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

HEART

LUNG

CANCER

DIAGNOSTICS

Heart and Stroke Improvement

Atrial fibrillation in primary care:making an impact on strokepreventionNational priority project final summaries

STROKE

October 2009

NHSNHS Improvement

Foreword

Introduction

Project Summaries

Incentivised detection and management of Atrial Fibrillation -North Somerset PCT

Atrial Fibrillation Screening Project - Bedford

Atrial Fibrillation in Primary Care - Dudley Health Economy

Atrial Fibrillation in Primary Care - Walsall Health Economy

To standardise and develop an information package that supportspatients along the referral pathway - Northamptonshire

Primary Care Arrhythmia Service - Eastern and Coastal Kent PCT

Primary Care Arrhythmia Service - Medway PCT

Atrial Fibrillation Opportunistic Screening and Patient Review Pilot -West Kent PCT

Management of Atrial Fibrillation in Primary Care -Lancaster and Morecambe

Atrial Fibrillation in Primary Care - Rotherham

Atrial Fibrillation in Primary Care Project - Sheffield

Near Patient INR Testing Project - Whitby Group Practice

Atrial Fibrillation in Primary Care - Woking and West Byfleet

GRASP-AF (Guidance on Risk Assessment for Stroke Prevention in AtrialFibrillation) - West Yorkshire

A sector wide approach to optimising therapy for Atrial Fibrillationpatients in Primary Care - South West London

Project Team Leads, Cardiac and Stroke Networks and Participating Sites

3Atrial fibrillation in primary care: making an impact on stroke prevention

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www.improvement.nhs.uk

4 Atrial fibrillation in primary care: making an impact on stroke prevention

Atrial fibrillation (AF) is the most commonsustained dysrhythmia, affecting at least 600,000(1.2%) people in England alone. It is also a majorcause of stroke.

Uniquely it also is an eminently preventable causeof stroke with a simple highly effective treatment.This treatment is also highly cost effective.

These facts underpinned the first phase of theHeart and Stroke Improvement Programmes’ workon stroke prevention and atrial fibrillation. Fifteencardiac and stroke networks participated in thenational programme working with primary caretrusts (PCTs), general practices, practice basedconsortia (PBC) and acute trusts. Projects wereundertaken addressing the detection of atrialfibrillation, whether patients are appropriatelytreated with anti-coagulants and considering thebest pathways for managing atrial fibrillation inprimary care.

The major outcomes of this work continue todemonstrate:

• A clear variation in identification rates for atrialfibrillation

• That opportunistic screening can significantlyincrease detection rates

• That many individuals who have already beenidentified to have atrial fibrillation and withknown risk factors putting them at high risk ofstroke, are not being treated with anti-coagulants

• That the management of AF in primary care isboth practical and a necessity.

It is clear that improving identification of peoplewith atrial fibrillation and inducing betterintervention could prevent many thousands ofstrokes each year. The personal cost of a stroke toan individual is incalculable. To be aware that inmany cases this was an identifiable and potentiallyavoidable situation can only increase the anxietiesto the sufferer and their carers.

The identification of those at risk and appropriatetreatment offers a real opportunity for achievingcost effective, high quality care, with the goal ofpreventing avoidable mortality and morbidity.

Dr Campbell CowanConsultant CardiologistNational Clinical LeadHeart Improvement Programme

Dr Matt FayGP with Special InterestNational Clinical LeadStroke Improvement Programme


Foreword



These national priority projects were establishedin 2007 in response to Chapter Eight of theNational Framework for Coronary Heart Disease;Arrhythmias and Sudden Cardiac Death, publishedin March 2005, which set out the qualityrequirements for the prevention and treatment ofpatients with cardiac arrhythmias.

This is underpinned by the publication by NICE in2006 of ‘Atrial Fibrillation. The management ofatrial fibrillation costing report’ which highlightedthat amongst patients with recognised AF, 46% ofthose who would benefit from warfarin are notreceiving it. Out of an estimated 355,000, only189,000 were actually receiving warfarin.

In December 2008 the publication of the NationalStroke Strategy affirmed the importance of thiswork for stroke prevention. Quality Marker 2states:• ‘Markers of a quality service: Risk factors,including hypertension, obesity, high cholesterol,atrial fibrillation (irregular heartbeats) anddiabetes, are managed according to clinicalguidelines, and appropriate action is taken toreduce overall vascular risk

• Action needed: Commissioners and providers useASSET to establish baseline and to ensure thatthere are systems in place locally for thefollowing key prevention measures: warfarin forindividuals with atrial fibrillation

• Measuring success: Greater proportion ofindividuals who have a history of stroke orcardiovascular disease or who are at a high riskwho have had advice and/or are receivingtreatment’.

Atrial fibrillation is a major predisposing factor tostroke, with 16,000 strokes annually in patientswith AF of which approximately 12,500 arethought to be directly attributable to AF. Theannual 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.

Appropriate anti-coagulation of all patients withrecognised AF would prevent approximately 4,500strokes per year and prevent 3,000 deaths.

A recent Department of Health1 cost benefitanalysis suggests that for stroke patients withAF there are around:• 4,300 deaths in hospital• 3,200 discharges to residential care• 8,500 deaths within the first year.However,• The treatment of AF with warfarin reduces riskof stroke by 50-70%

• The estimated total cost of maintaining onepatient on warfarin for one year, includingmonitoring, is £383

• The cost per stroke due to AF is estimated to be£11,900 in the first year after stroke occurrence.

The early learning from the eighteen individualprojects established was first published in May 2008‘Atrial Fibrillation in Primary Care:National Priority Project‘(www.heart.nhs.uk/priority_projects/summary_documents/af_summary.pdf).This document aims to capturethe final summary oftheir individualapproach, lessonslearned,improvementsto practice andqualityoutcomes, alsosharing tools andresourcesdeveloped toenable other healthcommunities todrive this agendaforward.

Introduction

1Department of Health Atrial Fibrillation cost benefit analysis. Marion Kerr, 2008.



Key learningA variety of approaches were undertakenresponding to the needs of the local healthcommunities; however each project sought toestablish a baseline to demonstrate improvementsto changes in practice against:• Numbers of new patients with AF identified, andtheir subsequent treatment

• Numbers of existing AF patients reviewed and,where necessary, subject to optimal therapy

• Establishment of a clear and agreed patientpathway for AF patients.

InnovationKey areas for the piloting new approachescentred on:• Detection of AF though opportunistic screeningat flu clinics

• Local enhanced service (LES) schemes fordetection, screening and review of AF

• New models for anticoagulation services inprimary and community settings

• Development of tools to support the review ofpatients with AF, risk stratify for stroke andconsider optimal therapy:• The Guidance on Risk Assessment for StrokePrevention in AF (GRASP-AF) tool now availablefor use across all GP clinical systems viawww.improvement.nhs.uk/graspaf

• Decision support tool ‘the Auricle’www.theauricle.co.uk

• Guidelines for primary to secondary care referral.

EducationAll projects found the need to include educationfor professional and patients around:• Pulse palpation• Barriers to anti-coagulation in primary care• ECG training and interpretation• Patient awareness.

Partnership workingOpportunities have been sought both nationallyand within local projects to work with the thirdsector and professional health organisationsto develop supporting resources, tools andeducational information to meet the continuousrequirement for ongoing and relevant informationfor both the professional and the patient.

These have included:• Department of Health (DH)• National Institute for Clinical Excellence (NICE)• Primary Care Cardiovascular Society (PCCS)• Atrial Fibrillation Association (AFA)• British Heart Foundation (BHF)• Heart Rhythm UK (HRUK)• The Stroke Association (SA)• Primary Care Information ManagementService (PRIMIS)

• Ambulance services.

Quality outcomesMany of the approaches have already begun tospread across the network of priority projects andthrough sharing the work nationally through NHSImprovement national learning events.

In particular we have seen:1. The early piloting of opportunistic screeningthrough pulse palpation at flu clinics byBedfordshire and Hertfordshire Heart andStroke Network which has led to this initiativebeing replicated in other areas. For example:

• The Colchester Practice Based CommissioningGroup incentivised 37 practices out of 43 toundertake this approach enabling:• 34,201patients to be screened in six weeks• 189 patients found with AF (0.55%)• Estimated numbers of strokes preventednext year = 5

• At an estimated annual cost saving of£220,000 this represented 322% return oninvestment in addition to improved qualityoutcomes for patients.

2. The GRASP-AF tool developed and piloted by theWest Yorkshire Cardiovascular Network incollaboration with their BHF Arrhythmia nursesand PRIMIS for use on GP clinical systems toidentify for review AF patients with high risk ofstroke, not on warfarin, has now been madeavailable for use across England.


The York Health Group PBC cluster used GRASP-AFacross their 24 practices with a total population of228,651 patients of which 3,613 patients with AFwere identified.

By June 2009:• The total number of reviews undertaken 716• Of which face-to-face reviews 110• New warfarin prescription 41(6%)• Awaiting further review including consultantreferral 37.

Access to the GRASP-AF tool is throughwww.improvement.nhs.uk/graspaf and has alreadybeen downloaded by over 100 practices in the firstcouple of months of release.

SummaryIt is clear that tools and resources are only part ofthe process; it requires a whole system approach tomake significant and sustainable change across thewhole pathway of care for patients with AF if weare to dramatically reduce their risk of stroke.

This will require collaborative working across thewhole health system between cardiac and strokenetworks, clinicians, commissioners, public healthand third sector organisations, in particular, tomaximise benefit.

Action was sought with key stakeholders to bringtogether a consensus approach across England toaddress the key factors in influencing, educatingand encouraging change in the identification andmanagement of these patients culminating in thepublication in June 2009 ‘Commissioning forStroke Prevention in Primary Care - The roleof Atrial Fibrillation’ (www.improvement.nhs.uk/heart/Portals/0/documents2009/AF_Commissioning_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.

Further pilots will also be undertaken to:

• understand the issues and potential solutions forthe management and optimal therapy for strokeand TIA patients with AF

• to model the potential impact on current servicesof new drugs for patients with AF.

In addition, to support communities that haveadded pulse palpation as part of their NHS HealthCheck Programme, to have access to the learningfor the management in primary care for patientswith AF.

The work of this national priority ‘stroke preventionin primary care: addressing atrial fibrillation’supports the national drive for:

• Quality outcomes through addressing optimaltherapy for AF patients

• Innovative approaches to access andmanagement in primary care for AF patients

• Productivity through reducing inappropriatereferrals to secondary care and bed days saved

• Prevention by reducing risk of stroke.

Many of these project sites are continuing to takethis work further into implementation, with theaim to embed into core practice and continue toshare their learning both nationally and locallythrough the cardiac and stroke networks andnational learning events.

