ANP to ANP ambulatory referral pathway for new onset atrial fibrillation: retrospective audit of the first one hundred patients through service

Background

An Advanced Nurse Practitioner (ANP) led Arrhythmia clinic was established in 2024 in our university teaching hospital, to provide expedited care to ambulatory patients with newly diagnosed Atrial Fibrillation (AF). The aims of this clinic include increasing patient access, delivering improved patient outcomes and providing timely evidence based, patient centred care. This pathway begins with undifferentiated patients at the door of the Emergency Department (ED) being diagnosed with AF by the ED ANP cardiology service, who then provide guideline based acute care, discharge (if appropriate) and fast track patients to Arrhythmia ANP service.

Aim

To investigate how successful the ANP to ANP new onset AF pathway and ANP Arrhythmia Clinic is at achieving:

1. Improved access to care/diagnostics.

2. Improving patient outcomes.

3. Delivering timely evidence based care.

Method

An audit of the first 100 patients through the pathway was undertaken. A dataset is maintained with data pulled from various electronic health records. Waiting time to ECHO, holter and to first assessment by ANP Arrhythmia were recorded and analysed.

To investigate the area of improved patient outcomes, re-presentations to the ED from time of diagnosis was reviewed for this group of patients using electronic patient records.

ESC key prescribed quality indicators (QI) were audited for 50 out of the first 100 patients through the pathway and who received face to face ANP Arrhythmia review in clinic. These included CHA2DS2-VA, HASBLED (primary QI's) and EHRA classification (secondary QI)(2).

Results

Waiting time to ANP Arrhythmia review from time of referral averaged 8 weeks. Consultant EP review: urgent 3-6 months, routine 15 months.

Echocardiogram: 88/100 (88%) were completed pre ANP Arrhythmia Review. Routine waiting time to ECHO: approx. 1 year outside of pathway.

Holter monitor: 90/100 (90%) were completed pre ANP Arrhythmia Review. Routine waiting time to Holter approx. 1 year outside of pathway.

Re-presentation to ED for cardiac reasons once diagnosed with AF: Of the 100 patients through pathway only 5/100 (5%) re-presented to ED for cardiac reasons. ESC guidelines 2020 highlight the annual hospitalisation/re-presentation rates for cardiac reasons once diagnosed with AF at 10-40% annually (1).

-Number of patients assessed for CHA2DS2-VA, EHRA and HASBLED: 50/50 (100%).

Conclusion

As a result of the ANP to ANP referral pathway for new onset AF and review in the ANP Arrhythmia clinic a number of clear outcomes are being achieved. Patients are being seen earlier with efficient access to appropriate diagnostics before review. This allows for earlier appropriate intervention and treatment plan. The number of re-presentations to the ED department for this cohort of patients is well below what the ESC describe as the norm.

Recommendations

Re-audit of pathway on a yearly basis.