishment of a clear and agreed patient • Ambulance services. pathway for AF patients. Quality outcomes Innovation Many of the approaches have already begun to Key areas for the piloting new approaches spread across the network of priority projects and centred on: through sharing the work nationally through NHS • Detection of AF though opportunistic screening Improvement national learning events. at flu clinics • Local enhanced service (LES) schemes for In particular we have seen: detection, screening and review of AF 1. The early piloting of opportunistic screening • New models for anticoagulation services in through pulse palpation at flu clinics by primary and community settings Bedfordshire and Hertfordshire Heart and • Development of tools to support the review of Stroke Network which has led to this initiative patients with AF, risk stratify for stroke and being replicated in other areas. For example: consider optimal therapy: • The Colchester Practice Based Commissioning • The Guidance on Risk Assessment for Stroke Group incentivised 37 practices out of 43 to Prevention in AF (GRASP-AF) tool now available undertake this approach enabling: for use across all GP clinical systems via • 34,201patients to be screened in six weeks www.improvement.nhs.uk/graspaf • 189 patients found with AF (0.55%) • Decision support tool ‘the Auricle’ • Estimated numbers of strokes prevented www.theauricle.co.uk next year = 5 • Guidelines for primary to secondary care referral. • At an estimated annual cost saving of £220,000 this represented 322% return on Education investment in addition to improved quality All projects found the need to include education outcomes for patients. for professional and patients around: 2. The GRASP-AF tool developed and piloted by the • Pulse palpation West Yorkshire Cardiovascular Network in • Barriers to anti-coagulation in primary care collaboration with their BHF Arrhythmia nurses • ECG training and interpretation and PRIMIS for use on GP clinical systems to • Patient awareness. identify for review AF patients with high risk of stroke, not on warfarin, has now been made Partnership working available for use across England. 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.www.improvement.nhs.uk
  6. 6. Atrial fibrillation in primary care: making an impact on stroke prevention 7The York Health Group PBC cluster used GRASP-AF Further pilots will also be undertaken to:across their 24 practices with a total population of228,651 patients of which 3,613 patients with AF • understand the issues and potential solutions forwere identified. the management and optimal therapy for stroke and TIA patients with AFBy June 2009: • to model the potential impact on current services • The total number of reviews undertaken 716 of new drugs for patients with AF. • Of which face-to-face reviews 110 • New warfarin prescription 41(6%) In addition, to support communities that have • Awaiting further review including consultant added pulse palpation as part of their NHS Health referral 37. Check Programme, to have access to the learning for the management in primary care for patientsAccess to the GRASP-AF tool is through with AF.www.improvement.nhs.uk/graspaf and has alreadybeen downloaded by over 100 practices in the first The work of this national priority ‘stroke preventioncouple of months of release. in primary care: addressing atrial fibrillation’ supports the national drive for:SummaryIt is clear that tools and resources are only part of • Quality outcomes through addressing optimalthe process; it requires a whole system approach to therapy for AF patientsmake significant and sustainable change across the • Innovative approaches to access andwhole pathway of care for patients with AF if we management in primary care for AF patientsare to dramatically reduce their risk of stroke. • Productivity through reducing inappropriate referrals to secondary care and bed days savedThis will require collaborative working across the • Prevention by reducing risk of stroke.whole health system between cardiac and strokenetworks, clinicians, commissioners, public health Many of these project sites are continuing to takeand third sector organisations, in particular, to this work further into implementation, with themaximise benefit. aim to embed into core practice and continue to share their learning both nationally and locallyAction was sought with key stakeholders to bring through the cardiac and stroke networks andtogether a consensus approach across England to national learning events.address the key factors in influencing, educatingand encouraging change in the identification and The following case study summaries represent anmanagement of these patients culminating in the overview of their work achieved by the end ofpublication in June 2009 ‘Commissioning for April 2009 and the tools and resources theyStroke Prevention in Primary Care - The role have generously made available to share can beof Atrial Fibrillation’ (www.improvement.nhs.uk/ accessed from the NHS Improvement website at:heart/Portals/0/documents2009/AF_Commissioning www.improvement.nhs.uk/afprojectsummaries_Guide_v2.pdf).The next stage of this work will commence with afurther nine projects from October 2009, buildingfrom this platform of evidence based learning anddemonstrable outcomes for the improvement ofthe identification, diagnosis and optimal therapyfor AF patients. www.improvement.nhs.uk
  7. 7. 8 Atrial fibrillation in primary care: making an impact on stroke prevention 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 incentives for this work to be done had to be January 2008 - December 2008 increased to reflect the labour-intensive nature of this task. Scope of project • To increase the detection rate of patients over There seems to be poor communication and the age of 65 with atrial fibrillation through cohesion between GPs and secondary care opportunistic screening, with incentives paid for clinicians when it comes to management of AF. each new diagnosis made and confirmed on ECG GPs have expressed a reluctance to change • To improve the management of known AF medication that was initially prescribed or patients over the age of 65 by reviewing their recommended by cardiologists, but admit little management and optimising it where dialogue about the most appropriate management appropriate. of these patients. Baseline position What went well • Nine practices completed the project Practices were very positive about the benefits • The combined over 65 population for these nine associated with this project and involved most GPs, practices was 16,062 (representing 19% of the nurses and health care assistants. Many were also registered population for these practices) proactive in promoting the project to patients. • 1,421 of these patients were known to have AF, giving an over 65 AF prevalence of 8.8%. All but one of the practices reported that whilst the incentives helped engage people, they believed What we did it was a very worthwhile project and that they Opportunistic screening was undertaken in the would have taken part anyway. There was strong nine practices, either in chronic disease clinics, on clinical leadership and close working relations with GP visits or practice nurse visits. A code was the participating practices. entered on to the computer system to capture this activity. Any suspected AF cases went on to have Key learning from work an ECG performed. For all confirmed cases a The change in project manager mid way through proforma was completed, outlining their risk score, the project proved a challenge. However, the management and any other relevant details. All network deputy director and one of the practice new