Atrial Fibrillation:Changing an Irregular Practice

Dr Shu-Yi Claire Chan, Dr Jessica Macready, Dr Bridget Kemball

Introduction

New atrial fibrillation (AF) is a common acute presentation on the medical take. Anecdotally, we noticed wide variation in the management of these patients at our hospital. An initial audit confirmed irregularities in management and follow-up. Based on the results of this audit, we were driven to develop a new Trust-wide guideline to ensure safe and standardised care for patients presenting with new AF.

Aims:

• Primary aim: To assess management and follow-up of patients presenting with new AF on the medical take

• Secondary aim: To create a new clinical guideline, in collaboration with key stakeholders, for dissemination and use Trust-wide

Audit Round One (Aug 2020)

19 patients with new AF identified, of these:

• 95% given appropriate rate control

• 12% inappropriately discharged without anticoagulation (despite high CHADS-VASC score)

For the 18 patients who survived to discharge there were discrepancies in follow-up:

• 25% of patients were inappropriately discharged without referral for an outpatient transthoracic echocardiogram (TTE)

• 44% were discharged with no follow-up

Existing Trust guidelines outdated and difficult to find

Action Plan (based on round one results)

• Clear need for updated standardised guidelines

• Clarification on follow-up:

• Clear criteria for specialist follow-up

• All patients should receive some form of follow-up given that many would be started on lifelong anticoagulation / rate control

• Signposting to New Medicines Service (pharmacy counselling in the community)

New Guideline (Jan-Oct 2021)

End Oct 2021: New Trust guideline created with input from pharmacy, cardiology, acute medicine, haematology and renal teams.

Education (Nov-Dec 2021)

PDSA education cycles occurred from Nov to Dec 2021, including education for the acute medical team, clinical fellows and foundation year 2 doctors.

Keywords e.g. ‘New Atrial Fibrillation’, ’AF’, ‘DOACs’ were used to make the guideline easily searchable.

• Improved awareness of existence of guideline and of guideline contents following education sessions

• Improved awareness of New Medicine Service

Audit Round Two (Dec-Jan 2022)

Re-audit Dec 21 to Jan 22; 18 patients with new AF identified.

Rate Control

• Most patients continued to receive appropriate rate control

• Reduction in harmful outcomes: zero patients had rate control inappropriately withheld

Anticoagulation

• Improvement in patients receiving appropriate anticoagulation from 68% to 78%

• Reduction in harmful outcomes (no anticoagulation or inappropriate choice of anticoagulant) from 16% to 6%

Follow-up

• Improvement in patients being appropriately followed up on discharge, from 53% to 89%

• Improvement in patients being referred for appropriate outpatient investigations, from 74% to 83%

Conclusions

The new Trust-wide guideline showed good uptake and awareness among junior staff after education cycles. Re-audit indicated some key improvements in the management and follow-up of patients presenting with new AF. It also identified areas where further improvement is required (no change seen between rounds 1 & 2), including:

• Clear rationale for inpatient specialist input

• Clear documentation of stroke risk and bleed risk scores

• Move to ORBIT rather than HASBLED for bleed risk scoring

Further education of junior doctors, on these specific points, could be a focus for a future PDSA cycle.

Creation of Treatment Escalation Plans for patients admitted to a general medical ward

Dr Sidharthan Ilangovan1, Dr Montana Jackson2, Dr Raj Tanday3

1 Junior Doctor, Barking Havering and Redbridge NHS Trust, 2 IMT, Barking Havering and Redbridge NHS Trust 3 Consultant Endocrinologist, Barking Havering and Redbridge NHS trust

Introduction

This is a QI project to evaluate the Creation of Treatment Escalation Plans for patients admitted to a general medical ward.

What are Treat escalation plans?

A Treatment Escalation Plan (TEP) is a form of advanced care planning and communication tool which is helpful in hospital for inpatients as they have the potential for acute deterioration and some may even be coming towards the end of their life. (1)

Why are TEPs useful?

