Poole AF/ A Flutter ClinicPoole AF/ A Flutter Clinic20112011
Diane BruceDiane Bruce
Consultant Cardiologist PHNHSFTConsultant Cardiologist PHNHSFT
BackgroundBackground
DLB –appointed 1994 “jobbing DLB –appointed 1994 “jobbing cardiologist”cardiologist”
GP lecture “Lets be active about AF”GP lecture “Lets be active about AF” 2010 Job planning changes-etc2010 Job planning changes-etc NICE guidance re AF clinicNICE guidance re AF clinic Main problem-setting up new serviceMain problem-setting up new service In current “cash strapped times”In current “cash strapped times”
AF in 1995AF in 1995
AF in 2011AF in 2011
““So- what happened next ?”So- what happened next ?”
Discussion with trust managersDiscussion with trust managers AF/Fl patients seen in many different AF/Fl patients seen in many different
settings –NOT new activitysettings –NOT new activity Aiming for consultant led rather than Aiming for consultant led rather than
nurse led- WHY ?nurse led- WHY ? - ability to prescribe Class Ic drugs- ability to prescribe Class Ic drugs - refer straight on for DCV/AVN/PVI- refer straight on for DCV/AVN/PVI -deal with precipitating cardiac -deal with precipitating cardiac
issues, if required.issues, if required.
Hurdles to overcomeHurdles to overcome
DLB availability/physiologistsDLB availability/physiologists ROOM availabilityROOM availability ECG/24h Tape/ECHOECG/24h Tape/ECHO Development of clinic proforma with Development of clinic proforma with
IT (and multiple “tweakings”)IT (and multiple “tweakings”) Email/Fax (to avoid need for typing)Email/Fax (to avoid need for typing) ““letting go” phenomenonletting go” phenomenon
Referral criteriaReferral criteria
Newly diagnosed AF or Atrial FlutterNewly diagnosed AF or Atrial Flutter OR AF/Flutter that is difficult to OR AF/Flutter that is difficult to
manage.manage. AF and concern re other procedureAF and concern re other procedure Eg surgery etcEg surgery etc
Going Live!Going Live!
11stst week in January 2011 week in January 2011 3/12 Pilot Project3/12 Pilot Project ONLY in house referrals-via elective ONLY in house referrals-via elective
OP referrals/in patient via MAU etcOP referrals/in patient via MAU etc 4 slots per week4 slots per week
April 2011- end of pilot April 2011- end of pilot Increased to 6 slots per weekIncreased to 6 slots per week
Clinic FormatClinic Format 6 patients 30 minute consultation6 patients 30 minute consultation All patients have 12 lead ECG/24 H All patients have 12 lead ECG/24 H
ECG/TTE –unless had in last 3/12ECG/TTE –unless had in last 3/12 Patients encouraged to bring someone Patients encouraged to bring someone
along with themalong with them Nuances of clinic explainedNuances of clinic explained Work through proformaWork through proforma Check all understoodCheck all understood AFA booklets/advice sheetsAFA booklets/advice sheets
AnticoagulationAnticoagulation
CHADS2 and CHADSvascCHADS2 and CHADSvasc Hasbled (if required)Hasbled (if required) Direct referral to anticoagulation Direct referral to anticoagulation
Clinic on same dayClinic on same day AFA advice sheetsAFA advice sheets
DC Cardioversion DC Cardioversion
Patients requiring DCVPatients requiring DCV Consented by DLBConsented by DLB Pre-clerking and date for DCV givenPre-clerking and date for DCV given ““meet and greet” staff on MIUmeet and greet” staff on MIU
DCV waiting list DCV waiting list
EP referralsEP referrals
Made same dayMade same day Urgent referrals via phone/fax/emailUrgent referrals via phone/fax/email Patients given info on AVN/PVI/Flutter Patients given info on AVN/PVI/Flutter
AblationAblation
Device ReferralDevice Referral