cases were validated by the lead clinician to managers helped minimise the impact of this ensure that they were truly opportunistic. An change. incentive payment was made for each new diagnosis. There was a feeling that the GP practices weren’t entirely clear of the aims of the project at the All known AF patients were entered onto a outset, and that the goal posts moved. database and reviewed using the CHADS2 risk There is a need when offering incentive payments tool. Where patients were not managed as per the that they reflect the labour intensity of the work. guidelines, they were reviewed to ascertain if medication could be optimised. Incentives were Outcomes paid for each patient audited, with an enhanced Opportunistic screening level of payment for each payment where a • 7,089 pulses were taken in the year period, medication change was made. which assuming patients only had their pulse taken once, represents 45% of the over 65 Key challenges population in the nine participating practices One of the key challenges at the outset was the • 66 new diagnoses were made, which were truly definition of ‘opportunistic’, and thus ascertaining opportunistic who was eligible for payment or not. Patients were • This equates to one new diagnosis for every 107 excluded from the project if they presented with pulses taken. The range of new diagnosis per symptoms where it would be reasonable to expect number of pulses taken was considerable (25 – the clinician to check their pulse. 560), which raises questions about the reliability of the data and the methodology used The time taken to review a large number of known AF patients also proved a challenge, and thewww.improvement.nhs.uk
  8. 8. Atrial fibrillation in primary care: making an impact on stroke prevention 9• Over 70% of the new diagnoses had a CHADS2 more sustainable, with a focus on treating new score of two or more and were therefore diagnoses appropriately in the first place. considered high risk. However, only half of these were prescribed warfarin, with the majority of Costs incurred the remaining patients either refusing warfarin or The spend for this incentivised project was being contraindicated. approximately £15,000 against an initial projection of £20,000. The cost not reflected in this is theReview of known AF patients project management time.• 1,075 patients with known AF over the age of 65 were reviewed, which was over 75% of the Patient, carer and staff involvement total known AF population in that age group Preliminary results were presented to the network’s across the nine practices patient, carer and public involvement group, who• Approximately 80% were reported to have showed keen interest in the project. They have permanent AF, and 20% paroxysmal AF strongly expressed a wish that a pulse check be• The male:female split was approximately 54% mandatory in the vascular checks screen. male, 46% female for both types of AF Feedback from staff involved in the project has• 20% of the known AF patients scored as low been very positive, with most reporting that it has risk on the CHADS2 tool (score 0-1), with 80% raised the profile of AF in their practices and considered high risk according to the tool. improved the way in which AF patients are Patients with permanent AF tended to have a managed, as well as improving attitudes to higher CHADS2 risk than those with warfarin prescription. paroxysmal AF. Resources and tools developed toTaking account of documented contraindications support the changesand patients refusing medication, 80% of patients Available for sharing via the Avon, Gloucestershire,with paroxysmal AF in the low risk category (a Wiltshire and Somerset (AGWS) Cardiac and StrokeCHADS2 score of 0-1) were found to be on Network website (www.agwscs.nhs.uk) and theappropriate medication, compared to over 90% of NHS Improvement website (www.improvement.those with permanent AF. In the high risk group nhs.uk/afprojectsummaries):(patients with a CHADS2 score of two or more), • AGWS North Somerset final report and49% of those with paroxysmal AF were treated appendices, including guidelines and proformas.according to the guidelines, compared to 73% ofthose with permanent AF. Future plans • Eight of the nine participating practices plan toThis demonstrates that patients with paroxysmal AF continue opportunistic screeningtend to be undertreated compared to those with • The results of this project are currently beingpermanent AF. disseminated across the PCT to decided how this can be rolled out to other practicesIn total 288 patients were identified as appropriate • Practices feel that a yearly pulse check should befor a medication change, but only 16 actually went added to Quality Outcomes Framework (QOF)on to have a change in medication. This represents for high risk groupsjust 1.5% of the 1,075 patients audited. • Some practices have added a pulse check to their chronic disease templatesGiven the number needed to treat with warfarin to • There is a strong feeling that a public awarenessprevent one stroke is 24, if the results from this campaign about AF would be beneficial, as wellproject were applied to the whole PCT population, as training to GPs on warfarin initiation.four strokes could be avoided in a population ofapproximately 200,000. Contact details Network Administrator:Challenges for sustainability Email: AGWSCSnetwork@UHBristol.nhs.ukThe review of known AF patients proved to be verytime consuming, with small numbers of patients Clinical lead:changed. The clinicians generally felt that the Dr Martin Himeopportunistic screening was more beneficial and www.improvement.nhs.uk
  9. 9. 10 Atrial fibrillation in primary care: making an impact on stroke prevention Atrial Fibrillation Screening Project Bedfordshire and Hertfordshire Heart and Stroke Network, Bedfordshire Primary Care Trust, 23 GP Practices Duration of project October 2008 Costs incurred Payment to practices - 10p per patient screened, Scope of project £60 per patient added to AF register. Opportunistic pulse screening at flu clincs Patient, carer and staff involvement What we did Patients, clinicians and practice staff all felt the • One practice originally targeted for pulse project was worthwhile and caused very little screening patients during flu clinics – Oct 2007. disruption to the flu clinic. (see publication ‘Heart Improvement: Atrial Fibrillation in Primary Care - National Priority The patients in particular were very pleased with Project’ (www.heart.nhs.uk/priority_projects the extra service when they understood the /summary_documents/af_summary.pdf) importance of the screening. • Subsequently a local enhanced service (LES) was developed to encourage wider uptake Resources and tools developed to support • One primary care trust (PCT) implemented this the changes during the flu season of 2008 Available for sharing by contacting project lead • Currently working with the three other PCTs in • Local enhanced service. the network through local implementation groups and practice based commissioning groups Future plans (PBC) to role out the LES for the 2009 flu season. • Continued expansion of the pulse screening in GP practices across Bedfordshire and Key challenges Hertfordshire and improve AF awareness in Engaging PBC groups. relation to stroke prevention • Offer regular training on the management What went well of AF. AF registers significantly improved in practices that took up the LES. Sites outside your network where your approach has been adopted by others Key learning from work North Yorkshire • Communication is essential Essex. • Posters and leaflets developed for patients • Ensure district general hospital (DGH) services Contact details are aware of this initiative, as this can increase Project and clinical lead: referrals into the cardiology department Delyth Williams significantly Email: Delyth.Williams@bedfordshire.nhs.uk • 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.www.improvement.nhs.uk
