Healthcare delivery
electrocardiogram monitoring has been done and a cardiac arrhythmic cause of stroke is still suspected.10
In adult patients with ischaemic
stroke or TIA of undetermined origin, the European Stroke Organisation (ESO) guidelines now also recommend the use of implantable devices for prolonged cardiac monitoring, instead of non-implantable devices, to increase the detection of sub-clinical AF.11
As a result of
this recommendation and the pilot’s success, healthcare decision-makers are now working to provide UCLH with additional resources, having recognised that long-term cardiac monitoring can more effectively detect AF and reduce the risk of secondary stroke.
Prioritising the patient experience In addition to resources saved, a crucial metric of the pilot was the patient experience. UCLH team aimed to collate as much evidence as possible, conducted via pre- and post-cardiac monitoring insertion questionnaires. The stroke patients were seen in the clinic for a pre-assessment consultant review with an assessment questionnaire before having their procedure. UCLH kept patients for an additional 30
minutes post-insertion, to monitor for signs of any post-insertion complications, including excessive bleeding, swelling, or pain at the insertion site, before discharging the patients. Nurse practitioners offered patients another face-to-face consultation or telephone review four to five days post-insertion and gave patients their telephone number, which they were encouraged to call for a wound review or if they had any concerns. Several patients emphasised that because of
the ICM, they felt reassured by being constantly monitored, and were able to return to their normal day-to-day life. This reinforced the new patient-centric pathway model and proved that feedback can help inform clinical practice and improve care and management of patients, delivering new and improved ways to treat and support those in need of care. There is still relatively little understanding
around cryptogenic stroke and AF across the UK. The development of the pilot at UCLH demonstrated the invaluable role of multidisciplinary teamwork in the stroke pathway. Remote, long-term monitoring devices, like ICMs, can reduce health disparities by improving the assessment of health risks and help us better manage long-term conditions, supporting people to live longer, healthier, more independent lives. The collective willingness to expand surgical skills in support of ICM insertion transformed the stroke care pathway, freeing up vital resources across various departments at UCLH. This may merely be an example of what can be achieved if processes like these are standardised across the board.
CSJ
References 1 NICE Impact stroke, 2019. Available at: https://
www.nhsresearchscotland.org.uk/uploads/ tinymce/NICE-Impact-stroke.pdf Last accessed April 2023. NHS Long Term Plan. Stroke care. Available at: https://www.longtermplan.nhs. uk/online-version/chapter-3-further-progress- on-care-quality-and-outcomes/better-care- for-major-health-conditions/stroke-care/. Last accessed April 2023.
2 Stroke Alliance for Europe at What Cost the
Economic Impact of Stroke in Europe Research Available at:
https://www.safestroke.eu/wp- content/uploads/2020/10/01.-At_What_Cost_ EIOS_Factsheet.pdf. Last accessed April 2023
3 Yaghi S, Elkind MS, 2014. Cryptogenic stroke: A diagnostic challenge. Neurology Clinical Practice. 4(5):386-393. doi: 10.1212/ CPJ.0000000000000086. PMID: 25317376; PMCID: PMC4196459. NICE. Stroke and TIA. What is the prevalence of stroke and TIA in the UK? Available at:
https://cks.nice.org.uk/ topics/stroke-tia/background-information/ prevalence/#:~:text=The%20incidence%20 of%20first-ever,126%2C000%20in%20England. Last accessed April 2023
4 Sanna T, et al, 2014. Cryptogenic Stroke and Underlying Atrial Fibrillation, New England Journal of Medicine; 370:2478-2486.
5 Mohan KM, et al, 2011, Stroke. 42:1489-1494. 6 Hankey GJ, 2014. Secondary stroke
prevention.Lancet Neurology. 13(2):178-194.
7 NHS England, 2019. The NHS Long-Term Plan. Available at: https://www.longtermplan.nhs. uk/ Last accessed April 2023
8 Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham Study. Arch Intern Med. 1987 Sep;147(9):1561-4. PMID: 3632164.
9 Stroke Association, 2018. AF: How can we do better? Available at:
https://www.stroke.org. uk/professionals/atrial-fibrillation-information- and-resources. Accessed April 2023.
10 NICE, 2020. Diagnostics Guidance 41: Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke. Available at
https://www.nice.org.uk/guidance/DG41. Last accessed April 2023
11 Rubiera M, et al, European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin. Eur Stroke J. 2022 Sep;7(3):VI. doi: 10.1177/23969873221099478. Epub 2022 Jun 3. Erratum in: Eur Stroke J. 2023 Mar;8(1):413. PMID: 36082257; PMCID: PMC9446336.
*The pilot was supported by an educational grant from Medtronic.
About the authors
The authors of this article include: neurology consultant, Dr. Arvind Chandratheva, consultant neurologist and stroke physician, clinical lead, Dr. Robert Simister, advanced stroke nurse practitioner, Selina Edwards and nurse practitioner, Roberto Macarimban from the University College London Hospital.
September 2023 I
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