There are situations in which doing everything possible may actually lead to more harm (suffering and distress) rather than less and may not be in the best interest of the patient (or even in line with the patient’s own wishes). What can be done and what should be done may not necessarily be the same thing. Thus this is the reason Treatment Escalation Plans should be discussed (amongst the clinical team and with the patient) and made based on personalised realistic goals whenever patients are admitted as inpatients. (1,2)

Crucially, a TEP provides on-call hospital staff with immediately accessible guidance about how to respond to an individual in times of crisis, especially out of hours and at weekends. A TEP becomes particularly important when there is agreement that interventions or referrals for more intensive care that are contrary to a person’s wishes or are futile or burdensome should not be undertaken. Equally in many patients who may have an agreed DNACPR, a TEP clarifies all the treatments and care that should continue.(1,2,3)

Current Guidelines

Currently there are no national guidelines dictating initiation of TEPs but there are many guidelines and clinical decision making aids available from NICE (i.e. Warwick model) to aid clinicians in TEP decisions. (3)

Aim

The aim was for 100% of patients admitted as inpatients to medical wards should have a treatment escalation plan documented

Cycle 1 Materials and Methods

QI Approval

Audit approval was sought and obtained from local clinical audit department and audit registered.

Timeframe

2 week period between 13/10/2021 – 27/10/2021

Participants

Patients admitted to Ash ward a King Georges Hospital for this 2 week duration were used as a representative sample. All patients admitted to ash ward during this 2 week period were included in this study without any exclusions.

Methodology

1. Examination of case notes was the primary method used to identify if patients had any treatment escalation plans in place

2. Forms of treatment escalation plans accepted for this study are as follows;

-

Filled up treatment escalation plan proformas in medical clerking notes

- Filled up treatment escalation plan proformas added on the ward (separately from the medical clerking booklet)

- Detailed written treatment escalation plans not utilising the proforma

3. The patient notes were examined to locate the aforementioned forms of Treatment Escalation Plans and the data was recorded in an anonymised and password protected excel sheet

Cycle 1 Results

Over the 2 week period 91 unique patients were admitted to ash ward and their notes were analysed. Of the 91 patients only 37 had a Treatment Escalation Plan on file. 54 patients did not have ay formal TEP available in their medical files. Thus only 40.65% of patients in this representative sample had a TEP available falling far short of the 100% standard set out at the introduction. (Figure 1)

Changes

The results of cycle 1 demonstrated that we were falling short of the expected standard when it comes to creating treatment escalation plans for inpatients as just under half of patients have TEP’s documented in their medical notes. This thus demonstrated the need for more education on the importance of Treatment Escalation plans and their implementation.

Recommendations

A 3 pronged approach was utilised to improve the uptake and creation of TEPs;

1. Education

2. Reinforcement

3. Access/convenience

Action plan

The recommendations above were actioned using the following practical changes on the ward;

1. A presentation to ward doctors during ward based teaching

2. Moving forward regular presentations on the importance of TEP’s and creating TEPs during ward based induction for incoming doctors

3. A poster was created that highlights the importance of TEP’s and shows how to create one (reinforcing the importance of TEPS daily)

4. Create and place TEP pro-formas prominently in the doctors office so that they are readily available to be added to medical notes of new patients. This serves to provide ready access to TEP proformas. This thus increases convenience and reduces resistance to the adoption of TEPs

Cycle 2 Results

The action plan above was implemented for a month and following which the data collection was repeated to assess the efficacy of the recommendations

Results

Over the 2 week period 66 unique patients were admitted to ash ward and their notes were analysed. Of the 66 patients 57 had a Treatment Escalation Plan on file. Only 9 patients did not have any formal TEP available in their medical files. Thus 86.36% of patients in this representative sample had a TEP available representing a marked improvement from the findings of the initial audit. (Figure 2)

Conclusion

Our data indicated improving education (with regular passive reinforcement) and improving access to TEP proformas to allow quicker decision making and better adherence to guidelines does improve adoption and creation of TEPs

Potential Pitfalls

Both QI cycles were performed within a 4 month period thus was not subject to the turnover of junior doctors. In past studies looking into implementing other forms of advanced care planning this junior doctor turnover has been found to be a point where improvements are diminished. (2) Therefore a 3rd cycle is planned for the future to verify if the results hold true despite junior doctor rotation.

Future Improvements

1. To combat the rotation of junior doctors education on TEP should be integrated as part of local ward induction programs.

2. Education on TEPs and their importance should be extended to involve other members of the MDT (nurses, physiotherapists, ect.) to allow multiple members to reinforce one another in creating TEPs