  10. 10. Atrial fibrillation in primary care: making an impact on stroke prevention 11Atrial Fibrillation in Primary Care - Dudley Health EconomyBlack Country Cardiovascular Network, Dudley PCT, Dudley Group ofHospitals Foundation Trust, Worcester Street Commissioning Cluster,Wychbury Medical CentreDuration of project • Searches at Wychbury Medical Centre to identifySeptember 2007 - ongoing further potential patients • Review of patients identified by searches forScope of project potential AF and anticoagulation treatment• Streamlining pathways and guidance for patients • Training and development sessions around the with AF by development of a AF primary care screening, detection and management of AF for pathway all GPs, practice nurses, health visitors and• Training and development of primary care district nurses attached to the practice practices to improve AF screening, detection and • Pulse checking for irregular rhythms added to all management within the primary care setting templates at pilot practice• Improving access to diagnostics - ECG • Integration with the Dudley stroke steering• Improving access to anticoagulation services. group to develop a plan for roll out of the project borough wide.Baseline positionFull review and audit carried out at Worcester Key challengesStreet Commissioning Cluster against NICE Practice engagement - our original pilot practiceguidance July-September 2007. received all of the training but then would not engage in the screening process due to prioritiesInvestigation of Quality and Outcomes Framework around moving to a new practice premises in the(QOF) data - July 2007. Baseline assessment of near future.hospital admissions at Russells Hall Hospital. We decided to abandon work with this practiceWhat we did and move on to another site for pilot purposes.• Baseline investigation at Worcester Street Practice against NICE guidance What went well• Formation of project group as sub-group of the Engagement between primary care practitioners Coronary Heart Disease (CHD) Local and the cardiologists during training sessions. Implementation Team• Action planning at pilot practice following Key learning from work baseline assessment It is difficult to engage primary care to complete• Searches at Worcester Street Practice to identify this work with their busy schedules unless funding further potential patients is available to incentivise.• Review of patients identified by searches for potential AF Outcomes• Draft AF guidelines developed Establishment of the AF pathway is still in• Development of outreach anticoagulation clinic development but this will be available when at Worcester Street Practice completed and launched to the wider health• ECG provision training at Worcester Street economy. Practice for health care assistants (HCAs)• Pulse checking for irregular rhythms added to all Challenges for sustainability templates at pilot practice To spread this health economy wide it may need to• Finalisation of draft AF guidelines prior to pilot be incorporated into a local enhanced service.• Carried out a borough wide primary care antiplatelet/anticoagulant audit in atrial Pulse checking has been incorporated locally into fibrillation in conjunction with the practice based the NHS Health Check Programme. pharmacy team• Identification of second pilot practice – Wychbury Costs incurred Medical Centre Only staff time which for this pilot was given free• Action planning at practice following baseline of charge. assessment www.improvement.nhs.uk
  11. 11. 12 Atrial fibrillation in primary care: making an impact on stroke prevention 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.ukwww.improvement.nhs.uk
  12. 12. Atrial fibrillation in primary care: making an impact on stroke prevention 13Atrial Fibrillation in Primary Care – Walsall Health EconomyBlack Country Cardiovascular Network, NHS Walsall, Walsall HospitalsNHS Trust, Lichfield Street SurgeryDuration of project • AF guidelines to support the diagnosis andSeptember 2007 - ongoing treatment of AF in primary care and a referral pathway from primary care into secondary careScope of project has now been agreed and the documentation• To deliver high quality care in line with Chapter disseminated to all GP practices to allow for Eight of the National Service Framework (NSF) further guidance• To reduce emergency admissions for arrhythmia • Pulse checking for irregular rhythms has been• To develop streamlined whole pathways of care added to all templates following IMPACT to reduce bed days and outpatient visits for this education sessions group of patients • As part of the IMPACT campaign, practice• Develop an arrhythmia care pathway pharmacists identified the proportion of AF• Improve access to anti-coagulation services in patients currently prescribed anticoagulant/ primary care antiplatelet therapy• Improve access to ECGs in primary care. • Using the CHADS2 scoring system, an audit of the practice population at Lichfield Street SurgeryBaseline position was carried out. Those on the practice AF• Baseline investigation at Lichfield Street Surgery register were identified using EMIS software. against NICE guidance Patients not documented as receiving warfarin• Baseline assessment of hospital admissions at were identified as possible candidates for therapy. Walsall Manor Hospital Patients were excluded from risk stratification• Baseline assessment antiplatelet/anticoagulant if they had: audit in atrial fibrillation across all practices in 1. Documented return to sinus rhythm but Walsall, in conjunction with the practice based remained on the AF register pharmacy teams. 2. Contraindications to warfarin therapy 3. Declined warfarin therapy in the last 12 monthsWhat we did 4. A forthcoming appointment with their GP• An audit was undertaken to look at 60 patients about commencing warfarin. coded with a primary diagnosis of AF, how they Using medical records a CHADS2 score was were admitted and their length of stay. In calculated for each patient. Those with a conjunction with this a specialist registrar in CHADS2 score ≥ 2 were sent a letter to their public health has completed the report on the home address explaining that they may benefit review undertaken on behalf of the group from warfarin therapy. They were invited to the• The medicines management team ran an surgery for a non-urgent consultation with a IMPACT educational campaign on the general practitioner of their choice to discuss management of atrial fibrillation and secondary starting warfarin. Four weeks after letters had prevention of stroke. The IMPACT campaign was been sent, the practice population was re- developed to encourage a more structured and audited to determine the impact of the intervention evidence-based approach to patient • Piloted AF screening at flu clinics at pilot practice management. IMPACT pharmacists carried out from 28 September 2008 to 4 December 2008. face-to-face meetings with practices during the Clinical staff felt the radial pulse of all patients period of the campaign and all practices have having influenza vaccine. In a practice population now been completed. The IMPACT presentation of 7,504 a total of 1,324 pulses were recorded. was also delivered to year two doctors at the Of those recorded 1,262 were found to be Manor Hospital as part of their ongoing regular and 62 were found to be irregular. Of the educational programme, Heart Care 62 irregular pulses, 33 were known to have AF, Rehabilitation Centre clinicians and hospital seven were found to have AF following an ECG pharmacy staff and seven are awaiting an ECG. Fifteen were• Formation of project group as sub-group of the found to have an ECG sinus rhythm with other CHD local implementation team reporting also causes of irregular pulse. These results show it to the long term conditions group was a worthwhile initiative that hopefully other• Searches on systems at pilot practice to identify practices take up next year. Seven new cases of further potential patients and review of patients AF were identified and seven more sent off for identified from search ECGs. www.improvement.nhs.uk