The following case study summaries represent anoverview of their work achieved by the end ofApril 2009 and the tools and resources theyhave generously made available to share can beaccessed from the NHS Improvement website at:www.improvement.nhs.uk/afprojectsummaries



Duration of projectJanuary 2008 - December 2008

Scope of project• To increase the detection rate of patients overthe age of 65 with atrial fibrillation throughopportunistic screening, with incentives paid foreach new diagnosis made and confirmed on ECG

• To improve the management of known AFpatients over the age of 65 by reviewing theirmanagement and optimising it whereappropriate.

Baseline position• Nine practices completed the project• The combined over 65 population for these ninepractices was 16,062 (representing 19% of theregistered population for these practices)

• 1,421 of these patients were known to have AF,giving an over 65 AF prevalence of 8.8%.

What we didOpportunistic screening was undertaken in thenine practices, either in chronic disease clinics, onGP visits or practice nurse visits. A code wasentered on to the computer system to capture thisactivity. Any suspected AF cases went on to havean ECG performed. For all confirmed cases aproforma was completed, outlining their risk score,management and any other relevant details. Allnew cases were validated by the lead clinician toensure that they were truly opportunistic. Anincentive payment was made for each newdiagnosis.

All known AF patients were entered onto adatabase and reviewed using the CHADS2 risktool. Where patients were not managed as per theguidelines, they were reviewed to ascertain ifmedication could be optimised. Incentives werepaid for each patient audited, with an enhancedlevel of payment for each payment where amedication change was made.

Key challengesOne of the key challenges at the outset was thedefinition of ‘opportunistic’, and thus ascertainingwho was eligible for payment or not. Patients wereexcluded from the project if they presented withsymptoms where it would be reasonable to expectthe clinician to check their pulse.

The time taken to review a large number of knownAF patients also proved a challenge, and the

incentives for this work to be done had to beincreased to reflect the labour-intensive nature ofthis task.

There seems to be poor communication andcohesion between GPs and secondary careclinicians when it comes to management of AF.GPs have expressed a reluctance to changemedication that was initially prescribed orrecommended by cardiologists, but admit littledialogue about the most appropriate managementof these patients.

What went wellPractices were very positive about the benefitsassociated with this project and involved most GPs,nurses and health care assistants. Many were alsoproactive in promoting the project to patients.

All but one of the practices reported that whilstthe incentives helped engage people, they believedit was a very worthwhile project and that theywould have taken part anyway. There was strongclinical leadership and close working relations withthe participating practices.

Key learning from workThe change in project manager mid way throughthe project proved a challenge. However, thenetwork deputy director and one of the practicemanagers helped minimise the impact of thischange.

There was a feeling that the GP practices weren’tentirely clear of the aims of the project at theoutset, and that the goal posts moved.There is a need when offering incentive paymentsthat they reflect the labour intensity of the work.

OutcomesOpportunistic screening• 7,089 pulses were taken in the year period,which assuming patients only had their pulsetaken once, represents 45% of the over 65population in the nine participating practices

• 66 new diagnoses were made, which were trulyopportunistic

• This equates to one new diagnosis for every 107pulses taken. The range of new diagnosis pernumber of pulses taken was considerable (25 –560), which raises questions about the reliabilityof the data and the methodology used

Incentivised detection and management of Atrial FibrillationAvon, Gloucestershire, Wiltshire and Somerset Cardiac and Stroke Network,Nine GP Practices in North Somerset PCT



• Over 70% of the new diagnoses had a CHADS2score of two or more and were thereforeconsidered high risk. However, only half of thesewere prescribed warfarin, with the majority ofthe remaining patients either refusing warfarin orbeing contraindicated.

Review of known AF patients• 1,075 patients with known AF over the age of65 were reviewed, which was over 75% of thetotal known AF population in that age groupacross the nine practices

• Approximately 80% were reported to havepermanent AF, and 20% paroxysmal AF

• The male:female split was approximately 54%male, 46% female for both types of AF

• 20% of the known AF patients scored as lowrisk on the CHADS2 tool (score 0-1), with 80%considered high risk according to the tool.Patients with permanent AF tended to have ahigher CHADS2 risk than those withparoxysmal AF.

Taking account of documented contraindicationsand patients refusing medication, 80% of patientswith paroxysmal AF in the low risk category (aCHADS2 score of 0-1) were found to be onappropriate medication, compared to over 90% ofthose with permanent AF. In the high risk group(patients with a CHADS2 score of two or more),49% of those with paroxysmal AF were treatedaccording to the guidelines, compared to 73% ofthose with permanent AF.

This demonstrates that patients with paroxysmal AFtend to be undertreated compared to those withpermanent AF.

In total 288 patients were identified as appropriatefor a medication change, but only 16 actually wenton to have a change in medication. This representsjust 1.5% of the 1,075 patients audited.

Given the number needed to treat with warfarin toprevent one stroke is 24, if the results from thisproject were applied to the whole PCT population,four strokes could be avoided in a population ofapproximately 200,000.

Challenges for sustainabilityThe review of known AF patients proved to be verytime consuming, with small numbers of patientschanged. The clinicians generally felt that theopportunistic screening was more beneficial and

more sustainable, with a focus on treating newdiagnoses appropriately in the first place.

Costs incurredThe spend for this incentivised project wasapproximately £15,000 against an initial projectionof £20,000. The cost not reflected in this is theproject management time.

Patient, carer and staff involvementPreliminary results were presented to the network’spatient, carer and public involvement group, whoshowed keen interest in the project. They havestrongly expressed a wish that a pulse check bemandatory in the vascular checks screen.Feedback from staff involved in the project hasbeen very positive, with most reporting that it hasraised the profile of AF in their practices andimproved the way in which AF patients aremanaged, as well as improving attitudes towarfarin prescription.

Resources and tools developed tosupport the changesAvailable for sharing via the Avon, Gloucestershire,Wiltshire and Somerset (AGWS) Cardiac and StrokeNetwork website (www.agwscs.nhs.uk) and theNHS Improvement website (www.improvement.nhs.uk/afprojectsummaries):• AGWS North Somerset final report andappendices, including guidelines and proformas.

Future plans• Eight of the nine participating practices plan tocontinue opportunistic screening

• The results of this project are currently beingdisseminated across the PCT to decided how thiscan be rolled out to other practices

• Practices feel that a yearly pulse check should beadded to Quality Outcomes Framework (QOF)for high risk groups

• Some practices have added a pulse check to theirchronic disease templates

• There is a strong feeling that a public awarenesscampaign about AF would be beneficial, as wellas training to GPs on warfarin initiation.

Contact detailsNetwork Administrator:Email: [email protected]

Clinical lead:Dr Martin Hime




Atrial Fibrillation Screening ProjectBedfordshire and Hertfordshire Heart and Stroke Network,Bedfordshire Primary Care Trust, 23 GP Practices

Duration of projectOctober 2008

Scope of projectOpportunistic pulse screening at flu clincs

What we did• One practice originally targeted for pulsescreening patients during flu clinics – Oct 2007.(see publication ‘Heart Improvement: AtrialFibrillation in Primary Care - National PriorityProject’ (www.heart.nhs.uk/priority_projects/summary_documents/af_summary.pdf)

• Subsequently a local enhanced service (LES)was developed to encourage wider uptake

• One primary care trust (PCT) implemented thisduring the flu season of 2008

• Currently working with the three other PCTs inthe network through local implementationgroups and practice based commissioning groups(PBC) to role out the LES for the 2009 flu season.

Key challengesEngaging PBC groups.

What went wellAF registers significantly improved in practices thattook up the LES.

Key learning from work• Communication is essential• Posters and leaflets developed for patients• Ensure district general hospital (DGH) servicesare aware of this initiative, as this can increasereferrals into the cardiology departmentsignificantly

• Important to have AF management pathways inplace to support initiative.

Outcomes• 23 practices used the LES• 6,000 patients screened• 122 new patients added to the AF register.

Costs incurredPayment to practices - 10p per patient screened,£60 per patient added to AF register.

Patient, carer and staff involvementPatients, clinicians and practice staff all felt theproject was worthwhile and caused very littledisruption to the flu clinic.

The patients in particular were very pleased withthe extra service when they understood theimportance of the screening.

Resources and tools developed to supportthe changesAvailable for sharing by contacting project lead• Local enhanced service.

Future plans• Continued expansion of the pulse screening inGP practices across Bedfordshire andHertfordshire and improve AF awareness inrelation to stroke prevention

• Offer regular training on the managementof AF.

Sites outside your network where yourapproach has been adopted by othersNorth YorkshireEssex.

Contact detailsProject and clinical lead:Delyth WilliamsEmail: [email protected]


Duration of projectSeptember 2007 - ongoing

Scope of project• Streamlining pathways and guidance for patientswith AF by development of a AF primary carepathway

• Training and development of primary carepractices to improve AF screening, detection andmanagement within the primary care setting

• Improving access to diagnostics - ECG• Improving access to anticoagulation services.

Baseline positionFull review and audit carried out at WorcesterStreet Commissioning Cluster against NICEguidance July-September 2007.

Investigation of Quality and Outcomes Framework(QOF) data - July 2007. Baseline assessment ofhospital admissions at Russells Hall Hospital.

What we did• Baseline investigation at Worcester Street Practiceagainst NICE guidance

• Formation of project group as sub-group of theCoronary Heart Disease (CHD) LocalImplementation Team

• Action planning at pilot practice followingbaseline assessment

• Searches at Worcester Street Practice to identifyfurther potential patients

• Review of patients identified by searches forpotential AF

• Draft AF guidelines developed• Development of outreach anticoagulation clinicat Worcester Street Practice

• ECG provision training at Worcester StreetPractice for health care assistants (HCAs)

• Pulse checking for irregular rhythms added to alltemplates at pilot practice

• Finalisation of draft AF guidelines prior to pilot• Carried out a borough wide primary careantiplatelet/anticoagulant audit in atrialfibrillation in conjunction with the practice basedpharmacy team

• Identification of second pilot practice – WychburyMedical Centre

• Action planning at practice following baselineassessment

• Searches at Wychbury Medical Centre to identifyfurther potential patients

• Review of patients identified by searches forpotential AF and anticoagulation treatment

• Training and development sessions around thescreening, detection and management of AF forall GPs, practice nurses, health visitors anddistrict nurses attached to the practice

• Pulse checking for irregular rhythms added to alltemplates at pilot practice

• Integration with the Dudley stroke steeringgroup to develop a plan for roll out of theproject borough wide.

Key challengesPractice engagement - our original pilot practicereceived all of the training but then would notengage in the screening process due to prioritiesaround moving to a new practice premises in thenear future.

We decided to abandon work with this practiceand move on to another site for pilot purposes.

What went wellEngagement between primary care practitionersand the cardiologists during training sessions.

Key learning from workIt is difficult to engage primary care to completethis work with their busy schedules unless fundingis available to incentivise.

OutcomesEstablishment of the AF pathway is still indevelopment but this will be available whencompleted and launched to the wider healtheconomy.

