af collaborative event - surrey - pages - kss ahsn ... · in 2015/16 68,093 new af cases ... these...

AF Collaborative Event -

Surrey

Tuesday 20th June 2017

Welcome

Peter Carpenter QPSC Programme Director, KSS AHSN

KSS AHSN

A National Perspective

of AF

Shakti Dookeran Population Health Service Manager & AF-related Stroke

Prevention Lead

Public Health England

National AF-related stroke prevention

programme

Shakti Dookeran, Population Health Service Manager (National AF

programme lead)

‘do once’ elements

System leadership & prioritisation

Strengthen clinical

leadership

Consistent communication

Improving data flows

Disseminate good practice

National support - local leadership

7 Presentation title - edit in Header and Footer

Detection gap: 25-30%

of people with AF are

estimated to be

undiagnosed

Protect gap ~13-25% of

people known to have

AF and are at risk are

not treated

Correct gap: Of those

on treatment it is

estimated that ~35%

maybe uncontrolled

Care pathway - gaps and opportunities

Ambition and objectives

To reduce the incidence of avoidable AF-related strokes by 5,000

nationally over the next 5 years by:

I. Increasing the proportion of known AF patients who are offered and started on

appropriate treatment from 74% to 89% over the next 5 years

II. Introducing regular systematic audit in all practices (using tool such as GRASPAF) to

identify people at risk who are not anticoagulated or who are sub-optimally

anticoagulated

III. Increasing opportunistic detection rates in line with expected prevalence through

NHS Health Checks and other mechanisms

IV. Strengthening and upskilling clinical leadership on AF


Starting from a good position …


Levers and support in the system

• NICE CG180 guidance & resources

• AF system leadership

• RICH data – QOF, NCVIN, SSNAP, HES, social care

• Strategic planning guidance

• The STP Aide memorie on prevention & primary care

• 5YfV next steps

• Local health and care planning; menu of preventative interventions

• NHS Right care CVD prevention optimal value pathway

• AHSN AF community - spread and adoption programme

• Voluntary sector – Stroke Association, British Heart Foundation, AFA

• Commercial & pharma sector contributions


System wide action on AF detection

In 2015/16

68,093 new AF cases detected ~2000 AF-related strokes prevented

~£40 million savings health and social care


Key focus areas for 16/17:

• Continue to support and join up work led by the AF AHSN community,

voluntary sector, NHS Rightcare, PHE and other partner agencies

• Scope out process to nationalise TTR data

• Deliver 3 regional AF accelerator events

• Share learning from the AF programme model to other CVD secondary

prevention programmes

• Supporting optimal prescribing and management of therapies

• Strengthen messages on vascular dementia risk

• Support development of version 2 of the AF landscape tool


Take action to prevent AF –related stroke


Thank you

[email protected]


mailto:[email protected]



Tackling the AF Challenge

Dr Michael Hickman Consultant Cardiologist / STP Lead – Surrey Heartlands

Royal Surrey County Hospital NHS FT

Refreshment break

Patient Story

Rosemary Najim

Atrial Fibrillation from patients’ perspectives.

Vagal AF -onset at night.

Low potassium – diet plus added in magnesium

Age. Diagnosed 2013 mild Left Atrium dilation. No underlying heart/ thyroid issues. Borderline Hypertension.

Patients’ concerns re diagnosis and treatment Source.Health Unlocked 7,700 members online ( up from 2500 in 2013) 56 wanted to put points forward for you! Re Diagnosis. Length of time this can take was main concern.Several patients – 5 or 6 years .( obvious results here as re-modelling and worsening AF result) Their suggestions , to sum up with two quotes: Patient 1. “My diagnosis would have been faster if my PAF had been caught on repeated ECGs over a 6 year period. My complaint was always the same- I can’t breathe properly. Perhaps advice to such a patient could be to take their own pulse/ come to the clinic as soon as episode starts.”

Patient 2

”My GP was very sympathetic about my AF symptoms ( palpitations, fast HR and near fainting) and clearly suspected AF but was unwilling to make firm diagnosis without evidence. My own research lead me to Alive cor/Kardia, the evidence he needed, referral to a cardiologist and treatment plan. As a result, I have far fewer episodes and feel much better than I did in the 12 months of uncertainty beforehand.” This experience was echoed by many and their suggestions included a) Possible loan of Kardia device to patients where AF suspected( details

of device- usefulness, daughter. Other devices are possible. Our M D involved in a wrist/press button device he thinks may be better)

b) B) copy what one surgery is doing - all patients over 65 have pulse checked when attending. Another’s surgery take pulses at flu clinic.