  13. 13. 14 Atrial fibrillation in primary care: making an impact on stroke prevention • It is worth using the services of the cardiac Resources and tools developed to arrhythmia nurse as putting older people with AF support the changes on warfarin is much more effective in preventing Available for sharing on the NHS Improvement strokes and has proved to be as safe (BAFTA website (www.improvement.nhs.uk/ study Lancet 2007) if regular INR monitoring is afprojectsummaries): adhered to • Impact campaign • Arrhythmia clinic referrals at two pilot practices • AF guidelines has been working well and has now been • AF referral form. extended to all GP practices in Walsall. This clinic has 12 slots per week and is receiving regular Future plans appropriate referrals • Looking to integrate more with the Walsall • Integration with the Walsall Stroke Stroke Operational Group Operational Group • Engaging remaining practices to refer to the • Presentation to the local medical committee cardiac arrhythmia service using the AF (LMC) on the arrhythmia pathway. Teaching and guidelines. education sessions to nurses from primary and secondary care have evaluated well Contact details • Measures for AF will be monitored using Chronic Project lead: Disease Register (CDR) Intell. Angela Nelson Email: Angela.nelson@walsall.nhs.uk Key challenges Engaging other practices still remains an issue. Not Clinical lead: all practices are using the referral guidelines as Dr Rumi Jaumdally intended and are still referring to cardiologists. Email: Rumi.jaumdally@walsallhospitals.nhs.uk 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.www.improvement.nhs.uk
  14. 14. Atrial fibrillation in primary care: making an impact on stroke prevention 15To standardise and develop an information package that supportspatients along the referral pathwayEast Midlands Cardiac and Stroke Network (formerly LeicestershireNorthamptonshire & Rutland Cardiac Network), GP Practices,Northamptonshire PCTDuration of project Key learning from work10 August 2007 - 01 August 2008 • Open project up to more GP practices at an earlier stage. This might be time consuming butScope of project it would ensure take up.To standardise and develop an information packagethat supports patients along the referral pathway. Outcomes• Process map the patient pathway • QOF indicators not yet available for• Identify key information points project period.• Evaluate available information• Identify who gives what to whom Challenges for sustainability• Survey users on information and its benefit • The data quality team has been disbanded so (quality, clarity and timeliness) can no longer carry out the audit.• Develop a pathway with clear information indicators. Costs incurred • ECG training across countyBaseline position • Printing cost for folderInformation taken from QOF across sample of GP • Both funded from network resources.practices. Base line questionnaire on needs andpathways. Patient, carer and staff involvement • Staff have found CHADS2 and ECG informationWhat we did useful and ECG training has evaluated well.• Evaluated feedback from questionnaire• Assessed outcome from a data quality audit on Future plans 25 practices • Planned further training on ECG skills• Brought together all evidence from NICE etc. • Include AF management in stroke workplan including QOF and how to build a register • Anticoagulation baseline across East Midlands• Developed a folder of pathways and evidence and project planned for 2009/10 including the use of CHADS2 scoring and ECG • Audit of QOF data to see if prevalence and lower recognition indicators changes.• Delivered ECG basic skills training for GP practices Contact details• Distributed folder across Northamptonshire Project lead:• Asked for data quality team to run audit across Ben Knight Northamptonshire to assess impact of project Email: benknight@nhs.net• Planned roll out of project across East Midlands in 2009/10. Clinical lead: Dr ShribmanKey challenges Email: jonathan@shribman.co.uk• 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. www.improvement.nhs.uk
  15. 15. 16 Atrial fibrillation in primary care: making an impact on stroke prevention 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 Key learning from work November 2008 - ongoing • For a primary care arrhythmia service to be successful, it needs support from the Scope of project neighbouring acute trusts’ consultant To develop a primary care arrhythmia service cardiologists which will: • Concentrate your initial efforts on those • Help GP practices identify AF and other practices which can see the benefit of what arrhythmia patients by encouraging you are doing. opportunistic screening • Ensure existing AF patients are on optimal Outcomes therapy (searches undertaken by use of • It is too early to say what the outcomes are as GRASP-AF tool) the arrhythmia nurses have only started helping • Provide nurse-led primary care arrhythmia clinics practices identify new patients and review • Undertake and co-ordinate the patients existing ones. diagnostic investigations • Where necessary, refer patients’ to secondary Challenges for sustainability care clinic for further management • Having permanently employed arrhythmia nurses • Manage appropriate patients within the will ensure sustainability. arrhythmia service, or • Refer patients back to the GP for management Resources and tools developed to support within primary care the changes • The service will act as the point of contact for All available for sharing by contacting the sudden cardiac death, ensuring families have project lead: access to screening tests and information where • Business case appropriate. • Draft primary care education plan • Arrhythmia nurse job description. The three arrhythmia nurses are already in post and visiting practices. Contact details Project lead: What we did Tim Waite A business case was prepared and submitted to the Email: tim.waite@nhs.net PCT. This was approved and recruitment began in summer 2008 for three arrhythmia nurses the last Clinical leads: of which was in post by the end of November Dr Mark Fenton 2008. Consultant Cardiologist East Kent Hospitals University NHS Key challenges Foundation Trust • Not all practices have welcomed the arrhythmia Email: mark.fenton@nhs.net nurses and see them as an ‘interference’ Conversely, others have been very supportive. Shelley Sage • There are only three arrhythmia nurses to cover a Head of Community Cardiology Nurses population of 710,000 and 115 GP practices. Eastern and Coastal Kent PCT Email: shelley.sage@eastcoastkent.nhs.uk What went well • Rapid approval of the business case by the PCT.www.improvement.nhs.uk/heart