Challenges for sustainabilityTo spread this health economy wide it may need tobe incorporated into a local enhanced service.

Pulse checking has been incorporated locally intothe NHS Health Check Programme.

Costs incurredOnly staff time which for this pilot was given freeof charge.

Atrial Fibrillation in Primary Care - Dudley Health EconomyBlack Country Cardiovascular Network, Dudley PCT, Dudley Group ofHospitals Foundation Trust, Worcester Street Commissioning Cluster,Wychbury Medical Centre



Patient, carer and staff involvementPositive feedback was received from the practiceregarding the training they received.

Resources and tools developed tosupport the changesAvailable for sharing from the Dudley PCT website(www.dudley.nhs.uk) and the NHS Improvementwebsite (www.improvement.nhs.uk/afprojectsummaries):• AF primary care pathway.

Future plansCurrently planning how to spread the workeconomy wide once the electronic version of AFprimary care pathway is complete includingintegrated work with the Dudley strokesteering group.

Contact detailsProject lead:Joanne GutteridgeEmail: [email protected]

Clinical lead:Dr Craig Barr/Dr Joe MartinsEmail: [email protected]: [email protected]




Scope of project• To deliver high quality care in line with ChapterEight of the National Service Framework (NSF)

• To reduce emergency admissions for arrhythmia• To develop streamlined whole pathways of careto reduce bed days and outpatient visits for thisgroup of patients

• Develop an arrhythmia care pathway• Improve access to anti-coagulation services inprimary care

• Improve access to ECGs in primary care.

Baseline position• Baseline investigation at Lichfield Street Surgeryagainst NICE guidance

• Baseline assessment of hospital admissions atWalsall Manor Hospital

• Baseline assessment antiplatelet/anticoagulantaudit in atrial fibrillation across all practices inWalsall, in conjunction with the practice basedpharmacy teams.

What we did• An audit was undertaken to look at 60 patientscoded with a primary diagnosis of AF, how theywere admitted and their length of stay. Inconjunction with this a specialist registrar inpublic health has completed the report on thereview undertaken on behalf of the group

• The medicines management team ran anIMPACT educational campaign on themanagement of atrial fibrillation and secondaryprevention of stroke. The IMPACT campaign wasdeveloped to encourage a more structured andevidence-based approach to patientmanagement. IMPACT pharmacists carried outface-to-face meetings with practices during theperiod of the campaign and all practices havenow been completed. The IMPACT presentationwas also delivered to year two doctors at theManor Hospital as part of their ongoingeducational programme, Heart CareRehabilitation Centre clinicians and hospitalpharmacy staff

• Formation of project group as sub-group of theCHD local implementation team reporting alsoto the long term conditions group

• Searches on systems at pilot practice to identifyfurther potential patients and review of patientsidentified from search

Atrial Fibrillation in Primary Care – Walsall Health EconomyBlack Country Cardiovascular Network, NHS Walsall, Walsall HospitalsNHS Trust, Lichfield Street Surgery

• AF guidelines to support the diagnosis andtreatment of AF in primary care and a referralpathway from primary care into secondary carehas now been agreed and the documentationdisseminated to all GP practices to allow forfurther guidance

• Pulse checking for irregular rhythms has beenadded to all templates following IMPACTeducation sessions

• As part of the IMPACT campaign, practicepharmacists identified the proportion of AFpatients currently prescribed anticoagulant/antiplatelet therapy

• Using the CHADS2 scoring system, an audit ofthe practice population at Lichfield Street Surgerywas carried out. Those on the practice AFregister were identified using EMIS software.Patients not documented as receiving warfarinwere identified as possible candidates for therapy.Patients were excluded from risk stratificationif they had:1. Documented return to sinus rhythm but

remained on the AF register2. Contraindications to warfarin therapy3. Declined warfarin therapy in the last 12 months4. A forthcoming appointment with their GP

about commencing warfarin.Using medical records a CHADS2 score wascalculated for each patient. Those with aCHADS2 score ≥ 2 were sent a letter to theirhome address explaining that they may benefitfrom warfarin therapy. They were invited to thesurgery for a non-urgent consultation with ageneral practitioner of their choice to discussstarting warfarin. Four weeks after letters hadbeen sent, the practice population was re-audited to determine the impact of the intervention

• Piloted AF screening at flu clinics at pilot practicefrom 28 September 2008 to 4 December 2008.Clinical staff felt the radial pulse of all patientshaving influenza vaccine. In a practice populationof 7,504 a total of 1,324 pulses were recorded.Of those recorded 1,262 were found to beregular and 62 were found to be irregular. Of the62 irregular pulses, 33 were known to have AF,seven were found to have AF following an ECGand seven are awaiting an ECG. Fifteen werefound to have an ECG sinus rhythm with othercauses of irregular pulse. These results show itwas a worthwhile initiative that hopefully otherpractices take up next year. Seven new cases ofAF were identified and seven more sent off forECGs.



• It is worth using the services of the cardiacarrhythmia nurse as putting older people with AFon warfarin is much more effective in preventingstrokes and has proved to be as safe (BAFTAstudy Lancet 2007) if regular INR monitoring isadhered to

• Arrhythmia clinic referrals at two pilot practiceshas been working well and has now beenextended to all GP practices in Walsall. This clinichas 12 slots per week and is receiving regularappropriate referrals• Integration with the Walsall StrokeOperational Group

• Presentation to the local medical committee(LMC) on the arrhythmia pathway. Teaching andeducation sessions to nurses from primary andsecondary care have evaluated well

• Measures for AF will be monitored using ChronicDisease Register (CDR) Intell.

Key challengesEngaging other practices still remains an issue. Notall practices are using the referral guidelines asintended and are still referring to cardiologists.

What went wellEngagement at pilot practice was very encouragingwith links to secondary care and cardiologists.

Key learning from workGetting practices to engage without additionalfunding remains an issue.

OutcomesThe referral pathway to the cardiac arrhythmiaservice works well with those GP practices engagedbut still some work to be done. Pulse checking hasbeen incorporated into the core set of checks forthe NHS Health Check Programme in Walsall.

Costs incurredOnly staff time.

Patient, carer and staff involvementPositive feedback has been received from thepractices involved and the cardiac arrhythmianurse.

Resources and tools developed tosupport the changesAvailable for sharing on the NHS Improvementwebsite (www.improvement.nhs.uk/afprojectsummaries):• Impact campaign• AF guidelines• AF referral form.

Future plans• Looking to integrate more with the WalsallStroke Operational Group

• Engaging remaining practices to refer to thecardiac arrhythmia service using the AFguidelines.

Contact detailsProject lead:Angela NelsonEmail: [email protected]

Clinical lead:Dr Rumi JaumdallyEmail: [email protected]



To 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 PCT

Duration of project10 August 2007 - 01 August 2008

Scope of projectTo standardise and develop an information packagethat supports patients along the referral pathway.• Process map the patient pathway• Identify key information points• Evaluate available information• Identify who gives what to whom• Survey users on information and its benefit(quality, clarity and timeliness)

• Develop a pathway with clear informationindicators.

Baseline positionInformation taken from QOF across sample of GPpractices. Base line questionnaire on needs andpathways.

What we did• Evaluated feedback from questionnaire• Assessed outcome from a data quality audit on25 practices

• Brought together all evidence from NICE etc.including QOF and how to build a register

• Developed a folder of pathways and evidenceincluding the use of CHADS2 scoring and ECGrecognition

• Delivered ECG basic skills training for GPpractices

• Distributed folder across Northamptonshire• Asked for data quality team to run audit acrossNorthamptonshire to assess impact of project

• Planned roll out of project across East Midlandsin 2009/10.

Key challenges• 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.

Key learning from work• Open project up to more GP practices at anearlier stage. This might be time consuming butit would ensure take up.

Outcomes• QOF indicators not yet available forproject period.

Challenges for sustainability• The data quality team has been disbanded socan no longer carry out the audit.

Costs incurred• ECG training across county• Printing cost for folder• Both funded from network resources.

Patient, carer and staff involvement• Staff have found CHADS2 and ECG informationuseful and ECG training has evaluated well.

Future plans• Planned further training on ECG skills• Include AF management in stroke workplan• Anticoagulation baseline across East Midlandsand project planned for 2009/10

• Audit of QOF data to see if prevalence and lowerindicators changes.

Contact detailsProject lead:Ben KnightEmail: [email protected]

Clinical lead:Dr ShribmanEmail: [email protected]



Duration of projectNovember 2008 - ongoing

Scope of projectTo develop a primary care arrhythmia servicewhich will:• Help GP practices identify AF and otherarrhythmia patients by encouragingopportunistic screening

• Ensure existing AF patients are on optimaltherapy (searches undertaken by use ofGRASP-AF tool)

• Provide nurse-led primary care arrhythmia clinics• Undertake and co-ordinate the patientsdiagnostic investigations

• Where necessary, refer patients’ to secondarycare clinic for further management

• Manage appropriate patients within thearrhythmia service, or

• Refer patients back to the GP for managementwithin primary care

• The service will act as the point of contact forsudden cardiac death, ensuring families haveaccess to screening tests and information whereappropriate.

The three arrhythmia nurses are already in post andvisiting practices.

What we didA business case was prepared and submitted to thePCT. This was approved and recruitment began insummer 2008 for three arrhythmia nurses the lastof which was in post by the end of November2008.

Key challenges• Not all practices have welcomed the arrhythmianurses and see them as an ‘interference’Conversely, others have been very supportive.

• There are only three arrhythmia nurses to cover apopulation of 710,000 and 115 GP practices.

What went well• Rapid approval of the business case by the PCT.

Key learning from work• For a primary care arrhythmia service to besuccessful, it needs support from theneighbouring acute trusts’ consultantcardiologists

• Concentrate your initial efforts on thosepractices which can see the benefit of whatyou are doing.

Outcomes• It is too early to say what the outcomes are asthe arrhythmia nurses have only started helpingpractices identify new patients and reviewexisting ones.

Challenges for sustainability• Having permanently employed arrhythmia nurseswill ensure sustainability.

Resources and tools developed to supportthe changesAll available for sharing by contacting theproject lead:• Business case• Draft primary care education plan• Arrhythmia nurse job description.

Contact detailsProject lead:Tim WaiteEmail: [email protected]

Clinical leads:Dr Mark FentonConsultant CardiologistEast Kent Hospitals University NHSFoundation TrustEmail: [email protected]

Shelley SageHead of Community Cardiology NursesEastern and Coastal Kent PCTEmail: [email protected]

Primary Care Arrhythmia Service - Eastern and Coastal Kent PCTKent Cardiovascular Network, Eastern and Coastal Kent PCT,East Kent Hospitals University NHS Foundation Trust

www.improvement.nhs.uk/heart



Scope of projectDevelop a primary care arrhythmia servicewhich will:• Help GP practices identify AF and otherarrhythmia patients by encouragingopportunistic screening

• Ensure existing AF patients are on optimaltherapy (searches undertaken by use ofGRASP-AF tool)

• Provide nurse led primary care arrhythmia clinics• Undertake and co-ordinate the patientsdiagnostic investigations

• Where necessary, refer patients to secondary careclinic for further management

• Manage appropriate patients within thearrhythmia service, or

• Refer patients back to the GP for managementwithin primary care

• The service will act as the point of contact forsudden cardiac death ensuring families haveaccess to screening tests and information whereappropriate.

