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