An arrhythmia clinical nurse specialist, qualified in health assessment and prescribing, attached to an electrophysiologist consultant reviews referred atrial fibrillation (AF) patients in clinic. There is a protected 35-40 minute appointment for a new patient to allow a full explanation of their condition and treatment pathway.
A lot of work goes on prior to the clinic appointment to facilitate best practice and holistic care, reflecting the NICE principles of ‘patient centred care’ and ‘personalised package of care and information’ (Recommendation 1.4, NICE NG196)
This example was originally submitted to demonstrate implementation of NICE CG180. This guidance has been updated and replaced by NG196. The example continues to align with recommendations in the updated guidance. The updated guidance should be referred to if replicating any aspect of this example.
Aims and objectives
The NICE guidance for AF sets out a template for care of the AF patient that has been incorporated and expanded on in local practice.
An arrhythmia clinical nurse specialist was tasked with specialising in an area of arrhythmia care and AF was chosen as an area where gains could potentially be made. Over a six year period various measures were gradually introduced to enhance the care of the AF patient. The current AF holistic care pathway reflects the recommendations within the NICE guidelines and includes additional content.
Multiple conferences were attended over the years and good examples of best practice were chosen and incorporated locally. Examples include:
- Anticoagulation assessment with better uptake of DOAC.
- Address comorbidities/lifestyle factors.
- Develop a good support system.
- Screen for Obstructive Sleep Apnoea.
Reasons for implementing your project
The care of AF patients was shared between multiple cardiologists and there was variability in management strategies. There was no point of contact once a patient was discharged and there was variation in follow up and support literature provided. Some specific areas were identified where an arrhythmia clinical nurse specialist might provide care under a more unified programme.
There was a realisation that AF related stroke was a major problem globally and locally and any measures that could be found to help combat this consequence were sought as advocated by NICE guidance (Section 1.4). The potential benefits of the DOACs were recognised and clearly they should be advocated. Education on all the pros and cons of each was sought. Patients suffering stroke while awaiting anticoagulation was recognised as a scenario that should be avoided. Patients turning up to clinic with previously identified AF and not anticoagulated was a similar area of concern.
NICE guidance does not focus to a great extent on comorbidities and lifestyle but these are known to be a major factor in the management of AF. Many patients seemingly had poor knowledge and effort in those areas.
NICE advocates a support system for AF patients (Section 1.4). Before the holistic pathway was created patients might have received some literature ad hoc but no contact phone number or other support.
There is a strong and not always well publicised link between AF and obstructive sleep apnoea. Screening for obstructive sleep apnoea was minimal.
How did you implement the project
Education sessions with outside speakers to give AF/anticoagulation talks to emergency portal meetings were organised. Speakers and training courses were offered to the Non-medical prescriber group and a recruited team of AF link nurses. Funding was secured via anticoagulation pharmaceutical companies to pay for external speakers I had sourced to speak on anticoagulation (without influence on content). The hospital emergency and medical clinical guidelines were updated to reflect the use of DOACs. An anticoagulation poster was designed and widely distributed and displayed throughout the Trust (Appendix 2). Anticoagulation was assessed in clinic using CHA2DS2-VASc and HASBLED as per NICE guidance (Recommendation 1.11.2), with assessment of TTR with warfarin (Recommendation 1.6.9) and renal function using the Cockcroft Gault formula and conversion if taking antiplatelet. As recommended by NICE there is access to left atrial appendage occlusion assessment for those unsuitable for anticoagulation (Recommendation 1.7.19).
To tackle lifestyle factors/comorbidities, at an early stage, all AF referrals are copied to cardiac rehabilitation. Relevant literature is posted out to patients and the offer to attend drop in education classes with talks from consultants/nurses/physiologists/nutritionists is made (The Heart Support Group). After attendance at arrhythmia clinic and the heart rhythm optimised with rate and rhythm control including access to ablation as indicated in NICE guidance. An invite is made to attend cardiac rehabilitation supervised exercise programme in local gyms and encouragement given to keep up regular exercise afterwards. Alternatively instruction on a home exercise programme is offered.
Bariatric surgery is discussed where appropriate and a referral recommended to the local speciality.