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.

Resources and tools developed tosupport the changesAvailable to share by contacting project lead• Business case.

Future plansThe same model is already in operation in Easternand Coastal Kent PCT.


Clinical leads:Dr Adrian StewartConsultant CardiologistMedway NHS Foundation TrustEmail: [email protected]

Mary KirkBHF ConsultantNurse Medway PCTEmail: [email protected]

Primary Care Arrhythmia Service - Medway PCTKent Cardiovascular Network, Medway PCT, Medway NHS Foundation Trust,Medway Maritime Hospital



Duration of project1 July 2009 - 31 February 2010

Scope of projectThe project has two aims: first to pilot the efficacyof opportunistic screening for atrial fibrillationwithin general practice of patients aged >65 years.This is in order to identify undiagnosed patientsand ensure that they are added to practice registersand rapidly gain access to the appropriatetreatment pathway (opportunistic screening hasbeen shown to increase detection of AF by 60%).The purpose is to make opportunistic pulse checksa matter of routine.

Second to review existing AF patients to ensurethey are on optimal therapy using the GRASP-AFtool.

Nine to ten GP practices in the South of West Kentare going to be involved in the project.

Baseline positionThe detailed planning of the project has just beencompleted and practices are now being recruitedto join the project.

What we did• The Kent Cardiovascular Network has providedfunding to support the project

• Baseline data will be collected before the start ofthe project.

Progress will be reported every two months andreviewed. Payments to practices are contingent onreceipt of the bi-monthly data.

Key learning from workUnable to report any key learning at the momentas project not due to start in earnest until July2009.

OutcomesUnable to report outcomes at the moment asproject not due to start in earnest until July 2009.

Resources and tools developed tosupport the changesAll available for sharing through contactingthe project lead:• Project proposal• Project process• Data collection forms• GP agreement to join the project.


Clinical lead:Dr Paul GoozeeEmail: [email protected]

Atrial Fibrillation Opportunistic Screening and Patient Review Pilot -South of West Kent - West Kent PCTKent Cardiovascular Network, West Kent PCT



Duration of project17 December 2007 - 31 March 2009

Scope of projectIn May 2007, members of the network primarycare group identified that the NICE clinicalguideline 36 published in June 2006 contained anumber of confusing algorithms, therefore unlikelyto be effectively implemented by GPs in primarycare. Previous work undertaken by Blackpool, Fyldeand Wyre health economy had produced analgorithm and supporting guidance focused onmanagement in primary care. This was shared andadapted for network wide use and assessment ofits effectiveness formed the basis for this project(Appendix A). The following objectives were set tosupport this evaluation and to align with therecommendations of the National HeartImprovement Programme:

• Ensure that AF prevalence in the practicesmatches what is expected nationally

• Ensure that all diagnoses have been confirmed asper NICE guidelines

• Ensure that all patients are receiving anti-platelet/anticoagulation therapy as appropriate

• Review prescribing trends for AF patients againstNICE/local guidelines

• Address training needs, in particular around ECGrecording and interpretation

• Review local anticoagulant service and addressservice improvements.

Baseline positionAccording to Quality Management and AnalysisSystem (QMAS) data, AF prevalence in all but oneof the six pilot practice is above nationally expectedlevels taken as 1% of total population, 4% of over65s and 10% of over 75s. However, somepractice’s registers required validating in view ofthe high elderly population. King Street, as auniversity practice was identified as an outlier inrelation to the expected prevalence, with aprevalence of 0.58%.

Baseline prevalence data (Appendix B) QOF datasuggests that confirmation of diagnosis is good.Baseline prescribing data (Appendix C) indicatesthat warfarin prescribing particularly in the >75s islower than recommended.

At the practice visits, training needs were identifiedin relation to ECG recording and interpretation. Itwas decided in view of the difficulties in

maintaining a rolling programme of ECG trainingand the subsequent resource implications that thiswould offer an ideal opportunity to pilot the role oftelemedicine for the interpretation of ECGs inprimary care.

What we did• Established a project steering group, withrepresentation from all stakeholders, to agreeaims and objectives, provide guidance andsupport to the project

• Developed a project guide to inform stakeholdersof background detail (Appendix D)

• Developed a communication plan to ensure thatstakeholders are kept informed of developments(Appendix E)

• Collated and analysed baseline and final data(working with network data analyst)

• Visited each practice team individually to outlineproject aims, request baseline data anddisseminate and discuss ‘management of AF inprimary care’ guidelines

• Following feedback from clinicians on theguidelines it was agreed that ‘acutepresentation of AF’ needed to be addressedwithin the supporting guidance. Amendmentswere made and resubmission to clinicalgovernance was undertaken

• A poster shared through the national team wasdisseminated to all practices for use in raisingawareness of AF and pulse checking as ascreening tool (Appendix F)

• A flyer was also produced by the network toexplain to patients the importance of ‘pulsechecks’ in identifying patients with AF and therisks associated with the condition (Appendix G)

• Worked in collaboration with colleagues insecondary care in relation to the localanticoagulation service, including a processmapping event. A summary of the learning andservice improvement ideas generated are detailedin Appendix H

• The use of telemedicine to support GPs in theinterpretation of ECGs was piloted

• The use of a single lead event monitor withinprimary care was piloted

• Following consultation with lead GPs from eachpractice, the two pilot projects were initiated infour practices and evaluated through the analysisof audit forms completed by the GPs(Appendix I, J)

• The governance issues surrounding these pilotswere addressed and supported by NHS NorthLancashire (Appendix K, L)

Management 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 Consortia



• Following analysis of the prescribing trends byNorth Lancashire Medicines Management,recommendations were made that could beincorporated into patient individualised medicinesreviews by either the practice pharmacist or GP

• Final sustainability score report was undertaken(Appendix M).

Key challenges• Maintaining engagement of the practice teams• The challenges within the telemedicine pilotincluded full engagement of all practices andindividual GPs and promoting use of the singlelead diagnostic tool

• The evaluation of the ECG interpretation auditwas time consuming and complex.

What went well• Enthusiasm from the project team was high andclinical leadership essential

• Involvement and support from the patientrepresentative proved helpful, both with themapping event of the local anticoagulationservice, and also in relation to feedback onleaflets and posters used throughout the project

• The steering group meetings were infrequent butattendance from every stakeholder group washigh (PBC, PCT, GP clinical lead, patient,network)

• Although the telemedicine pilot was seen as timeconsuming with a high administrative burden,out of all data entries the data was 98%complete.

Key learning from workRecurring themes were identified in relation to theidentification and management of patients with AF:• Final data collection has illustrated an increase inprevalence in all age groups across all practices.This may be due to raising the profile of AFwithin the practice teams, through the adoptionof the network guidelines, the initiation ofopportunistic screening methods or registervalidation

• Practices need to ensure that ‘manual pulsechecks’ are inserted into all appropriate chronicdisease templates. It was identified that since theincreased use of digital blood pressure (BP)monitors, pulse palpation was being neglected,when in actual fact it was all the more important

• Alternative methods of opportunistic screeninghave been discussed and shared by allparticipating practices, focusing in particular onthose at higher risk

• All practitioners have concerns about warfarinprescribing in >75s

• Many GPs are accessing the local anticoagulantservice differently and are not confident that thisaspect of their AF management is beingdelivered effectively. Local service provisionrequires review and could be addressedthrough PBC.

Telemedicine key learning• Assessment of GP competency to interpret ECGswas complex

• The use of the single lead diagnostic tool inprimary care was useful and quicker results wereobtained than accessing secondary care forambulatory monitoring

• Whilst this project assessed competency of GPsto interpret ECGs, it was highlighted that thequality of the ECG recording was equallyimportant.

OutcomesPractices have reported that as a result ofvalidation work and opportunistic screening theyhave increased numbers on their AF register.Final prevalence data and comparisons(Appendix N).

Discussions have begun with colleagues insecondary care in relation to some redesign of theanticoagulation service. A number of developmentshave been identified for discussion by the PBCconsortia.

Warfarin prescribing increased in half of thepractices however, more guidance is being soughtto support warfarin prescribing, particularly in>75s. Currently the NICE algorithm is still beingused to support decision making, although the useof the CHADS2 tool has been considered. Theopportunity to pilot the ‘Auricle’ decision supporttool was considered but declined on account of thedecision to undertake a telemedicine pilot.

The final data collection of prescribing trends inrelation to rate control of AF was variable.However, there was a reduction in the use ofdigoxin in four out of six of the practices. It wasconcluded that the support of the PCT MedicinesManagement Team is key to the success ofguideline implementation in relation to prescribing.Final prescribing data and comparisons(Appendix N).



Telemedicine pilotThe aims of the project were:• To assess ease of use and the clinical andpersonal impact of technology for ECGinterpretation and single lead diagnosticmonitoring

• To assess the required capacity and also theoutcomes of the interpretations for each of thereferral criteria (clinical symptoms, long-termconditions monitoring, screening prior to referral)

• To assess GP competency levels in relation toECG interpretation to inform GPs, secondarycare and PCTs

• To share findings and support widerdissemination.

Telemedicine results (Appendix 0)

NB: All appendices A-O are available fromthe NHS Improvement System

Summary and recommendations

Validation of registers• Practices need to have a register of patients with‘active’ disease, excluding patient’s who havebeen ‘cured’ by cardioversion or ablative therapy.Whilst the QOF register should reflect this, the‘atrial fibrillation resolved’ codes are often notused (validation will in fact tend to make theregisters smaller).

Medication reviews• Practices need to review patients medicationannually and adherence to the guidelines can besupported through recommendations frommedicines management.

Opportunistic screening• The recommendation from the guideline toopportunistic screening was adopted by thepractices and resulted in more AF patients beingidentified. Practices should ensure that manualpulse palpation checks are embedded within theappropriate chronic disease managementtemplates and that the whole primary care teamare aware of their responsibilities for screeningfor AF in their practice population.

Implementation of guidelines• Since the inception of the project, map ofmedicine has been adopted in most PCTs acrossthe network. It is recommended that formal linksbetween map of medicine and the guidelines areestablished in order to support itsimplementation.

Warfarin prescribing (particularly in >75yrs)• An agreed decision making tool used both inprimary and secondary care should be adoptedto reduce many of the uncertainties aroundprescribing and increase uptake. Consistency isprobably more important than which exact toolwe use e.g: CHADS2, NICE or SIGN.

