Poole AF/ A Flutter Clinic 2011 Diane Bruce Consultant Cardiologist PHNHSFT
Background u DLB –appointed 1994 “jobbing cardiologist” u GP lecture “Lets be active about AF” u 2010 Job planning changes-etc u NICE guidance re AF clinic u Main problem-setting up new service u In current “cash strapped times”
AF in 1995
AF in 2011
“So- what happened next ? ” u Discussion with trust managers u AF/Fl patients seen in many different settings –NOT new activity u Aiming for consultant led rather than nurse led- WHY ? u - ability to prescribe Class Ic drugs u - refer straight on for DCV/AVN/PVI u -deal with precipitating cardiac issues, if required.
Hurdles to overcome u DLB availability/physiologists u ROOM availability u ECG/24 h Tape/ECHO u Development of clinic proforma with IT (and multiple “tweakings”) u Email/Fax (to avoid need for typing) u “letting go” phenomenon
Referral criteria u Newly diagnosed AF or Atrial Flutter u OR AF/Flutter that is difficult to manage. u AF and concern re other procedure u Eg surgery etc
Going Live! u 1 st week in January 2011 u 3/12 Pilot Project u ONLY in house referrals-via elective OP referrals/in patient via MAU etc u 4 slots per week u April 2011 - end of pilot u Increased to 6 slots per week
Clinic Format 6 patients 30 minute consultation u All patients have 12 lead ECG/24 H ECG/TTE –unless had in last 3/12 u Patients encouraged to bring someone along with them u Nuances of clinic explained u Work through proforma u Check all understood u AFA booklets/advice sheets u u
Anticoagulation u CHADS 2 and CHADSvasc u Hasbled (if required) u Direct referral to anticoagulation Clinic on same day u AFA advice sheets
DC Cardioversion u Patients requiring DCV u Consented by DLB u Pre-clerking and date for DCV given u “meet and greet” staff on MIU u DCV waiting list
EP referrals u Made same day u Urgent referrals via phone/fax/email u Patients given info on AVN/PVI/Flutter Ablation
Device Referral u 5 patients had VVIR PPM u 2 patients had CRT-P u Others pending after DCV, ablation etc
Admissions u Very rare-from clinic 3 admissions with Aflutter with 2: 1 Block for TOE guided DCV If atrial clot- managed appropriately
Miscellaneous u Quality of Life questionnaire u “AFEQT” atrial fibrillation effect in quality of life u Using proforma outside of AF clinic
Demographics u AGE u RANGE less than 65 y= 52 (21 F, 31 M) u AGE RANGE 65 -75 (15 F, 30 M) u AGE RANGE 0 ver 75 (22 F, 24 M)
Demographics u CHADSvasc u u u SCORE 0 1 2 3 4 5 6 =19 =35 =28 =34 =12 =6 =4
Referrals u DCV u VVIR PPM u EP (all) u Urgent angiogram 2 u 30 5 7
Anticoagulation at presentation u On ASPIRIN 39% u On WARFARIN 24% u On nothing 46%
“ups and downs” u Increased waiting time due to number of referrals u ? solution- more clinics u AF follow up clinics now running twice monthly u Interest from Stroke practitioners u - stroke/cardiology MDT
“ups and downs” u “glitches” eg: -hold ups with booking u appointments u ECG problems u Avoiding duplication of tests etc u Increased wait for DCV as numbers increase (nurse led at Poole).
Feedback u From patients--- mostly good u “word of mouth referral” u Via Google? u Seeing patients now “cured” u New issue-demand for dabigatran etc u One complaint – u Speedier anticoagulation- re close link with clinic.
Feedback u From GP u Mainly good-constructive u 1 negative (re CHADS score etc) u BUT useful !! u Increased referrals
Other diagnoses u Uncontrolled u 2 Thyrotoxicosis ASD u 3 severe heart failure u 2 mitral valve repairs u Anaemia-not uncommon
Future Plans u Expansion of the clinic-more follow up clinics u Improve AF diagnosis with new monitors u Email clinic letters u Improving DCV waiting times u AUDIT u Etc, etc!
Thank You u Poole AF/Flutter clinic is TEAMWORK u Booking clerks/nurses/reception staff/physiologists/as well as me! u IT for proforma and all adjustments u Patients (putting up with my slow typing!) u AFA booklets and support
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