A multidisciplinary one-stop atrial fibrillation (AF) service serving a population of 180,000 with a substantially high prevalence of AF. The clinic provides comprehensive management to patients with newly diagnosed AF in addition to those with an established diagnosis who have ongoing symptoms. The service deals with all aspects of AF management including rhythm and rate control and prevention of stroke risk.
This example was originally submitted to demonstrate implementation of NICE CG180. This guidance has been updated and replaced by NG196. This example continues to align with recommendations in the updated guidance. The guideline NG196 should be referred to if replicating any aspect of this example.
Aims and objectives
The clinic was established in January 2009 as an initial six month pilot due to the high prevalence of AF in Carmarthenshire which was identified as the highest in Wales. It ensures one-stop optimal management and risk factor assessment of all patients diagnosed with AF for the first time whether paroxysmal, persistent or permanent. The main aim is to ensure that every patient leaves the clinic on the day of their visit with a definitive diagnosis, a global cardiovascular risk assessment and a clear and concise management plan in addition to assessment and commencement of appropriate stroke prevention.
Reasons for implementing your project
On realisation of the scale and higher prevalence of AF in our area it was clear that a formal initiative was required. Prior to the clinic being established no formal care pathways for AF management were available. Many patients were undiagnosed. Of those that were diagnosed many remained under primary care supervision with the remainder being referred to general cardiac clinics often resulting in a delay in initial assessment. Due to the nature of the cardiac clinics at the time the assessment and care of people with AF was often undertaken by doctors without a special interest in this area and a significant number remained under the care of general physicians.
Patients seen in general cardiac clinics were attending multiple appointments on different days with a variety of departments including ECG clinics, exercise testing sessions, anticoagulation clinics and multiple visits to outpatient cardiology with no consistency in medical supervision for their AF. The new AF clinic is a real 'one-stop shop'. Referrals are received from both primary and secondary care. We aim to see all patients within a maximum of 4 weeks. Referrers are encouraged to initiate stroke risk management, including anticoagulation, if the CHADS stroke risk score, which forms part of the simple AF clinic referral form, is 2 or more. They are also asked to arrange preliminary blood tests.
On the day of their visit patients undergo an initial interview with a cardiac specialist nurse, including a brief history, CHADSVASC and HASBLED scores, in line with the NICE AF guideline. Patients are then seen by the AF Consultant Cardiologist specialist who makes a diagnosis after a full examination, usually including ECG. Patients at risk of stroke are then counselled on If found to be at risk the consultant and anticoagulant nurses will provide counselling and discussion on appropriate anticoagulation (warfarin or new oral anticoagulants).
Every patient leaves the clinic with a clear rate or rhythm management plan, a full stroke risk assessment and treatment on the same day. Those patients requiring special tests or treatment, such as coronary angiography or DC cardioversion, will be given provisional expedited dates at this first appointment to allow holistic management.
How did you implement the project
Implementation was relatively straightforward. We commenced the service as a pilot and presented an audit at the end of the first 6 months of implementation to our hospital management team who have supported us to continue the service since 2009. The whole project has proven to be cost neutral.
The Consultant Cardiologist with a special interest in AF rearranged their sessions allowing one clinical session per week to run the service by taking out 'AF waiters' from the general cardiac clinic. This resulted in a general cardiac session being allocated as a dedicated AF clinic without impacting waiting times. The cardiac specialist nurses also re-arranged their sessions to align with the new clinic and the ECG department provided some echo slots to run alongside the clinic. Our anticoagulant nurses were happy to meet patients on the same day as it meant that they could resolve queries with us there and then. The anticoagulant nurses and pre-assessment nurses attended sessions at the early stages and this working arrangement has proven to be very successful and popular with staff. We were also supported by a number of dedicated anaesthetists and CCU staff who were keen to support our cardioversion service on a fortnightly bases and this was achieved by simply rearranging working commitments and remained entirely cost neutral.
The clinic works closely with the nearby tertiary cardiac service allowing seamless transfer of appropriate patients for AF ablation after all required preparation and management. A closely linked fortnightly DC cardioversion list is also run by the AF clinic cardiologist thus minimising waiting times for those requiring this treatment.
As the AF clinic started at the same time as a TIA clinic we have not been able to identify exact figures of strokes reduced due to the commencement of the clinic. However, we have seen a reduction in completed strokes in our catchment area and our stroke physicians agree that the AF clinic and the CV risk management it offers have definitely contributed to this improvement in patient outcomes. Importantly our AF clinic audits have demonstrated that 50-60 patients identified at risk of stroke had not been previously anticoagulated despite having a known diagnosis of AF. This risk was mitigated immediately through the clinic and should contribute to significant stroke prevention. Additionally many other patients with angina, valve disease and heart failure have been identified through the service all of whom have been appropriately managed and treated promptly
Key learning points
The appropriate management of atrial fibrillation needs to be recognised as a core service in every NHS organisation. The morbidity and mortality associated with AF is significant and prevention of devastating strokes is actually relatively simple and accessible to all.
By simply reorganising working arrangements and sessions we realised that a much improved service was possible as the patients were already at different locations within the system and therefore it was possible to streamline the clinic with no additional cost.
The one-stop shop element is achievable and is extremely reassuring to patients who truly value the holistic nature of the service.
An initiative like this requires a true multidisciplinary team effort and seamless transfer of care between sectors but all involved have found it extremely rewarding and thoroughly enjoy being part of the service.