  16. 16. Atrial fibrillation in primary care: making an impact on stroke prevention 17Primary Care Arrhythmia Service - Medway PCTKent Cardiovascular Network, Medway PCT, Medway NHS Foundation Trust,Medway Maritime HospitalDuration of project Resources and tools developed toSeptember 2007 - ongoing support the changes Available to share by contacting project leadScope of project • Business case.Develop a primary care arrhythmia servicewhich will: Future plans• Help GP practices identify AF and other The same model is already in operation in Eastern arrhythmia patients by encouraging and Coastal Kent PCT. opportunistic screening• Ensure existing AF patients are on optimal Contact details therapy (searches undertaken by use of Project lead: GRASP-AF tool) Tim Waite• Provide nurse led primary care arrhythmia clinics Email: tim.waite@nhs.net• Undertake and co-ordinate the patients diagnostic investigations Clinical leads:• Where necessary, refer patients to secondary care Dr Adrian Stewart clinic for further management Consultant Cardiologist• Manage appropriate patients within the Medway NHS Foundation Trust arrhythmia service, or Email: adrian.stewart@medway.nhs.uk• Refer patients back to the GP for management within primary care Mary Kirk• The service will act as the point of contact for BHF Consultant sudden cardiac death ensuring families have Nurse Medway PCT access to screening tests and information where Email: mary.kirk@medwaypct.nhs.uk appropriate.Business case for two primary care arrhythmianurses has been approved by the PCT Board withthe aim of having the nurses in post by latesummer 2009.Baseline positionQOF data for Medway PCT suggests an underidentification of approximately 1,300 AF patients.Key challengesLength of time it has taken to get approval for thebusiness case.Challenges for sustainabilityHaving permanently employed arrhythmia nurseswill ensure sustainability. www.improvement.nhs.uk
  17. 17. 18 Atrial fibrillation in primary care: making an impact on stroke prevention Atrial Fibrillation Opportunistic Screening and Patient Review Pilot - South of West Kent - West Kent PCT Kent Cardiovascular Network, West Kent PCT Duration of project Outcomes 1 July 2009 - 31 February 2010 Unable to report outcomes at the moment as project not due to start in earnest until July 2009. Scope of project The project has two aims: first to pilot the efficacy Resources and tools developed to of opportunistic screening for atrial fibrillation support the changes within general practice of patients aged >65 years. All available for sharing through contacting This is in order to identify undiagnosed patients the project lead: and ensure that they are added to practice registers • Project proposal and rapidly gain access to the appropriate • Project process treatment pathway (opportunistic screening has • Data collection forms been shown to increase detection of AF by 60%). • GP agreement to join the project. The purpose is to make opportunistic pulse checks a matter of routine. Contact details Project lead: Second to review existing AF patients to ensure Tim Waite they are on optimal therapy using the GRASP-AF Email: tim.waite@nhs.net tool. Clinical lead: Nine to ten GP practices in the South of West Kent Dr Paul Goozee are going to be involved in the project. Email: pg@hmg.nhs.net 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.www.improvement.nhs.uk
  18. 18. Atrial fibrillation in primary care: making an impact on stroke prevention 19Management of Atrial Fibrillation in Primary CareCardiac and Stroke Networks in Lancashire and Cumbria, Six GP practices inLancaster and Morecambe, Royal Lancaster Infirmary (University Hospitals ofMorecambe Bay NHS Trust), North Lancashire Primary Care Trust, Lancaster,Morecambe, Carnforth and Garstang Practice Based Commissioning ConsortiaDuration of project maintaining a rolling programme of ECG training17 December 2007 - 31 March 2009 and the subsequent resource implications that this would offer an ideal opportunity to pilot the role ofScope of project telemedicine for the interpretation of ECGs inIn May 2007, members of the network primary primary care.care group identified that the NICE clinicalguideline 36 published in June 2006 contained a What we didnumber of confusing algorithms, therefore unlikely • Established a project steering group, withto be effectively implemented by GPs in primary representation from all stakeholders, to agreecare. Previous work undertaken by Blackpool, Fylde aims and objectives, provide guidance andand Wyre health economy had produced an support to the projectalgorithm and supporting guidance focused on • Developed a project guide to inform stakeholdersmanagement in primary care. This was shared and of background detail (Appendix D)adapted for network wide use and assessment of • Developed a communication plan to ensure thatits effectiveness formed the basis for this project stakeholders are kept informed of developments(Appendix A). The following objectives were set to (Appendix E)support this evaluation and to align with the • Collated and analysed baseline and final datarecommendations of the National Heart (working with network data analyst)Improvement Programme: • Visited each practice team individually to outline project aims, request baseline data and• Ensure that AF prevalence in the practices disseminate and discuss ‘management of AF in matches what is expected nationally primary care’ guidelines• Ensure that all diagnoses have been confirmed as • Following feedback from clinicians on the per NICE guidelines guidelines it was agreed that ‘acute• Ensure that all patients are receiving anti- presentation of AF’ needed to be addressed platelet/anticoagulation therapy as appropriate within the supporting guidance. Amendments• Review prescribing trends for AF patients against were made and resubmission to clinical NICE/local guidelines governance was undertaken• Address training needs, in particular around ECG • A poster shared through the national team was recording and interpretation disseminated to all practices for use in raising• Review local anticoagulant service and address awareness of AF and pulse checking as a service improvements. screening tool (Appendix F) • A flyer was also produced by the network toBaseline position explain to patients the importance of ‘pulseAccording to Quality Management and Analysis checks’ in identifying patients with AF and theSystem (QMAS) data, AF prevalence in all but one risks associated with the condition (Appendix G)of the six pilot practice is above nationally expected • Worked in collaboration with colleagues inlevels taken as 1% of total population, 4% of over secondary care in relation to the local65s and 10% of over 75s. However, some anticoagulation service, including a processpractice’s registers required validating in view of mapping event. A summary of the learning andthe high elderly population. King Street, as a service improvement ideas generated are detaileduniversity practice was identified as an outlier in in Appendix Hrelation to the expected prevalence, with a • The use of telemedicine to support GPs in theprevalence of 0.58%. interpretation of ECGs was piloted • The use of a single lead event monitor withinBaseline prevalence data (Appendix B) QOF data primary care was pilotedsuggests that confirmation of diagnosis is good. • Following consultation with lead GPs from eachBaseline prescribing data (Appendix C) indicates practice, the two pilot projects were initiated inthat warfarin prescribing particularly in the >75s is four practices and evaluated through the analysislower than recommended. of audit forms completed by the GPs (Appendix I, J)At the practice visits, training needs were identified • The governance issues surrounding these pilotsin relation to ECG recording and interpretation. It were addressed and supported by NHS Northwas decided in view of the difficulties in Lancashire (Appendix K, L) www.improvement.nhs.uk