Follow up diagnoses and treatment • Further difficulties people listed re diagnosis included follow up tests and

subsequent referrals. These take very long time- problems listed refer mainly to lack of information/advice in the meantime.

• Over-riding concern is when/if A and E appropriate in symptomatic patients. Many suggested guidelines should be given. My experience re this.(HR /BP/ nausea etc)

• Questions like whether exercise is appropriate/ whether anti coagulation can be stopped after ablation/whether life expectancy is reduced through AF/ fear re minor procedures when AC.( tooth!)

• Example re member of our support group. 3 weeks in chair No information

• Patients wanted recognition of the fear AF causes rather than what one related as “ you’re having a few palpitations!!” She thought they were referring to 19th C way of dealing with women!

• Referrals often a problem- debates re Cardiologist v EPs always ongoing. Own experience.

• Major worry over whether to have ablation or not.

• Medications- example re AF to follow

Role of support groups. Anti-coagulation • Started Surrey ASG 2014 (recent group at Harefields

Hospital,Ian Health Unlocked) • Consultants from St Peters, St Georges, Royal

Brompton, Epsom and St Helier Trust. In addition to Dr Bogle and Dr Bajpai- Clinical and Arrhythmia leads Epsom and St Helier Hospital, Psychologists from Brompton, Cardiac Exercise team Epsom hospital, Lead Pharmacist Surrey Downs CCG, GPSi DR Emanuel and Dr Wong.Arrhythmia Nurses from Epsom and St Helier.

• Topics- Anti Coagulation, • Drug interactions. Rate and rhythmn control. Ablation,

Life style changes, • Diabetes, other heart conditions and AF,

Main functions of support groups • Education- on all topics just mentioned.

• Re-assurance about AF.- particularly helpful for new patients

• Practical advice re what to do when!

• ? Possible, in areas without a support group, to have small support groups in large practices? Incorporate in AC clinic?

Surrey ASG First Screening Event 2013 Ashley Centre

Ov

er

100

peo

ple

par

tici

pat

ed

in

our

free

EC

G/P

uls

e

Ch

eck

Eve

nt

Sout

hern

Tuto

rs

spon

sore

d

Surr

ey

Arrh

ythm

ia

Sup

port

Grou

p's

first

puls

e

chec

k

even

t in

the

Ashl

ey

Cent

re,

Eps

om o

n

Janu

ary

23rd

2015

.

Dr

Rich

ard

Bogl

e,

Con

sulta

nt

Card

iolog

ist at

Eps

om

and

St

Helie

r

NHS

Trus

t,

and

Chri

s

Croc

kfor

d

CEO

of

Card

iocit

y led

the

team

who

carri

ed

out

the

ECG

healt

h

chec

ks.

Heal

th

chec

ks

were

perf

orm

ed

usin

g

Alive

Cor

iPho

ne

App

and

Card

iocit

y’s

Rhyt

hmP

adG

P, a

simp

le

USB

conn

ecte

d

lead

1

and

lead

6

scre

enin

g

tool.

The

even

t

was

held

to

raise

awar

enes

s of

Hear

t

cond

ition

s,

parti

cular

ly

Arrh

ythm

ia,

and

enco

urag

e

peop

le to

be

mor

e

cons

ciou

s of

their

healt

h

gene

rally.

Peo

ple

were

treat

ed to

scre

enin

g

usin

g

both

tech

nolo

gies

and

seve

ral

hear

t

prob

lems

were

ident

ified,

allo

wing

patie

nts

to

go

to

their

GPs

for

furth

er

advi

ce

and

treat

ment

wher

e

appr

opri

ate.

Jane

Race

,

Chai

r

and

Fou

nder

of

Surr

ey

ASG

said

“The

even

t

was

a

huge

succ

ess

and

ident

ified

seve

ral

hear

t

cond

ition

s in

patie

nts.

We

are

very

grat

eful

to Dr

Rich

ard

Bogl

e

and

Step

hani

e

Crui

cksh

ank,

both

from

Eps

om

and

St

Helie

r

Hos

pital,

for

scre

enin

g

over

100

peop

le

toda

y, in

Eps

om’s

Ashl

ey

Cent

re.”

Surrey ASG screening events

• Over 100 members of the public screened with Alive Cor/Kardia. Dr Bogle, Lead cardiologist Epsom St Helier Hospital 4 new cases of AF. 10 other heart problems diagnosed.Cardiocity and others have helped.

• Surrey ASG has continued to organise- one in conjunction with local GPs and SDCCG and one with Dr Bajpai at the Borough Fun day.

• 4 or 5 AF patients at each event. Fits with estimates of undiagnosed cases nationally

• Next one in Ashley Centre again in September. • Patients referred to GP for AC and referral on where

needed.

