Quality Improvement in Atrial Fibrillation detection after ischaemic stroke (QUIT-AF)

Abstract

Background Paroxysmal atrial fibrillation (PAF) is a frequent cause of recurrent stroke but can be difficult to detect because of its episodic and often asymptomatic nature. We sought to improve rate of PAF detection through a quality improvement project (QIP) to deliver early prolonged inpatient cardiac monitoring on the stroke unit (SU). Methods A structured protocol for cardiac monitoring using 5-day event recorders was established. 'In-house' cardiac monitoring was implemented. Performance data on this change in service was analysed prospectively and summary statistics obtained. Results One-hundred and two ischaemic stroke (IS) patients undertook 5-day event recorder monitoring. Provision of monitors as an inpatient (IP) increased from 20% (pre-QIP pilot 2018) to 65.7% (during QIP). New AF was detected in 15 patients (14.7% vs 8.6% pre-QIP pilot 2018) with majority of new AF (13 patients; 19%) detected when monitors applied early (IP) after IS. Conclusion Although this study had a number of limitations, it did demonstrate that early and prolonged non-invasive IP cardiac monitoring could be delivered 'in-house' on the SU and improve AF detection rates.

Improving detection and management of atrial fibrillation after ischaemic stroke in Glasgow (IMPROVE-AF): A quality improvement project

“…In patients with new AF detected, the provision of 'inhouse' monitoring significantly reduced the time of stroke/TIA onset to oral anticoagulant commencement from 41 (Phase 1) to 14 days (Phase 2) (Figure 5), p < 0.01 compared to Phase 1. Of the 17 new cases in Phase 2, the majority (10) were detected between days 0 and 2 after stroke/TIA (Figure 6).…”

“…In addition, our AF detection rate is also comparable to a smaller sized QIP, 'Quality Improvement in Atrial Fibrillation Detection after Ischaemic Stroke' study which reported AF detection rate of 14.7%. 10 A higher rate of AF detection was demonstrated with more prolonged cardiac monitoring post-stroke, for example, 'The 30-Day Cardiac Event Monitor Belt for Recording Atrial Fibrillation after a Cerebral Ischemic Event (EMBRACE)' trial found AF in 16% of people in the prolonged cardiac monitoring group. 8 There were 413 patients with stroke/TIA who passed through the acute stroke unit QEUH, with 59% of patients undergoing cardiac monitoring in Phase 1.…”

“…[7][8][9] Recurrent stroke risk is highest in the first 30 days after stroke (12%) and as high as 8% in the first week. 10 The yield from AF monitoring is also greatest early suggesting the need for early investigation for the presence of AF. 11 Many clinical services, including our own struggle to deliver this and one of our key service development goals is to address this.…”

Quality Improvement

“…Bravata 2 Kamal 31 Levi 32 Sui 33 Chiu 34 Klingner 35 Hill 36 Droegemueller 37 Pines 38 Wharton 39 Kishore 40 Hospital engagement…”

“…37,38 Implementation of a pediatric stroke protocol over 7 years improved the use of magnetic resonance imaging (68%–78%) and increased National Institutes of Health Stroke Scale documentation (42%–82%). 39 Kishore et al 40 used an educational intervention (didactic session and hands on practice with simulation) to improve the detection of atrial fibrillation in 112 patients with stroke by ensuring delivery of early cardiac monitoring (20%–66%).…”