  19. 19. 20 Atrial fibrillation in primary care: making an impact on stroke prevention • Following analysis of the prescribing trends by • All practitioners have concerns about warfarin North Lancashire Medicines Management, prescribing in >75s recommendations were made that could be • Many GPs are accessing the local anticoagulant incorporated into patient individualised medicines service differently and are not confident that this reviews by either the practice pharmacist or GP aspect of their AF management is being • Final sustainability score report was undertaken delivered effectively. Local service provision (Appendix M). requires review and could be addressed through PBC. Key challenges • Maintaining engagement of the practice teams Telemedicine key learning • The challenges within the telemedicine pilot • Assessment of GP competency to interpret ECGs included full engagement of all practices and was complex individual GPs and promoting use of the single • The use of the single lead diagnostic tool in lead diagnostic tool primary care was useful and quicker results were • The evaluation of the ECG interpretation audit obtained than accessing secondary care for was time consuming and complex. ambulatory monitoring • Whilst this project assessed competency of GPs What went well to interpret ECGs, it was highlighted that the • Enthusiasm from the project team was high and quality of the ECG recording was equally clinical leadership essential important. • Involvement and support from the patient representative proved helpful, both with the Outcomes mapping event of the local anticoagulation Practices have reported that as a result of service, and also in relation to feedback on validation work and opportunistic screening they leaflets and posters used throughout the project have increased numbers on their AF register. • The steering group meetings were infrequent but Final prevalence data and comparisons attendance from every stakeholder group was (Appendix N). high (PBC, PCT, GP clinical lead, patient, network) Discussions have begun with colleagues in • Although the telemedicine pilot was seen as time secondary care in relation to some redesign of the consuming with a high administrative burden, anticoagulation service. A number of developments out of all data entries the data was 98% have been identified for discussion by the PBC complete. consortia. Key learning from work Warfarin prescribing increased in half of the Recurring themes were identified in relation to the practices however, more guidance is being sought identification and management of patients with AF: to support warfarin prescribing, particularly in • Final data collection has illustrated an increase in >75s. Currently the NICE algorithm is still being prevalence in all age groups across all practices. used to support decision making, although the use This may be due to raising the profile of AF of the CHADS2 tool has been considered. The within the practice teams, through the adoption opportunity to pilot the ‘Auricle’ decision support of the network guidelines, the initiation of tool was considered but declined on account of the opportunistic screening methods or register decision to undertake a telemedicine pilot. validation • Practices need to ensure that ‘manual pulse The final data collection of prescribing trends in checks’ are inserted into all appropriate chronic relation to rate control of AF was variable. disease templates. It was identified that since the However, there was a reduction in the use of increased use of digital blood pressure (BP) digoxin in four out of six of the practices. It was monitors, pulse palpation was being neglected, concluded that the support of the PCT Medicines when in actual fact it was all the more important Management Team is key to the success of • Alternative methods of opportunistic screening guideline implementation in relation to prescribing. have been discussed and shared by all Final prescribing data and comparisons participating practices, focusing in particular on (Appendix N). those at higher riskwww.improvement.nhs.uk
  20. 20. Atrial fibrillation in primary care: making an impact on stroke prevention 21Telemedicine pilot Implementation of guidelinesThe aims of the project were: • Since the inception of the project, map of• To assess ease of use and the clinical and medicine has been adopted in most PCTs across personal impact of technology for ECG the network. It is recommended that formal links interpretation and single lead diagnostic between map of medicine and the guidelines are monitoring established in order to support its• To assess the required capacity and also the implementation. outcomes of the interpretations for each of the referral criteria (clinical symptoms, long-term Warfarin prescribing (particularly in >75yrs) conditions monitoring, screening prior to referral) • An agreed decision making tool used both in• To assess GP competency levels in relation to primary and secondary care should be adopted ECG interpretation to inform GPs, secondary to reduce many of the uncertainties around care and PCTs prescribing and increase uptake. Consistency is• To share findings and support wider probably more important than which exact tool dissemination. we use e.g: CHADS2, NICE or SIGN.Telemedicine results (Appendix 0) Telemedicine • It was difficult to assess ease of use andNB: All appendices A-O are available from acceptability of the service by the practices asthe NHS Improvement System they found the audit process was time consuming and high levels of administrationSummary and recommendations were required. This may have influenced the perception of the telemedicine serviceValidation of registers • Interpretation skills amongst GPs vary and• Practices need to have a register of patients with assessment would be best done individually ‘active’ disease, excluding patient’s who have rather than as part of a wider audit. Full been ‘cured’ by cardioversion or ablative therapy. participation from all GPs as individuals was not Whilst the QOF register should reflect this, the achieved and did not highlight any one particular ‘atrial fibrillation resolved’ codes are often not practice with a training requirement or used (validation will in fact tend to make the competency issue registers smaller). • Assessment of the requirements for practical ECG recording training should be consideredMedication reviews • Some GPs felt that they would prefer to see the• Practices need to review patients medication ECG at recording as opposed to only having annually and adherence to the guidelines can be sight of it when receiving the report supported through recommendations from • The turnaround time from Broomwell was seen medicines management. as a positive benefit of the service and the recommendation for practices to assess theirOpportunistic screening own ECG interpretation processes should be• The recommendation from the guideline to implemented opportunistic screening was adopted by the • PCTs should assess both elements of the practices and resulted in more AF patients being telemedicine service as an operational need prior identified. Practices should ensure that manual to implementation. Assessment of need should pulse palpation checks are embedded within the be carried out on an individual practice basis appropriate chronic disease management • Proposed telemetric links between primary and templates and that the whole primary care team secondary care may well support GPs further and are aware of their responsibilities for screening PCTs should horizon scan future developments for AF in their practice population. • 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. www.improvement.nhs.uk