All patients get the arrhythmia nurse office phone number. Literature on AF, anticoagulation and any planned procedures derived from a variety of reliable sources are proffered. Literature from the British Heart Foundation and AF Association offer access to further support networks.
A very low threshold was used for referring the AF patient for obstructive sleep apnoea assessment. An increased waiting list for obstructive sleep apnoea testing was addressed again with the help of the cardiac rehabilitation team with education in the process of assessment and referral for obstructive sleep apnoea so that it happens earlier while waiting for AF clinic.
It is very rare now for a patient to attend clinic without anticoagulation already having been assessed. Everything that can be done to reduce AF related stroke is a massive benefit to the healthcare economy and wellbeing of the individual and family. The Sentinel Stroke National Audit Programme data continually informs on our improving stroke prevention performance and work continues with other projects also contributing in this area.
It is well documented that dealing effectively with comorbidities/lifestyle can be more effective than medical/surgical remedies in the treatment of AF. A holistic pathway for the local management of AF patients with cost neutral measures involving the multidisciplinary team and getting patients involved in the self-management of their condition at an early stage means that when they attend clinic there is more time to concentrate on rate and rhythm management and this is easier to do with less intervention. The work done with the cardiac rehabilitation team prior to the clinic visit has allowed each clinic slot to be shortened and an extra clinic slot allocated to reduce waiting times and increase revenue. There would be a potential further cost saving generated as there would likely be less expensive interventions with electrical cardioversion, antiarrhythmic medication and ablation by tackling comorbidities/lifestyle earlier.
A good support system means that there is less likelihood of emergency admission or repeat A+E attendance when just advice is needed. The Facebook group helps to answer frequent questions that come up with issues including AF and holiday insurance that have been asked and answered frequently before and can be done better via peer support. There would potentially be a cost saving with fewer emergency admissions and readmissions with a well-managed and supported patient.
Hundreds of AF patients have been identified and assessed for obstructive sleep apnoea. Many are now established on continuous positive airways pressure systems and likely would need less intensive measures in the future management of their AF in terms of medication, electrical cardioversion and ablation. An abstract on Obstructive Sleep Apnoea and AF was presented by the team this year at the Heart Rhythm Congress meeting in Birmingham and published in ‘E P Europace’.
Is sleep apnoea unrecognised in patients with atrial fibrillation?
C Broughton S Piracha K McGibbon T Phan M B Allen
EP Europace, Volume 20, Issue suppl_4, October 2018, Pages iv7–iv8,https://doi.org/10.1093/europace/euy198.008
Published: 10 October 2018
Key learning points
Everything that has been learned over the last six years and gradually implemented could be done at an early stage by anyone setting up new clinical nurse specialist AF clinics today if they have similar services locally to access. It is important to identify and engage key people who are keen and enthusiastic to help.
Attending specialist conferences was particularly helpful. There was usually information picked up that could be implemented locally.
Determination is needed to push through on issues that need to be addressed and just keep trying different avenues if one seems closed off. Publicise what you are doing as I know I am guilty of working in isolation to an extent and not sharing best practice enough. Case studies for areas of best practise have been submitted on various forums this year and we were ‘Highly Commended’ for the British Heart Foundation Champions award this year for AF services.
Do not reinvent the wheel. Please feel free to contact our centre and we will gladly share any content that may be helpful.
I declare BHF sponsorship for the ‘I’m in control of my AF’ booklets that we order free from their website and also they have sponsored me more than once to attend the ‘Heart Rhythm Congress’ including last year when we presented our abstract on AF and sleep apnoea. The BHF have paid for my entry ticket on 3 occasions over the years at a cost of around £350 per 3 day pass. I approached pharma companies Bayer and Daiichi-Sankyo to pay for external speakers I had sourced to speak on anticoagulation. They each sponsored 1 time. I do not have the figure for the standard fee for the speaker that was paid by each firm once to him so on 2 occasions in total combined. There was no other pharma funding. I believe Daiichi-Sankyo provided sandwiches for an AF link nurse meeting also on 1 occasion. The speaker (pharma funded) helped other prescribers understand the use of the various DOACs and the importance of not delaying anticoagulation.