Telemedicine• It was difficult to assess ease of use andacceptability of the service by the practices asthey found the audit process was timeconsuming and high levels of administrationwere required. This may have influenced theperception of the telemedicine service

• Interpretation skills amongst GPs vary andassessment would be best done individuallyrather than as part of a wider audit. Fullparticipation from all GPs as individuals was notachieved and did not highlight any one particularpractice with a training requirement orcompetency issue

• Assessment of the requirements for practicalECG recording training should be considered

• Some GPs felt that they would prefer to see theECG at recording as opposed to only havingsight of it when receiving the report

• The turnaround time from Broomwell was seenas a positive benefit of the service and therecommendation for practices to assess theirown ECG interpretation processes should beimplemented

• PCTs should assess both elements of thetelemedicine service as an operational need priorto implementation. Assessment of need shouldbe carried out on an individual practice basis

• Proposed telemetric links between primary andsecondary care may well support GPs further andPCTs should horizon scan future developments

• The single lead diagnostic device may not havebeen fully utilised, but access to a mobile, easyto use and accessible diagnostic within primarycare, specifically for arrhythmia patients was seenas effective and useful.



Challenges for sustainabilityA sustainability score and report was undertakenderived from the NHS Sustainability Model andGuide, developed by the NHS Institute forInnovation and Improvement. The sustainabilitymodel is a diagnostic tool that is used to predictthe likelihood of sustainability for improvementprojects and this has been applied to ourmanagement of atrial fibrillation in primary careproject.

Recommendations• Review the organisational link between the PCTand PBC to establish adequate quality metrics

• Staff training in relation to Atrial Fibrillationmanagement

• Raise the profile of AF and review itsmanagement in primary care. Incentivisation maybe required to sustain services for AF patients ingeneral

• Links to the NHS Health Check Programmeand the prevention of cardiovascular diseaseshould incorporate the screening for AF.

Sustainability score report (appendix M).

Costs incurred• Costings for the telemedicine pilot were £6,000for a period of three months for the fourparticipating practices. Broomwell contributed£2,000 to these costs with the network fundingthe balance

• A project manager was appointed and fundedthrough Heart Improvement Programme moniesfor two days a week for the duration of theproject

• The project lead was assigned to work one daya month on the project out of her three dayworking week as a service improvementmanager for the network.

Patient, carer and staff involvement• Patients reported liking the use of the single leaddevice and found it easy to use

• Staff reported that they felt much more aware ofatrial fibrillation and their role in screening andidentifying patients with the condition

• Staff became more aware of the network and itsrole in supporting the management of heartdisease.

Resources and tools developed tosupport the changes:Available for sharing from NHS Improvementwebsite (www.improvement.nhs.uk/af/projectsummaries):• Baseline prevalence data• Baseline prescribing data• Project guide• Project communication plan• Poster – Stroke the Beat• Flyer – Why have your pulse checked• Process map and action plan• Audit form – ECG interpretation• Audit form – One lead device• Serious untoward incident reporting algorithm• Patient consent – Telemedicine pilot• Sustainability score report• Final prevalence/prescribing data• Telemedicine powerpoint presentation.

Future plans• The network plans to share this report initiallywith the participating practices and the host PCTand thereafter to the other PCTs in the region

• It also intends to align the learning with futuredevelopments in relation to prevention anddetection of cardiovascular disease.

Sites outside of the network where theapproach has been adoptedApart from sharing developments with othernetworks involved in the national priority project,the guideline has also been shared with aneighbouring network area at their annualeducational event.

Contact detailsProject leads:Lauren Butler and Jean HayhurstEmail: [email protected]: [email protected]

Clinical lead:Dr Andrew GallagherEmail: [email protected]



Duration of projectJuly 2007 - ongoing

Scope of projectThe initial aim of the project was to addressatrial fibrillation, to ensure correct diagnosis,appropriate treatment within primary care andreferral to secondary care as required.

As the project was progressing the PCT was inthe process of introducing near patient testingfor anticoagulation in primary care and the focuschanged to concentrate on developing thisservice.

An ongoing rolling program of training has beeninitiated for staff across primary care whichincludes ECG training (both undertaking andinterpretation), hypertension updates, CHDupdates, CHD diploma, heart failure (HF)updates, stroke study days and cardiovascularrisk assessment days (with the opportunity ofbecoming accredited).

Baseline positionThe population being reviewed was that withinthe Rotherham PCT sector. The aim was toreview what services were available within bothsecondary and primary care for patients withatrial fibrillation or for those at risk ofdeveloping atrial fibrillation. This also covers thepopulation affected by the development of thenear patient testing service for anticoagulation.

What we did• Evaluated how many practicesundertook ECGs:• Who undertook the ECG• Who interpreted the ECG• What training they had received• When had they received the training• Did they refer the patient into the openaccess service in secondary care

• Scoping exercise to identify what training andcompetencies are available to support nearpatient testing for anticoagulation

• Developed a rolling program of training forstaff across primary care including GPs, nurses,health care assistants and allied healthprofessionals

• Set up ‘train the trainers’ for people workingwith the south asian population to adviseabout the risk and symptoms of cardiovasculardisease and these are to be repeated andaimed at all BME populations

• Held public awareness sessions for peoplefrom the south asian population to raiseawareness about cardiovascular disease andthese are to be repeated and are open to thegeneral population

• The Coronary Heart Disease LocalImplementation Team (LIT) encompassedstroke and became the Cardiovascular Disease(CVD) LIT – the lead physician for stroke andthe PCT lead for stroke both sit on this group

• A stroke pathway group has been establishedwhich feeds into the CVD LIT

• A gap analysis on atrial fibrillation wasundertaken – and as a result of this a patientsafety group for anticoagulation has beenestablished to drive the work forward on nearpatient testing including developing servicespecifications, standard operating proceduresand a programme of training

• Other areas of work relating to atrialfibrillation identified in the gap analysis will bepicked up once the work aroundanticoagulation has been completed

• A review of admissions to secondary care in2007 with a primary diagnosis of atrialfibrillation was undertaken, and also of thosewith a secondary diagnosis of atrialfibrillation/flutter – several had a diagnosis ofTIA, stroke or cerebral haemorrhage

• Reviewing how to introduce manual checkingof pulse within primary care.

Key challenges• Getting manual pulse adopted by GP practicesas a routine check

• Setting up the anticoagulation near patienttesting service

• Getting atrial fibrillation on to the strokeagenda

• Reviewing the whole of the atrial fibrillationpathway

• Identifying training opportunities to supportanticoagulation services

• Ensuring that other areas identified as needingattention within the gap analysis are targeted.

Atrial Fibrillation in Primary Care in RotherhamNorth Trent Network of Cardiac Care, NHS Rotherham



What went well• The training programme has been verysuccessful and continues to be so. Staff withingeneral practice including GPs, nurses andhealth care assistants have attended the studydays and undertaken diploma courses. Muchof the training is now being repeated, and wehope to offer diplomas in stroke and atrialfibrillation in the future

• Gap analysis identified that there were majorissues in developing the work around nearpatient testing and anticoagulation and thisled to the initiation of the patient safetygroup for anticoagulation and targeted workin this area

• The standard operating procedure and servicespecification are being developed for the nearpatient testing service for anticoagulationunder locally enhanced services (LES)

• Meetings have been held to review what theeducational needs for people who areinitiating treatment are as against those whowill be maintaining treatment, and how to linkthese in with the competencies. Training daysare being developed for practice staff who willbe maintaining patients for anticoagulation.

Key learning from work• Perseverance• Linking atrial fibrillation in with the strokeagenda

• How to have manual pulse checking acceptedas routine – this is ongoing

• That although near patient testing is importantthere are still many other areas which needreview as identified in the gap analysis foratrial fibrillation.

• The near patient testing service will also insome areas include initiation of the treatmentand this will have an impact on the number ofpatients who currently have to be referred andseen in secondary care for this service.


Outcomes• That a locally enhanced service (LES) will drivethe work around near patient testing andanticoagulation within Rotherham

• That patients who would have had to attendsecondary care for this service may now beable to access it at a local level

• Atrial fibrillation is rising up the strokeagenda.

Challenges for sustainability• There are issues around getting manual pulsechecking accepted as a routine check

• Ensuring that staff attend regular updatesregarding the near patient testing.

Future plans• To set up educational training days for staffwithin primary care – both GP practices andprovider services – and also to link in withnursing and care homes and the housebound

• To have manual pulse checking adopted asroutine.

Contact detailsProject lead:Ann BainesEmail: [email protected]


Duration of projectMarch 2008 - March 2009

Scope of projectIn Sheffield, there is considerable variation indiagnosis of AF across the city, demonstrated bythe wide variation in QMAS (QOF) reporting for2006/7. The percentage of patients with AF whoare currently treated with warfarin therapy is alsovariable. A steering group was established withclinicians from general practice, the acute trust,public health and provider services. SheffieldTeaching Hospital Foundation Trust (STHFT) plannedto pilot a fast track AF clinic alongside the AFprimary care project, enabling pilot practices to fasttrack appropriate patients to secondary care(Appendix A). Ten practices were identified in

areas of high deprivation which also linked to theenhanced public health programmes. Six of the tenpractices were invited and recruited betweenMarch 2008 and October 2008. Practices wereasked to:

• Use opportunistic screening to identify patientswith AF over the age of 65

• Run a MIQUEST query which would riskstratify patients using the NICE algorithm andwould assist practices in reviewing currentmanagement of patients with AF

• Refer appropriate patients to the enhancedpublic health programmes in their area (e.g.weight management programmes)

• Refer appropriate patients to the pilot fasttrack AF clinic at STHFT.

Atrial Fibrillation in Primary Care ProjectNorth Trent Network of Cardiac Care, Sheffield PCT, Sheffield Teaching HospitalsFoundation Trusts (Northern General Hospital), Six GP practices


Baseline position

Results of opportunistic screening for atrial fibrillationfor patients over 65 in pilot GP practices


What we didThe project approach was to identify pilot practicesthrough prevalence and individual practice data.Practices would be asked to screen patients usingopportunistic screening of patients 65 and over(reference the SAFE Study. Health TechnologyAssessment 2005; 9:1-74). Support would beprovided to enable practices to review currentmanagement of patients with a diagnosis of AFand to review their protocols to ensure they areevidenced based and consistent with current bestpractice. Support would be offered to practices todevelop appropriate treatment services such aspracticed based anticoagulation services.

Six practices were recruited. All six practices agreedto use the opportunistic screening approach for theidentification of AF in the over 65s. Two practicesopted out of searching their system forunidentified patients and management review ofcurrent patients using the MIQUEST query, as thepractices have systems in place to do this. Fourpractices were happy to discuss running theMIQUEST query once it had been developed andtested. The MIQUEST query risk stratified patientsaccording to NICE stroke risk algorithm. All sixpractices welcomed the opportunity to refer to theenhanced public health programmes and the pilotfast track AF clinic.