  21. 21. 22 Atrial fibrillation in primary care: making an impact on stroke prevention Challenges for sustainability Resources and tools developed to A sustainability score and report was undertaken support the changes: derived from the NHS Sustainability Model and Available for sharing from NHS Improvement Guide, developed by the NHS Institute for website (www.improvement.nhs.uk/af Innovation and Improvement. The sustainability /projectsummaries): model is a diagnostic tool that is used to predict • Baseline prevalence data the likelihood of sustainability for improvement • Baseline prescribing data projects and this has been applied to our • Project guide management of atrial fibrillation in primary care • Project communication plan project. • Poster – Stroke the Beat • Flyer – Why have your pulse checked Recommendations • Process map and action plan • Review the organisational link between the PCT • Audit form – ECG interpretation and PBC to establish adequate quality metrics • Audit form – One lead device • Staff training in relation to Atrial Fibrillation • Serious untoward incident reporting algorithm management • Patient consent – Telemedicine pilot • Raise the profile of AF and review its • Sustainability score report management in primary care. Incentivisation may • Final prevalence/prescribing data be required to sustain services for AF patients in • Telemedicine powerpoint presentation. general • Links to the NHS Health Check Programme Future plans and the prevention of cardiovascular disease • The network plans to share this report initially should incorporate the screening for AF. with the participating practices and the host PCT and thereafter to the other PCTs in the region Sustainability score report (appendix M). • It also intends to align the learning with future developments in relation to prevention and Costs incurred detection of cardiovascular disease. • Costings for the telemedicine pilot were £6,000 for a period of three months for the four Sites outside of the network where the participating practices. Broomwell contributed approach has been adopted £2,000 to these costs with the network funding Apart from sharing developments with other the balance networks involved in the national priority project, • A project manager was appointed and funded the guideline has also been shared with a through Heart Improvement Programme monies neighbouring network area at their annual for two days a week for the duration of the educational event. project • The project lead was assigned to work one day Contact details a month on the project out of her three day Project leads: working week as a service improvement Lauren Butler and Jean Hayhurst manager for the network. Email: lauren.butler@csnlc.nhs.uk Email: jean.hayhurst@csnlc.nhs.uk Patient, carer and staff involvement • Patients reported liking the use of the single lead Clinical lead: device and found it easy to use Dr Andrew Gallagher • Staff reported that they felt much more aware of Email: andrew.gallagher@gp-P81056.nhs.uk 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.www.improvement.nhs.uk
  22. 22. Atrial fibrillation in primary care: making an impact on stroke prevention 23Atrial Fibrillation in Primary Care in RotherhamNorth Trent Network of Cardiac Care, NHS RotherhamDuration of project • Set up ‘train the trainers’ for people workingJuly 2007 - ongoing with the south asian population to advise about the risk and symptoms of cardiovascularScope of project disease and these are to be repeated andThe initial aim of the project was to address aimed at all BME populationsatrial fibrillation, to ensure correct diagnosis, • Held public awareness sessions for peopleappropriate treatment within primary care and from the south asian population to raisereferral to secondary care as required. awareness about cardiovascular disease and these are to be repeated and are open to theAs the project was progressing the PCT was in general populationthe process of introducing near patient testing • The Coronary Heart Disease Localfor anticoagulation in primary care and the focus Implementation Team (LIT) encompassedchanged to concentrate on developing this stroke and became the Cardiovascular Diseaseservice. (CVD) LIT – the lead physician for stroke and the PCT lead for stroke both sit on this groupAn ongoing rolling program of training has been • A stroke pathway group has been establishedinitiated for staff across primary care which which feeds into the CVD LITincludes ECG training (both undertaking and • A gap analysis on atrial fibrillation wasinterpretation), hypertension updates, CHD undertaken – and as a result of this a patientupdates, CHD diploma, heart failure (HF) safety group for anticoagulation has beenupdates, stroke study days and cardiovascular established to drive the work forward on nearrisk assessment days (with the opportunity of patient testing including developing servicebecoming accredited). specifications, standard operating procedures and a programme of trainingBaseline position • Other areas of work relating to atrialThe population being reviewed was that within fibrillation identified in the gap analysis will bethe Rotherham PCT sector. The aim was to picked up once the work aroundreview what services were available within both anticoagulation has been completedsecondary and primary care for patients with • A review of admissions to secondary care inatrial fibrillation or for those at risk of 2007 with a primary diagnosis of atrialdeveloping atrial fibrillation. This also covers the fibrillation was undertaken, and also of thosepopulation affected by the development of the with a secondary diagnosis of atrialnear patient testing service for anticoagulation. fibrillation/flutter – several had a diagnosis of TIA, stroke or cerebral haemorrhageWhat we did • Reviewing how to introduce manual checking• Evaluated how many practices of pulse within primary care. undertook ECGs: • Who undertook the ECG Key challenges • Who interpreted the ECG • Getting manual pulse adopted by GP practices • What training they had received as a routine check • When had they received the training • Setting up the anticoagulation near patient • Did they refer the patient into the open testing service access service in secondary care • Getting atrial fibrillation on to the stroke• Scoping exercise to identify what training and agenda competencies are available to support near • Reviewing the whole of the atrial fibrillation patient testing for anticoagulation pathway• Developed a rolling program of training for • Identifying training opportunities to support staff across primary care including GPs, nurses, anticoagulation services health care assistants and allied health • Ensuring that other areas identified as needing professionals attention within the gap analysis are targeted. www.improvement.nhs.uk