Use patients, collaboration and listening!! • Lots of the replies to my request for things people felt important to tell you involved using our experiences, at a time of limited

resources, and listening!!

• Examples of making small differences

• Kent ,Surrey and Sussex, AF start to finish project 2014

• My vagal AF low resting HR, beta blockers 3 studies .

• Source European Heart Journal 2008

• One thousand five hundred and seventeen patients with paroxysmal AF participated in the Euro Heart Survey on AF.

• We categorized patients according to trigger pattern as reported by the physician: adrenergic (AF associated with

• exercise, emotion or during daytime only and absence of vagal triggers), vagal (postprandial or night time only,

• without presence of adrenergic triggers) and mixed (combination of vagal and adrenergic triggers). Vagal AF was

• found in 91 patients (6%), adrenergic in 229 patients (15%) and mixed in 175 (12%) patients. Underlying heart

• disease was equally prevalent in the three groups. Among patients with vagal AF, 73% were treated with non-

• recommended drugs according to the guidelines. In vagal AF, non-recommended treatment was associated with a

• shift to persistent or permanent AF in 19% of the patients, compared with none in the group receiving recommended

• treatment (P 1⁄4 0.06).

• The guidelines contest prescription of a beta-blocker, sotalol, digi- talis or propafenone in patients with vagal AF.

Result!

• Incorporated this advice into the Start to Finish Kent Surrey and Sussex project, and later into SDCCG guidance.

• SDCCG listened re anti-coagulation ( and NICE guidelines change) When Surrey ASG started we would have about 4 patients at each meeting with Chads Vasc scores indication that AC needed.and were on asprin or nothing

• Lead Pharmacist, Liz Clark, and Dr Subo Emanuel great work to encourage AC with GPs and also LC spoke at Surrey ASG and advised.

Main Action now re AF Pulse / ECG screening • Great work since 2014 re AC to prevent stroke

• Can’t AC until diagnosed so

• Next step – find the 4 in 100 of population with AF so can be AC and prevent strokes

• Experience on stroke prevention group SDCCG. Nurse “Not all strokes are AF related.”

• AF strokes are more debilitating. East Surrey A and E stroke consultant confirmed that 6 out of 9 recent stroke deaths were strokes caused by AF

• Simple to take pulses/ teach patients how to check for themselves!

• Any questions?

Detect. Review. Protect

Jan Bayly Cardiovascular Lead

KSS AHSN

Workshop:

British Heart Foundation – taking

learning to action: practical steps

Helen O’Kelly, Health Service Engagement Lead

Regina Giblin, Clinical Development Coordinator

Taking learning to action:

practical steps from the BHF

Helen O’Kelly

Health Service Engagement Lead

Regina Giblin

Clinical Development Coordinator

Fewer people die early or suffer from cardiovascular disease (CVD)

People have lower risk factors, helping prevent CVD

Fewer people die of heart attacks, and out of hospital cardiac arrest survival rate increases from below 10%

All people with cardiovascular disease and cardiac conditions get the information, guidance and support they need

‘2020 VISION’

Implement Influence Empower

Implementation in Practice: the BHF

approach

Pump Prime

& Test Hypothesis

Redesign care and support

pathways

Evaluate & build

evidence base

Publish and Disseminate

Evidence & new

hypotheses

IMPLEMENT

EMPOWER

INFLUENCE

Spread

& Adoption of Best Practice

Informed & empowered

patients, carers & professionals

BHF exit

Being the change

agent for CVD, the BHF will work with health system

leaders to:

• Make the case for change at a health system level to improve evidence based CVD care

• Use our best practice portfolio and evidence based practice to challenge variation in care and identify sustainable solutions that respond to the challenges of the health system in quality, efficiency and effectiveness

• Act as a catalyst for change by convening senior decision makers and practitioners to identify challenges, opportunities and solutions to improve CVD care through communities of practice

• Educate and empower signpost to training and resources for health professionals to optimise delivery of the best care to people living with or at risk of developing CVD including via the BHF Alliance

Health

Services

Engagement

Team

RightCare

• 1.4 million in England with AF- 30%

undiagnosed, over half untreated or poorly

controlled

• Anticoag. Prevents 2/3 of strokes in AF

CVD Prevention Primary Care- RightCare

https://www.youtube.com/watch?v=A1EQF9cvqhk

Patient perspectives




Stroke Association: https://www.stroke.org.uk/professionals/af-how-can-we-do-better

https://www.stroke.org.uk/professionals/af-how-can-we-do-better











AF Strokes in Surrey Heath CCG


What can practices do to find and treat the missing high risk patients?