5 patients had VVIR PPM5 patients had VVIR PPM 2 patients had CRT-P2 patients had CRT-P Others pending after DCV, ablation Others pending after DCV, ablation
etcetc
AdmissionsAdmissions
Very rare-from clinicVery rare-from clinic
3 admissions with Aflutter with 2:13 admissions with Aflutter with 2:1
Block for TOE guided DCVBlock for TOE guided DCV
If atrial clot- managed appropriatelyIf atrial clot- managed appropriately
MiscellaneousMiscellaneous
Quality of Life questionnaireQuality of Life questionnaire ““AFEQT” atrial fibrillation effect in AFEQT” atrial fibrillation effect in
quality of lifequality of life
Using proforma outside of AF clinicUsing proforma outside of AF clinic
DemographicsDemographics
AGE RANGE less than 65y= 52AGE RANGE less than 65y= 52 (21 F, 31 M)(21 F, 31 M)
AGE RANGE 65-75 (15 F, 30 M)AGE RANGE 65-75 (15 F, 30 M)
AGE RANGE 0ver 75 (22 F, 24 M)AGE RANGE 0ver 75 (22 F, 24 M)
DemographicsDemographics
CHADSvasc SCORE 0 =19CHADSvasc SCORE 0 =19 1 =351 =35 2 =282 =28 3 =343 =34 4 =124 =12 5 = 65 = 6 6 =46 =4
ReferralsReferrals
DCV 30DCV 30
VVIR PPM 5VVIR PPM 5
EP (all) 7EP (all) 7
Urgent angiogram 2Urgent angiogram 2
Anticoagulation at presentationAnticoagulation at presentation
On ASPIRIN 39%On ASPIRIN 39%
On WARFARIN 24%On WARFARIN 24%
On nothing 46%On nothing 46%
““ups and downs”ups and downs”
Increased waiting time due to Increased waiting time due to number of referralsnumber of referrals
?solution- more clinics?solution- more clinics AF follow up clinics now running AF follow up clinics now running
twice monthlytwice monthly Interest from Stroke practitionersInterest from Stroke practitioners - stroke/cardiology MDT- stroke/cardiology MDT
““ups and downs”ups and downs”
““glitches” eg:-hold ups with bookingglitches” eg:-hold ups with booking appointmentsappointments ECG problemsECG problems Avoiding duplication of tests etcAvoiding duplication of tests etc Increased wait for DCV as numbers Increased wait for DCV as numbers
increase (nurse led at Poole).increase (nurse led at Poole).
Feedback Feedback
From patients--- mostly goodFrom patients--- mostly good ““word of mouth referral”word of mouth referral” Via Google?Via Google? Seeing patients now “cured”Seeing patients now “cured” New issue-demand for dabigatran etcNew issue-demand for dabigatran etc One complaint –One complaint – Speedier anticoagulation- re close Speedier anticoagulation- re close
link with clinic.link with clinic.
FeedbackFeedback
From GPFrom GP Mainly good-constructiveMainly good-constructive 1 negative (re CHADS score etc)1 negative (re CHADS score etc) BUT useful !!BUT useful !! Increased referralsIncreased referrals
Other diagnosesOther diagnoses
Uncontrolled ThyrotoxicosisUncontrolled Thyrotoxicosis 2 ASD2 ASD 3 severe heart failure3 severe heart failure 2 mitral valve repairs2 mitral valve repairs Anaemia-not uncommonAnaemia-not uncommon
Future PlansFuture Plans
Expansion of the clinic-more follow Expansion of the clinic-more follow up clinicsup clinics
Improve AF diagnosis with new Improve AF diagnosis with new monitorsmonitors
Email clinic lettersEmail clinic letters Improving DCV waiting timesImproving DCV waiting times AUDITAUDIT Etc,etc!Etc,etc!
Thank YouThank You
Poole AF/Flutter clinic is TEAMWORKPoole AF/Flutter clinic is TEAMWORK Booking clerks/nurses/reception Booking clerks/nurses/reception
staff/physiologists/as well as me!staff/physiologists/as well as me! IT for proforma and all adjustmentsIT for proforma and all adjustments Patients (putting up with my slow Patients (putting up with my slow
typing!)typing!) AFA booklets and supportAFA booklets and support