Key challenges• Lengthy process developing MIQUEST query asthe IT person was not given any dedicated timefor the project. Different practice systems meantamendments to MIQUEST

• Actually getting appointments to visit practices.• Difficulty getting everyone to meetings due toother commitments. Attendances at projectmeeting were good for the first six months butthen began to tail off.

What went wellThe practices visited were all very keen toparticipate in the opportunistic screening becausethere were no targets or extra workload involved.One practice contacted the enhanced public healthprogramme and set up a weight managementprogramme for their patients. Five patients werereferred to the fast track AF clinic at the NorthernGeneral Hospital.

Key learning from work• The project practices may have been too small• Perhaps recruit all interested practices not justthose linked to enhanced public healthprogrammes

• Identify resource needs prior to the project –although we did this it was on an ad hoc basiswhich is why it took so long to develop theMIQUEST query

• Commitment needed from practices to reviewtheir patients when they have been identified.

Outcomes• Sixteen new patients were identified by four ofthe six pilot practices between April 2008 andFebruary 2009. Extrapolating these results to thewhole of Sheffield practices identifies 248 newpatients

• Due to the lengthy process of developing theMIQUEST query and the availability of the ITspecialist the query was not tested in a practicewith live data until March 2009

• The test resulted in the identification of:• Seven patients risk stratified as high risk with adiagnosis of AF who are not on warfarin orasprin and have no contraindications recorded

• 38 patients at high risk with a diagnosis of AFwere on asprin only with no contraindicationsrecorded

• 23 patients did not have their diagnosisconfirmed by ECG and other reviewdiagnosis (2)

• The practice was given a report with namedpatient data and asked to consider reviewingthese patients. The practice plan to reviewthese patients

• These results should be viewed with caution aswe were unable to access exception reportinginformation at the time. We plan to run thequery in another pilot practice. GPs have beenasked to comment on the accuracy andusefulness of the information provided andwhether patients have been reviewed as a resultof the information

• Quick reference AF management guidelines havebeen developed for GPs

• The guidance has been approved by the areaprescribing committee and PEC and have beencirculated to all GP practices in the city.

Note: Anticoagulation in general practice – is aseparate PCT project.



Costs incurredNone

Patient, 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 todevelop arrhythmia services and pathways inprimary care

• Sheffield Teaching Hospital NHS Foundation Trusthave developed a palpitations clinic which runsalongside the AF clinic

• Plans to develop the service further to includepost ICD patients

• Palpitation service in primary care to commencefrom June 2009, followed by 24 hour ECGservice in primary care.

Contact detailsProject lead:Colette LongfordEmail: [email protected]

Clinical lead:Dr Brian HopkinsEmail: [email protected]



Duration of projectAugust 2007 - March 2008

Scope of projectThe project aimed to:• Reduce the number of INR tests required tomaintain good control

• Improve patient convenience• Improve efficiency in the use of GP/nurse time• Reduce the potential for dosing error.

Baseline position• Current practice population 15,133• AF registers showed 229 patients in practice onwarfarin from a possible 267.

• A case note review was performed to ensurepatients were not inappropriately untreated

• A satisfaction survey was performed on staff andpatients. Whilst staff were dissatisfied with theservice, patients found the current serviceefficient and were generally satisfied

• Using lab-based testing at baseline position

What we did• Equipment purchased by practice managerincluding three Coagucheck XS plus monitoringmachines, testing strips and INR star software

• All nursing staff trained in the use of equipmentand the use of the software

• Appointment slots redesigned• Mechanism of calibrating equipment andvalidating tests set up with lab

• System set up within the practice with GP whowill check and advise on results if required.

Key challenges• Training delays due to staff sickness and covermeant there were some delays transferring to thenew system

• Disseminating timetable of changing practice tothe GP partners

• The district nursing team found the changesmade them more involved in the dosing processwhich their PCT were unhappy with. Thisresulted in the practice nurses having to takeover the dosing and informing patients once theINR result was obtained by the communitynurses. Not ideal but not appropriate to have atwo-tiered system with some patients on lab-based testing and some patients on nearpatient testing.

What went well• The patients adjusted very well to thechange over

• The company we used to supply the equipmentwere easy to contact and gave us lots of support

• The support from the network was brilliant.

Key learning from work• Good planning makes all the difference• Be aware that not all changes are positivefor everyone.

Outcomes• Practice registers were audited and any patientsnot on warfarin with no coded contraindicationwere checked

• CSW time on telephone – measured as 21 hoursper week using the old system – dramaticallyreduced as fewer lab tests required.

Challenges for sustainabilityNone that we are aware of, apart from the districtnurse situation which is frustrating.

Costs incurredApproximately £9,400 last year for testing stripsand the quality control testers for the machines toRoche. Approximately £150 per machine forNEQAS testing. Pump priming costs were paid byNEYNL Cardiac and Stroke Network.

Patient, carer and staff involvementAll positive from patients. District nurse teamfound it challenging however since the practicenurses have taken over the dosing and informingpatients once the INR result was obtained this hasimproved.

Future plansNo future plans to expand or apply elsewhere bythis practice although learning shared withy otherareas for their use.

Sites outside the network where theapproach has been adopted by othersJackie Edwards, Practice PharmacistWest Kirby Health Centre, Wirral PCT.

Contact detailsProject and clinical lead:Melanie DunwellEmail: [email protected]

Near Patient INR Testing Project - Whitby Group PracticeNorth and East Yorkshire and Northern Lincolnshire (NEYNL) Cardiac and StrokeNetwork, Whitby Group Practice, Robin Hoods Bay Surgery (satellite surgery)




Atrial Fibrillation in Primary CareSurrey Heart and Stroke Network, 13 GP practicesin Woking and West Byfleet, Surrey PCT

Duration of projectJanuary 2008 - October 2008

Scope of projectTo improve detection and treatment of atrialfibrillation in a sample of practices in Woking andWest Byfleet in order to make best practicerecommendations for rollout across Surrey.

Baseline positionThirteen practices with a combined population of107,304. Of these patients, 1,346 were alreadyregistered by March 2007 as having AF, giving aprevalence of 1.25%.

What we did• A clinical lead was appointed for the project• A project steering group that included a GPSIcardiology, PCT commissioning lead, consultantcardiologist, pharmacist and IT lead wasestablished

• Thirteen out of 15 practices across three practicebased commissioning groups were recruited.

There were three stages to practice involvement inthe project:• Attendance at a lunchtime session practiceupdate to be led by consultant cardiologist,covering primary care management of AF

• Opportunistic screening to detect people withatrial fibrillation twinned with piloting the use ofa hand-held ECG machine

• Review of patients already diagnosed with AF toimprove rates of anticoagulation (strokeprevention).

Patient satisfaction was sought on information thatthey receive about AF through a targetedquestionnaire and a focus group.

Opportunistic screeningPractices were given a care pathway to follow forthree months requiring patients aged over 64 yearswho were not on the AF register to have theirpulse taken when presenting for an appointmentat the practice. A basic care pathway with READcodes was given to all GPs in the pilot practices,along with various reminder posters and flyers forboth clinicians and patients.

In addition, practices were given a hand-held ECGmonitoring device called the Omron Heart Scanand corresponding software.

Review of patientsPractices were asked to use MIQUEST (GRASP-AF) search and spreadsheet being developed byWest Yorkshire Cardiovascular Network withPRIMIS+ to identify AF patients, risk stratify forstroke using CHADS2 and review for prescribingwarfarin as part of an incentivised scheme.

Key challenges• Maintaining momentum in wide range ofpractices

• Getting information back from practices.

What went wellMost were happy to do the opportunisticscreening without payment and continue totake pulses now opportunistically, although notroutinely recorded.

Key learning from work• The MIQUEST search identified patients whohad AF in the past but no longer did,generating unneeded patient reviews

• CHADS2 was welcomed by the majority ofpractices as an easily administered stroke riskdecision making tool

• There is a wide variety of practice withrespect to who to prescribe warfarin tofor AF.

Outcomes

Practice updates34 clinicians, mostly GPs, attended twosessions. Overall evaluation was excellent; GPsreally welcomed local educational updates ofsuch a high quality and indicated a preferencefor such updates in the future. However, it wasdifficult to arrange mutually convenient datesand times in outer Woking, the largest areawith most of the pilot practices.

Opportunistic screeningThree practices out of a potential 13 returnedinformation on numbers of people newlydiagnosed with AF following opportunisticpulse palpation.

• 407 patients out of 3,000 patients over the ageof 65 years, who attended the three practicesover the three month period were READ codedfor pulse palpation (13.6%). 11.5% of these407 patients had an irregular pulse (47)

• 18 went on to be diagnosed with atrialfibrillation (4.4% of those READ coded for pulsepalpation).

There was a wide variance in use and acceptabilityof the Omron Heart Scan. The majority of practicesdid not find it useful. There were issues withdownloading the software that allowed cliniciansto view the ECG trace in greater magnification anda single-trace ECG was not clinically acceptable formost GPs when investigating possible AF. One GPwho found it very useful was one with a specialinterest in cardiology.

Review of patients• 56% of all AF patients had a CHADS2 score oftwo or more i.e. were high risk for stroke

• 41% (378) of these ‘high risk for stroke’ patientswere not being prescribed warfarin; aspirin wasthe most common antithrombotic alternativewith a small number being prescribed clopidogrel

• Nine out of the 13 practices that were sentreports that highlighted these patients carriedout patient reviews. The remaining four did notreturn audit forms

• 178 (71%) patients in these nine practices hadtheir notes reviewed to see if they could besafely switched to warfarin

• 41 patients attended for medication review(the remainder was ruled out as being unsuitablefor warfarin following a review of their notes)

• Eight patients were switched to warfarinamounting to 2% of the total number ofpatients in these nine practices who werehighlighted as being at high risk of stroke.

The overall conversion rate to warfarin is very low,certainly in comparison to Leeds where the sameexercise was carried out but patients’ notes wereinitially reviewed by arrhythmia nurse specialistwith 50% being tagged as ‘appropriate forwarfarin’. The main reason given for patients notbeing switched to warfarin was ‘not suitable’.

AF guidelines were circulated to all practices inSurrey in June 2008. This includes a care pathway.

A service specification is being written for atrialfibrillation.

All practices are to be sent very clear informationabout warfarin and stroke; practice-basedpharmacists have agreed to talk to all practicesabout GRASP-AF and CHADS2, the aim being toreview all patients in Surrey to see if more could beconverted from aspirin to warfarin to preventstroke.

Acute trust cardiology departments are to write toGPs whenever they refer patients for AFinvestigation/management asking them to CHADS2score where appropriate.