1. Compare recorded prevalence with the expected prevalence of AF for your

practice.

2. Use tools such as GRASP-AF to search for codes that suggest probable or

possible uncoded AF.

3. Do opportunistic pulse checking in settings where AF more likely to be

detected e.g. long term condition clinics, flu clinics and blood pressure

checks.

4. Ensure everyone found to have an irregular pulse is offered a 12-lead ECG

to determine the rhythm.













What can practices do to improve stroke risk reduction in AF?

1. Offer stroke risk assessment with CHA2DS2-VASc to all people with non-

valvular AF.

2. Offer anticoagulation to adults where CHA2DS2-VASc risk score is 2 or

above.

3. Use HAS-BLED to identify risk factors that can be modified in order to

mitigate the risk of bleeding - e.g. alcohol, medication and high blood

pressure.

4. Keep the quality of anticoagulation under close review by regularly checking

that the individual Time in Therapeutic Range (ITTR) of those on warfarin is

greater than 65%. Adherence to both warfarin and NOACs should also be

regularly checked.












BHF Funded

Integrated care awards

• NHS Lanarkshire

• NHS Tayside

• NHS Fife

• East Cheshire NHS Trust

• Oxleas NHS Trust

• NHS Bristol

• North Somerset CCG

• ABM University health Board

• Betsi Cadwaladr UHB

NHS

Lanarkshire

NHS Tayside

NHS Fife

East Cheshire

NHS Trust

Oxleas NHS

Trust

NHS Bristol

North

Somerset

CCG

Betsi

Cadwaladr

UHB

ABM

University

Health Board

NHS Lanarkshire

• Practice List size: 588,572

• GP Practices: 114

• Acute Hospitals: 3

• CHD prevalence: 4.6%

• AF register: 1.4%

The NHS Lanarkshire Experience

• The project aimed to improve the care delivered in primary care for people

with a diagnosis of atrial fibrillation (AF). A key focus of the project was to

identify the stroke risk and to support safe and effective prescribing of

anti-coagulation.

• 97 practices in the area in 2012, 59 completed the project.

• Over 8,000 people on the AF register which represented 1.4% of the patient

list. After 12 months the prevalence in the participating practices was 1.67%

ISD Scotland 2014.

Management of AF in Primary Care

patient

BHF

Secondary care

NHS Lanarkshire

CHD MCN

Primary care

Atrial Fibrillation project

Rationale:

To Improve the quality of care for patients with AF Across NHS Lanarkshire through audit and education

Sign up

install software

Audit review

Education session

Clinic coaching session

Review of Audit at 6mths and 12 months

Primary care timeline

1. CHA2DS2 VASc> 1: currently not on anticoagulant

2. CHA2DS2 VASc=1: male only: not on anticoagulant

3. CHA2DS2 VASc=0: on either antiplatelet or

anticoagulant

4. All those on both antiplatelet and anticoagulant

5. AF resolved status

Focused “lists”

Stokes from AF predicted this year

• Focus Group, Education and Audit- GRASP AF

• The project saw a relative stroke reduction of 14% of

those currently diagnosed with AF, which meant 13

strokes saved in first year.

• The latest available QOF data indicates that the

prevalence of AF increased during the project.

• GPs and practice nurses reported that they were more

actively case finding for AF and that pulse checks

became an integral part of a patient’s assessment.

The NHS Lanarkshire Experience

• Hearte AF module; based on the project

education

• Primary care guideline

• Patient self-management tool

• Primary Care staff survey demonstrated :

Increased understanding and awareness

of AF in primary care- especially around

stroke risk and case finding

Project Legacies

• For an undiagnosed patient?

• When you have a patient with AF?

• For a patient who isn't managing their AF?

• What are your challenges and barriers?

What does your service look like?

Management goals

Atrial Fibrillation

Exclude/treat underlying cause

Reduce thromboembolic risk

Prevent circulatory instability

rate/rhythm control

What does your service look like?

• What problem that you’ve identified can

you solve?

• What have you heard today that you want

to try?

What are your ideas for change?


Change concepts

• Evidence; scientific results

• Critical thinking or observation of current system

• Creative thinking

• Hunches

• Mental leaps...extrapolating from other situations

Selecting changes

• Copy: use the literature, experience of others, hunches and theories

• Be strategic: set priorities based on the aim, known problems, and feasibility

• Avoid technical slow-downs

• Avoid low impact changes

Langley, G.J., Nolan, K.M., Nolan, T.W, Norman, C.L., & Provost, L.P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd Ed.). San Francisco: Jossey-Bass.