  23. 23. 24 Atrial fibrillation in primary care: making an impact on stroke prevention What went well Outcomes • The training programme has been very • That a locally enhanced service (LES) will drive successful and continues to be so. Staff within the work around near patient testing and general practice including GPs, nurses and anticoagulation within Rotherham health care assistants have attended the study • That patients who would have had to attend days and undertaken diploma courses. Much secondary care for this service may now be of the training is now being repeated, and we able to access it at a local level hope to offer diplomas in stroke and atrial • Atrial fibrillation is rising up the stroke fibrillation in the future agenda. • Gap analysis identified that there were major issues in developing the work around near Challenges for sustainability patient testing and anticoagulation and this • There are issues around getting manual pulse led to the initiation of the patient safety checking accepted as a routine check group for anticoagulation and targeted work • Ensuring that staff attend regular updates in this area regarding the near patient testing. • The standard operating procedure and service specification are being developed for the near Future plans patient testing service for anticoagulation • To set up educational training days for staff under locally enhanced services (LES) within primary care – both GP practices and • Meetings have been held to review what the provider services – and also to link in with educational needs for people who are nursing and care homes and the housebound initiating treatment are as against those who • To have manual pulse checking adopted as will be maintaining treatment, and how to link routine. these in with the competencies. Training days are being developed for practice staff who will Contact details be maintaining patients for anticoagulation. Project lead: Ann Baines Key learning from work Email: Ann.baines@rotherhampct.nhs.uk • 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.www.improvement.nhs.uk
  24. 24. Atrial fibrillation in primary care: making an impact on stroke prevention 25Atrial Fibrillation in Primary Care ProjectNorth Trent Network of Cardiac Care, Sheffield PCT, Sheffield Teaching HospitalsFoundation Trusts (Northern General Hospital), Six GP practicesDuration of project areas of high deprivation which also linked to theMarch 2008 - March 2009 enhanced public health programmes. Six of the ten practices were invited and recruited betweenScope of project March 2008 and October 2008. Practices wereIn Sheffield, there is considerable variation in asked to:diagnosis of AF across the city, demonstrated bythe wide variation in QMAS (QOF) reporting for • Use opportunistic screening to identify patients2006/7. The percentage of patients with AF who with AF over the age of 65are currently treated with warfarin therapy is also • Run a MIQUEST query which would riskvariable. A steering group was established with stratify patients using the NICE algorithm andclinicians from general practice, the acute trust, would assist practices in reviewing currentpublic health and provider services. Sheffield management of patients with AFTeaching Hospital Foundation Trust (STHFT) planned • Refer appropriate patients to the enhancedto pilot a fast track AF clinic alongside the AF public health programmes in their area (e.g.primary care project, enabling pilot practices to fast weight management programmes)track appropriate patients to secondary care • Refer appropriate patients to the pilot fast(Appendix A). Ten practices were identified in track AF clinic at STHFT. Baseline position Results of opportunistic screening for atrial fibrillation for patients over 65 in pilot GP practices www.improvement.nhs.uk
  25. 25. 26 Atrial fibrillation in primary care: making an impact on stroke prevention What we did Key learning from work The project approach was to identify pilot practices • The project practices may have been too small through prevalence and individual practice data. • Perhaps recruit all interested practices not just Practices would be asked to screen patients using those linked to enhanced public health opportunistic screening of patients 65 and over programmes (reference the SAFE Study. Health Technology • Identify resource needs prior to the project – Assessment 2005; 9:1-74). Support would be although we did this it was on an ad hoc basis provided to enable practices to review current which is why it took so long to develop the management of patients with a diagnosis of AF MIQUEST query and to review their protocols to ensure they are • Commitment needed from practices to review evidenced based and consistent with current best their patients when they have been identified. practice. Support would be offered to practices to develop appropriate treatment services such as Outcomes practiced based anticoagulation services. • Sixteen new patients were identified by four of the six pilot practices between April 2008 and Six practices were recruited. All six practices agreed February 2009. Extrapolating these results to the to use the opportunistic screening approach for the whole of Sheffield practices identifies 248 new identification of AF in the over 65s. Two practices patients opted out of searching their system for • Due to the lengthy process of developing the unidentified patients and management review of MIQUEST query and the availability of the IT current patients using the MIQUEST query, as the specialist the query was not tested in a practice practices have systems in place to do this. Four with live data until March 2009 practices were happy to discuss running the • The test resulted in the identification of: MIQUEST query once it had been developed and • Seven patients risk stratified as high risk with a tested. The MIQUEST query risk stratified patients diagnosis of AF who are not on warfarin or according to NICE stroke risk algorithm. All six asprin and have no contraindications recorded practices welcomed the opportunity to refer to the • 38 patients at high risk with a diagnosis of AF enhanced public health programmes and the pilot were on asprin only with no contraindications fast track AF clinic. recorded • 23 patients did not have their diagnosis Key challenges confirmed by ECG and other review • Lengthy process developing MIQUEST query as diagnosis (2) the IT person was not given any dedicated time • The practice was given a report with named for the project. Different practice systems meant patient data and asked to consider reviewing amendments to MIQUEST these patients. The practice plan to review • Actually getting appointments to visit practices. these patients • Difficulty getting everyone to meetings due to • These results should be viewed with caution as other commitments. Attendances at project we were unable to access exception reporting meeting were good for the first six months but information at the time. We plan to run the then began to tail off. query in another pilot practice. GPs have been asked to comment on the accuracy and What went well usefulness of the information provided and The practices visited were all very keen to whether patients have been reviewed as a result participate in the opportunistic screening because of the information there were no targets or extra workload involved. • Quick reference AF management guidelines have One practice contacted the enhanced public health been developed for GPs programme and set up a weight management • The guidance has been approved by the area programme for their patients. Five patients were prescribing committee and PEC and have been referred to the fast track AF clinic at the Northern circulated to all GP practices in the city. General Hospital. Note: Anticoagulation in general practice – is a separate PCT project.www.improvement.nhs.uk
  26. 26. Atrial fibrillation in primary care: making an impact on stroke prevention 27Costs incurredNonePatient, carer and staff involvementAlthough the project has ended opportunisticscreening and reviewing the management ofpatients with AF has now become part of theprimary/secondary prevention phase of our strokeproject. Practice staff and PBC through the strokeproject have expressed an interest in the results ofthe project.Resources and tools developed tosupport the changesAvailable 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 detailsProject lead:Colette LongfordEmail: Colette.longford@sheffieldpct.nhs.ukClinical lead:Dr Brian HopkinsEmail: b.j.hopkins@sheffield.ac.uk www.improvement.nhs.uk