Challenges for sustainabilityIf we utilise practice-based pharmacists to continue‘spreading the word’ about AF, ensuring that it is intheir work plan, it could be sustained quite well.They are already planning to review beta blockerswhich will include some AF patients as well ashand delivering the AF and warfarin flyer that weare currently developing.

The best way to make sustainable changes thoughis via contracts i.e. QOF. Including CHADS2 scoringin QOF for AF patients would make a big impacton awareness.

Costs incurredSummary• To trial use in primary care to see if they reduceneed for 12-lead ECGs £5,872.06

• To trial use in community to see if they improvedetection of AF £2,998.00

• To encourage practitioners to follow NICEguidance when managing AF £165.00

• To attract clinicians to education session withVince Paul £56.68

• To carry out a focus group with AF patients tobetter understand their experiences of having AF£171.66

• To encourage review of patients from MIQUESTsearch £1,139.00

• Feedback from practices - cancelled due to lackof interest £235.00

• Arrhythmia and SCD masterclass £1330.00.

NB. Full budget is available through the NHSImprovement System.



Patient, carer and staff involvement

Patient satisfactionTwo of the pilot practices posted out aquestionnaire to all the patients on their AFregisters:• Information about AF was not routinely givenout to these patients. Most reported that they‘felt alone’ at the time of diagnosis and had noone to ask questions

• Most were aware of the stroke risk concomitantwith having AF, but the majority were muchmore concerned with controlling their AFsymptoms e.g. palpitations

• They were not really sure what meaningfulactions they could take to reduce their risk ofstroke

• There were lots of questions about medication,surgical interventions, cardioversion, symptoms.It really felt as though there is a large unmetneed in this patient group

• Developing a support group for people with AFwas popular at the focus group session itself. Allreported how good it was to talk to other peoplewith the same condition and to swap tips andadvice. Linking AF patients with existing cardiacsupport groups at the time of diagnosis wouldbe the most efficient way of ensuring suchpatients received peer support.

Resources and tools developed tosupport the changesAvailable for sharing through the NHSImprovement website (www.improvement.nhs.uk/afprojectsummaries):• Project budget• Poster to remind clinicians to take pulse• West Surrey AF in primary care final report• Final protocol for AF in primary care project• Project budget.

Future plansNone at present

Sites outside of the network where theapproach has been adopted by othersContacted by networks in Kent and Sussex fordetails of the project and shared project protocolsand other resources.

Contact detailsProject lead:Liz PatroeEmail: [email protected]

Clinical lead:Dr. Vince Paul provided initial support.



Duration of projectSeptember 2007 - January 2009

Scope of project• To develop a MIQUEST IT based search tool torun on all GP practices covering all IT systems torisk assess for stroke and score all diagnosed AFpatients using CHADS2

• The tool will produce excel spreadsheetinformation on all AF patients allowing GPpractices in order of risk score to review theirpatients and manage according to need

• The tool will also provide access to evidencebased medicine within advice files and a podcast.

Baseline positionPhase one (development stages):• Six practices• Population: 55,500• AF register: 722• Prevalence: 1.3%• Number of patients CHADS2 score >1: 398(55.1%)

• Number of patients CHADS2 score >1:not on warfarin: 176 (44.2%)

The above pilot demonstrated potential numbersafter running the tool.

Phase two:• Eight practices• Population: 65,000• AF register: 981• Prevalence: 1.4%• Number of patients CHADS2 score >1: 422(43%)

• Number of patients CHADS2 score >1not on warfarin: 221 (52%) (BHF Nursesundertook reviews)

• Number of patients reviewed: 168• Number of patients with nocontraindication: 78 (46%)

• Number of patients with relativecontraindications: 63 (38%)

• Number of patients with absolutecontraindications: 27 (16%)

The second pilot showed the first pilot’sestimations in terms of numbers expected wereaccurate.

Figures unknown as to how many patients wereprescribed warfarin from reviews as GP would needto agree and prescribe following nurses’recommendation.

After tool completed and available for use:

York Group Project:• 24 practices• Population: 230,960• AF register: 3678• Prevalence: 1.6%• Number of patients CHADS2 score >1 not onwarfarin (for review): 935 (25%)

• Estimated number of patients with nocontraindications to warfarin: 473 (51%)

Project due to complete June 2009.

What we didThe early stages of the project were spentengaging relevant people to commit to the project.Once agreement was reached on the scope ofproject, business cases were written for networkfunding to develop the tool. Meetings werearranged with PRIMIS+, cost agreed andcommencement of writing the algorithms began.

The tool had been produced in a pilot phaseworking only on EMIS based IT systems, the phaseone calculations and findings were carried out todemonstrate the early workings of the tool, thiscontributed to the process of securing Networkfunds. Whilst the tool was being developed fully aphase two stage of using the EMIS based tool wascarried out demonstrating further evidence for thework.

During the later stages of the tool being finalised(2008) the network approached a PBC alliance inYork (Network Primary Care Clinical Lead memberof York Health Group) and meetings were arrangedwith PBC board to present the tool and gainagreement to participate in first live project of theGRASP-AF tool. Agreement was reached andpresentations to the PBC practices took place inJanuary 2009.

GRASP-AF (Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation)West Yorkshire Cardiovascular Network. Early stages of project Leeds PCT andLeeds Teaching Hospitals Trust. During development of tool test sites in Bradfordand Airedale PCT, Kirklees PCT, Wakefield PCT. Completion of tool – York HealthGroup participating in live project to demonstrate working of tool in practice



Sign up completed by all 24 practices 30 January2009. Project commenced 12/13 February withtraining for practice staff. The review completiondate was the 30 April 09 with recording sheetsreturned by 7 May and the GRASP-AF tool re runto show a difference by 22 May. Full reportavailable from June 2009.

The network development manager (NDM)produced a toolkit that covers how to use the tool,what the tool can do, ‘things to remember’ andexamples of work carried out in West Yorkshire,including examples of business cases, sign upforms, invite letters, recording sheets,contraindication frameworks etc.

A network approach to the roll out of the tool hasbeen produced and during 2009 meetings havebeen arranged by the NDM of the West YorkshireCardiovascular Network (WYCN) to present thetool to PCTs and PBC alliances to encourageimplementation. Support of the NDM and networkteam is available for any PCT/PBC alliance acrossthe network wishing to undertake GRASP-AF.The WYCN website hosted the tool with accessonly allowed via the NDM. The tool has nowbeen made available for use nationally via theNHS Improvement website at:www.imrovement.nhs.uk/graspaf.

Key challengesThroughout the early stages of the project,engagement with the relevant people in the PCTwas challenging. Identifying who had responsibilityfor cardiac work within the PCT was difficult, asthis role was not one undertaken specifically by thePCT since Commissioning a Patient Led NHS(CPLNHS). The project did span across both thecardiac and stroke agenda but the stroke lead hada specific work programme already agreed for2008 which left very little room for manoeuvre,therefore no support was available. However, a GPwho sat on the PCT PEC did support the earlystages of the project and offered his expertise andinsights to primary care working on to developinga tool to run on primary care IT systems.

Time was also a challenge whilst working withPRIMIS to develop the tool as the clinical workloadsof the West Yorkshire HCP whilst developing thealgorithms for the tool still took place. Clinics,interventions and patient diagnosis and

management were still the professional’s day joband patients were their priority so making extratime to write the algorithms, advice and pod castwere difficult. Arranging for local sites to run thefirst test also proved a challenge, again trying to fitinto the busy GP day.

What went wellEarly discussions with PRIMIS+ on developing thetool. The clinicians and management at PRIMISwere very keen, excited and enthused by the ideaof the tool. PRIMIS also supported the testing ofthe tool when time was against us by identifyingand using established practices who regularlysupport PRIMIS work to test the tool.

The presentation of the tool to the WYCN board –full support and agreement that AF/strokeprevention would be a priority for 2009/10 and thevehicle to do this would be GRASP-AF. GRASP-AFis in our work programme and remains a priority.

Local target events across Leeds – the BHFarrhythmia nurses held many events raising theawareness of GRASP AF and educating practices inAF as a condition, warfarin as a drug and how touse the tool. They also offered their support inreviewing patients.

The specific GP education sessions included in theYork project – pre-questionnaires were completedand post-questionnaires will also be completed tosupport the results of the project. The training wasGP specific, covering not only the project and toolbut clinical understanding of AF, warfarin as aprescription drug and the diagnosing andmanaging AF – very GP focussed including casestudies. The session evaluated excellently anddiscussions are ongoing to reproduce the trainingon a large scale to support the GRASP-AF.

The support of the Atrial Fibrillation Alliance(AFA), Arrhythmia Alliance (AA) and British HeartFoundation (BHF) – all who are keen to support themarketing of GRASP-AF. The WYCN purchasedpatient information from AFA for every GP practiceto encourage a consistent approach and messageto patients when it comes to AF and strokeprevention.



Key learning from work• A lot of preparatory work is required in order toset up a network roll out plan – approximately12 months

• Engaging with primary care is a challenge eventhough links were already established within thennetwork

• Having a primary care GP clinical lead is vital inorder to succeed – a champion and advocatethat will bridge the potential clinical gaps anddemonstrate it is possible to implement withincurrent working commitments

• A clinical AF lead, local cardiologists willing tosupport the network’s activities

• Having a proven structure and plan for leadingindividual projects across a network – managingyour time is key as other areas of work as anetwork development manager do have animpact on this work and still require to beachieved

• Team spirit and support – knowing that you cancount on the support of your team.

OutcomesAreas across West Yorkshire are beginning toembrace GRASP-AF with new projectscommencing. All data from projects will becaptured by WYCN and shared both locally,regionally and nationally.

The York project, once completed will be able toshare outcomes in terms of numbers of AF patientsreviewed and, where necessary, optimal therapy.Number of strokes prevented will also be known.

Individual practices who were test sites for the toolhave demonstrated other benefits fromimplementing the tool including ‘cleaned up’ AFregisters (finding patients incorrectly coded forexample and, patients that were being prescribedwarfarin from the hospital but not known to thepractice). AF annual reviews have also been set upto ensure year on year risk scoring takes place andbest management continues. Warfarin has beenprescribed to appropriate patients in these test sites(total ten across three practices).

Challenges for sustainability• Hoping practices, whilst undertaking the workREAD code accurately their findings, otherwiseif the tool is repeated to show improvement orindeed annually, they will identify all the samepeople again

• That GRASP-AF does not ‘drop off’ the radar -other projects and areas of priority are alwaysgoing to be introduced and efforts channelledinto whatever is new next

• There is no element in the existing QOF tosupport practices to continue reviewing andstroke risk scoring their AF patients and worriesthat this will become a ‘one off’ exercise -patient’s stroke risk will change annually due toage and may change due to other contributingfactors, meaning they need assessing annually.

