Healthcare delivery
transforming the stroke treatment process at UCLH, while freeing up St Barts’ time for other arrhythmia procedures.
Detection and early intervention after cryptogenic stroke Detecting paroxysmal AF, where present, is critical to the prevention of secondary strokes and aligned with the priorities of the NHS Long Term Plan to provide quality care at the right time, improve patient outcomes, and tackle health inequalities.7 Of the over one million stroke survivors living in the UK, a disproportionate number are living with AF.3
People with AF are five times
more at risk of stroke than those without the condition.8
Remote patient monitoring allows
healthcare teams to monitor patients outside the hospital, reprogramme devices, and capture medical data from patients without needing to arrange an in-clinic visit. This data can be transmitted electronically to consultants for clinical assessment. Remote patient monitoring technology can identify several cardiac conditions including AF, by regularly monitoring cardiac changes in data points such as heart rhythm and heart rate. This enables healthcare professionals to reduce unnecessary hospital visits for stroke patients while keeping a close eye on their condition.
ICMs can be used in patients who are
suspected to be suffering from AF or have had a stroke of an unknown source (cryptogenic stroke). Intermediate cardiac monitoring, with wearable external monitors over 30 days, may miss up to 88% of patients with AF,4
whereas
ICMs can favourably inform clinical decision- making by continuously monitoring cardiac rhythm for three to four years after insertion. With the correct identification of AF, consultants can prescribe anticoagulation treatments, reducing the risk of secondary stroke by up to two-thirds.9
The value of long-term cardiac monitoring and holistic support At UCLH, the revised pathway follows an initial period of cardiac monitoring to help determine the aetiology of a patient’s stroke.
Once consultants have identified whether the stroke is of a cryptogenic or embolic stroke of an undetermined source (ESUS), the patient is allocated the appropriate care. If the stroke is cryptogenic, the patient is referred to the UCLH pilot scheme, whereby they are added to a novel online referral system, which enables consultants to refer patients quickly onto the ICM pathway. Once referred, a clinical assessment is then carried out by the stroke nurse practitioners, and the ICM device is inserted by the nurses themselves. The focus remains on the “door to detection” and whether it is completed in a timely and efficient way. In the pilot’s infancy, UCLH was the only hospital practising a stroke nurse-led arrhythmia pathway. Therefore, practical decisions, such as determining the number of staff required to carry out the procedure, or the sourcing of a prespecified room, needed to be pre-determined. St Barts Health NHS Trust had an established cardiac care team and invited the UCLH nurse practitioners to observe their existing insertion model, enabling the nurses to study and understand the process and implement many of its tried and tested practices. The pilot was heavily supported by multidisciplinary teams, including cardiology and neurology consultants. The nurse practitioners found it reassuring to have stroke consultants present, should they be required to intervene during the cardiac monitoring insertion. Several nurses had never completed a small surgical procedure independently and so there were consultants present at every procedure, overseeing the insertion until the nurses were fully
confident.The pilot helped to
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demonstrate the full scope of the stroke nurse practitioners’ integral link to the pathway’s success and ICM adoption, while being the best source of patient comfort and symptom recognition.
Evidence, optimise, standardise The UCLH team aimed to improve processes from the outset, but the next stage was to continue to optimise and standardise the pathway. As the new stroke arrhythmia pathway became more refined, Edwards and Macarimban, alongside other nurse practitioners, decided to evolve it further. The team developed a specialist AF referral process that standardised how the AF patient group was referred to stroke services. This better enabled UCLH to quantify its data and develop metrics that paved the way for an even more efficient stroke care pathway. The nurse practitioners began with a small Friday triage team and suitable candidates were then referred to a face-to-face appointment by a consultant. The UCLH pilot study resulted in an AF
detection rate of 30% within the first six months, and an average time from pre-assessment to cardiac monitoring insertion of 73 days. This exceeded the hospital’s expectations and consequently, more cases of AF were detected using ICMs than via the standard 12 lead ECG or other short-term devices. As a result, consultants could treat the necessary patients with anti-coagulants, reducing their risk of secondary stroke and hospital readmission. ICMs have been recommended by the National Institute for Health and Care Excellence (NICE) in its 2020 Diagnostics Guidance as a cost-effective option to detect AF after a cryptogenic stroke where non-invasive
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