Complete List of Change Concepts Eliminate Waste

1. Eliminate things that are not used

2. Eliminate multiple entry

3. Reduce or eliminate overkill

4. Reduce controls on the system

5. Recycle or reuse

6. Use substitution

7. Reduce classifications

8. Remove intermediaries

9. Match the amount to the need

10. Use Sampling

11. Change targets or set points

Improve Work Flow 12. Synchronize

13. Schedule into multiple processes

14. Minimize handoffs

15. Move steps in the process close together

16. Find and remove bottlenecks

17. Us automation

18. Smooth workflow

19. Do tasks in parallel

20. Consider people as in the same system

21. Use multiple processing units

22. Adjust to peak demand

Optimize Inventory 23 Match inventory to predicted demand

24 Use pull systems

25 Reduce choice of features

26 Reduce multiple brands of same item

Change the Work Environment

27. Give people access to information

28. Use Proper Measurements

29. Take Care of basics

30. Reduce de-motivating aspects of pay system

31. Conduct training

32. Implement cross-training

33. Invest more resources in improvement

34. Focus on core process and purpose

35. Share risks

36. Emphasize natural and logical consequences

37. Develop alliances/cooperative relationships

Enhance the Producer/customer relationship

38. Listen to customers

39. Coach customer to use product/service

40. Focus on the outcome to a customer

41. Use a coordinator

42. Reach agreement on expectations

43. Outsource for “Free”

44. Optimize level of inspection

45. Work with suppliers

Manage Time

46. Reduce setup or startup time

47. Set up timing to use discounts

48. Optimize maintenance

49. Extend specialist’s time

50. Reduce wait time

Manage Variation 51. Standardization (Create a Formal Process)

52. Stop tampering

53. Develop operation definitions

54. Improve predictions

55. Develop contingency plans

56. Sort product into grades

57. Desensitize

58. Exploit variation

Design Systems to avoid mistakes 59. Use reminders

60. Use differentiation

61. Use constraints

62. Use affordances

Focus on the product or service

63. Mass customize

64. Offer product/service anytime

65. Offer product/service anyplace

66. Emphasize intangibles

67. Influence or take advantage of fashion trends

68. Reduce the number of components

69. Disguise defects or problems

70. Differentiate product using quality dimensions

Added for 2nd Edition 71. Change the order of process steps

72. Manage Uncertainty, Not Tasks

Langley, G.J., Nolan, K.M., Nolan, T.W, Norman, C.L., & Provost, L.P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd Ed.). San Francisco: Jossey-Bass.

• What problem that you’ve identified can

you solve?

• What have you heard today that you want

to try?


Prioritise!

What is your

‘golden’ idea?

Where is the best

focus for your

effort?

• Keep it easy, practical

• Reduction in AF patients on aspirin only

• Increase in AF patients receiving

appropriate treatment

How would you know if you made a difference?

Measurement plan What will I

measure?

What is the

data source?

Who will

collect it?

Who needs to

look at it?

When will we

review?

Some time to plan!

• What is achievable quickly and what takes

more time to prepare?

• Who do I need to involve?

Just get started….

What are you going to do?

Planning worksheet What can I

do...

...by Monday? …in 30 days? …in 60 days? …in 90 days?

What is

achievable in a

short time

frame?

What needs

work to get

going?

Who do I need

to involve?

BHF resources

Available to order or download at bhf.org.uk/publications

https://www.bhf.org.uk/publications.aspx

Heart Helpline

We're here to help you, whether you're calling about yourself or

someone you care about.

Our cardiac nurses and heart health advisors are on hand to help you

answer any questions or concerns you have about heart health and

heart conditions.

Benefits for members

• A valued connection with the BHF

• Annual learning and development allowance

• Access to learning and development information

• Access to a bespoke online discussion forum

• Access to Alliance regional and national events

• Access to BHF resources

• Your BHF e-newsletters

• Free subscription to the Heart Matters Membership and magazine

Sign up: bhf.org.uk/alliance

Join the BHF Alliance

Heart Matters

Our free service offers support and information for people looking to improve their heart health.

As a member you'll benefit from:

a welcome pack

access to our online community

free email support

a dedicated Helpline

regular issues of Heart Matters magazine

access to a members' area

Stay in touch!

Let us know what you do and how it goes.

Contact for more info and support:

Helen O’Kelly

Health Service Engagement Lead for South East

[email protected]

Here are the links to our resources:

https://www.bhf.org.uk/healthcare-professionals/best-practice

and the Stroke Association How can we do better?





















Summary, next steps &

close

Peter Carpenter

af collaborative event - surrey - pages - kss ahsn ... · in 2015/16 68,093 new af cases ... these...

Documents