Costs incurred• To develop the tool to work on all IT systems£12,000 (network funded)

• A total cost of hours by the clinical Lead, BHFarrhythmia nurses and NDM of the network hasnot been including in the above costing

• The clinical lead for Chapter Eight of the NSF issalaried for his agreed sessions for networkactivities

• The network has financially supported the Yorkproject to provide timely results in order tosupport implementation across West Yorkshire,provide results for national use, and to supportthe building of CHART ONLINE, a national datacollection facility, total cost approximately£15,000. This includes practice payments toparticipating staff costs as well as lead GP andNDM time involved in project, the trainingsessions and all associated administrative work.

Patient, carer and staff involvement• The feedback from the GPs currently in theproject has been excellent, all agree an areaworthwhile undertaking and all very positive onthe training received

• The final questionnaire will provide valuablefeedback covering every aspect of the project.

• A number of local GPwSi involved in testingGRASP fed back how good the tool is and howeasy it is to download and interpret the results;these GPs lead locally in the cardiac field butwere noble enough to say even in their practicethe tool found work to be done.



Resources and tool developed tosupport the changesAvailable to share via the NHSImprovement website (www.improvement.nhs.uk/afprojectsummaries):• Toolkit to accompany GRASP-AF tool(www.improvement.nhs.uk/graspaf).

Future plansAs this is a network priority in 2009/10 the roll outand implementation has already begun in WestYorkshire.

Sites outside of the network where theapproach has been adopted by othersOur neighbours North and East Yorkshire andNorth Lincolnshire (NEYNL) have access to the toolvia the website (West Yorkshire and NEYNL sharethe same website). The NDM have supported andcontinue to support the lead in Hull to implementGRASP-AF.

Contact detailsProject lead:Adele GrahamEmail: [email protected]

BHF Arrhythmia Nurse:Keith Tyndall

Clinical lead:Dr Campbell CowanEmail: [email protected]



Duration of projectJune 2007 - still ongoing

Scope of projectThe project planned to improve the quality of initialdiagnosis and ongoing management of existingpatients with atrial fibrillation through severaldifferent mechanisms:• The agreement of sector wide guidelines,pathways and protocols for:• the management of atrial fibrillation inprimary care

• rapid access arrhythmia clinics• cardioversion

• The development of an audit tool for use acrossthe sector

• A coordinated approach to supporting practicesto carry out the audit

• The delivery of an education event to supportprimary care.

Baseline positionA preliminary audit from one practice suggestedthat at least 30% of patients on the AF registercould benefit from having their therapy optimised.

What we didSector wide guidelines for the management ofatrial fibrillation in primary care were developedwith the clinical lead and a GP lead for CHD fromone PCT with input from the cardiac network.These were then launched at an educational eventattended by over 50 GPs. The guidelines went tothe prescribing committee of each PCT in thenetwork.

Through a sector wide team of BHF arrhythmianurses, we worked with each individual PCT andacute trust to agree pathways and protocols forrapid access clinics to ensure timely and accurateassessment and diagnosis and also cardioversionservices to ensure timely treatment whereappropriate.

We carried out the audit in two practices todevelop and refine the audit tool. We thenattended the relevant cardiac meetings in each PCTto discuss this work and offer support to targetingpractices. The audit tool was also offered to eachPCT. One PCT adopted the audit to investigate andaddress anticoagulation therapy as part of itsprescribing incentive scheme with take up varying

across PBC clusters. A BHF arrhythmia nursesupported one practice to review and optimise allidentified patients.

An education event was organised, covering allaspects of arrhythmias but with a focus on themanagement of atrial fibrillation in primary care.92 people attended and 98% of peoplecompleting evaluation forms said that they hadlearnt something that would change their currentpractice.

As this work developed, we also had theopportunity to take part in a pilot for The Auricle, aweb based tool that has been created by a GP inSuffolk to guide GPs through reviewing their AFpatients CHADS2 score and their medication. Thetool also has the capacity to send the informationto a consultant in local hospital for additionalcomments and decision support via email (and fora small fee), potentially saving on unnecessaryoutpatient appointments. As this appeared to fitwell with the aims of our project to improvediagnosis and management of patients with atrialfibrillation, we spent a significant amount of timedeveloping links between one PCT and an acutetrust and progressing a pilot project. However, thePCT then decided that they did not want toproceed with the pilot but wanted to develop alocal algorithm to refer to the BHF arrhythmianurse rapid access clinic at the acute trust.

Key challengesThe main challenge was competing workloads fornetwork staff and BHF arrhythmia nurses. In theareas where we were most successful atprogressing this project, it required significant inputfrom network staff and a BHF arrhythmia nurse tokeep the momentum going and make progress.

Although PCTs expressed an interest in the audittool, the take up was low. It may have been moreappropriate to share this at PBC and/or individualpractice level to ensure all practices were aware ofthis. Where we did share the audit tool, there waslittle feedback from practices as to how manypatients had been identified and reviewed, despiterequesting this information when the tool wasshared.

Changing priorities for PCTs also provided achallenge, especially for The Auricle element of thiswork.

A sector wide approach to optimising therapy for AtrialFibrillation patients in Primary CareSouth West London Cardiac and Stroke Network, Richmond and Twickenham PCT,Wandsworth tPCT, Kingston PCT, Sutton and Merton PCT, Croydon PCT, St George’sHospital, Kingston Hospital, Epsom and St Helier Hospitals, Mayday Hospital, QueenMary’s Hospital, Roehampton



What went wellThe development of local pathways and protocolshas ensured that there is a joined up approach todiagnosis and management of patients with atrialfibrillation. For example, patients who are sent bytheir GP for an ECG who are found to be in atrialfibrillation have their ECG report sent back to theirGP together with a referral form for the rapidaccess arrhythmia clinic. Rapid access clinics areensuring that patients are seen in a timely manner.

The adoption of the AF pilot as part of theprescribing incentive scheme was a goodmechanism to drive this work forward to a wideraudience, although take up varied across PBCclusters in the PCT.

The BHF arrhythmia nurse working with a practiceto review all patients who had been optimised ason sub-optimal therapy ensured these patientswere reviewed in an appropriate manner. Thepractice was very positive about this level ofsupport and the additional informal learning thatthis method offered.

The education events were extremely well receivedwith positive feedback from attendees.

Key learning from work• It is important to have network staff to drive thiswork forward at PCT level as without it, thiswork slows down or stops

• BHF arrhythmia nurse services need to be linkedinto primary care to ensure there is anappropriate route for patients to receive fast andaccurate diagnosis and ongoing management.

Outcomes• 200 existing AF patients were reviewed at threepractices and where appropriate, their treatmentwas optimised

• Clear pathways have been agreed at five acutetrusts and four PCTs, with 100 patients benefitingfrom the new AF pathway at one acute trust, withsimilar uptake across all trusts in the sector

• Over 200 patients benefited from faster access tocardioversion at one trust. Wait times werehalved from 12 weeks to six weeks as part of theestablishment of a clear and agreed pathway forAF patients

• Three out of 10 practices in one PBC clusteradopted the prescribing incentive scheme atone PCT

• 150 clinicians attended two educational events.

Challenges for sustainabilityAs mentioned previously, it is important to ensurethat this work remains a priority with cardiac andstroke networks to support and facilitate PCTs todrive this work forward.

Costs incurredNone, as this project was carried out using existingstaff and resources.

Patient, carer and staff involvementPatients have been very positive about the servicesprovided by the BHF arrhythmia nurses and theirability to see patients in a timely manner.

The practice who worked with a BHF arrhythmianurse to review atrial patients was very positiveabout this level of support and the additionalinformal learning that this method offered.

The network’s patient and carer representativegroup is keen for this work to be extended toinclude identification of new cases of atrialfibrillation.

Resources and tools developed to supportthe changesAvailable for sharing via the South West LondonCardiac and Stroke Network website at:www.southwestlondoncardiacnetwork.nhs.uk• AF audit tool for GP practice.

Future plansThe next stage of this work would be to developand adopt a sector wide approach to theidentification of new cases of atrial fibrillation andensuring appropriate diagnosis and ongoingmanagement for this group of patients.

Contact detailsProject lead:Michelle BullEmail: [email protected]

Clinical lead:Professor John CammEmail: [email protected]



Avon, Gloucestershire, Wiltshire and SomersetCardiac and Stroke NetworkAngela KellNorth Somerset PCT, nine GP practices.

Bedfordshire and Hertfordshire Heartand Stroke NetworkDelyth WilliamsPrimary Care Trust, 23 GP practices

Black Country Cardiovascular NetworkJoanne Gutteridge, Angela NelsonDudley PCT, Dudley Group of Hospitals FoundationTrust, Worcester Street Commissioning Cluster,Wychbury Medical Centre, Litchfield Street Surgery,NHS Walsall, Walsall Hospitals NHS Trust

East Midlands Cardiac and Stroke Network(formerly Leicestershire, Northamptonshire &Rutland Cardiac Network)Ben KnightGP practices, Northamptonshire PCT

Kent Cardiovascular NetworkTim WaiteMedway PCT, Medway NHS Foundation Trust(Medway Maritime Hospital) Eastern and Coastal KentPCT, East Kent Hospitals University NHS FoundationTrust, West Kent PCT

Cardiac and Stroke Networks inLancashire and CumbriaLauren Butler, Jeannie HayhurstSix GP practices in Lancaster and Morecambe,Royal Lancaster Infirmary (University Hospitals ofMorecambe Bay NHS Trust), North Lancashire PrimaryCare Trust, Lancaster, Morecambe, Carnforth andGarstang Practice Based Commissioning Consortia

North Trent Network of Cardiac CareAnn Baines, Colette LongfordNHS Rotherham, Sheffield PCT, Sheffield TeachingHospital NHS Foundation Trust (Northern GeneralHospital), six GP practices

North and East Yorkshire and NorthernLincolnshire Cardiac and Stroke NetworkMelanie DunwellWhitby Group Practice, Robin Hoods Bay(satellite surgery)

Surrey Heart and Stroke NetworkLiz Patroe,13 General practices in Woking and West Byfleet,Surrey PCT

West Yorkshire Cardiovascular NetworkAdele Graham, Keith TyndallLeeds PCT, Leeds Teaching Hospitals NHS Trust, YorkHealth Group, Bradford and Airedale PCT, KirkleesPCT, Wakefield PCT.

South West London Cardiac andStroke NetworkRichmond and Twickenham PCT, WandsworthPCT, Kingston PCT, Sutton and Merton PCT,Croydon PCT, St George’s Hospital, KingstonHospital, Epsom and St Helier Hospitals, MaydayHospital , Queen Mary’s Hospital, Roehampton



Project Team Leads, Cardiac and Stroke Networksand Participating Sites

Dr Campbell CowanNational Clinical Lead, Consultant Cardiologist

Dr Matt FayNational Clinical Lead, General Practitioner

Sue HallNational Improvement Lead, NHS Improvement

National Team Members

NHSNHS Improvement

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