No abstract

Background Atrial fibrillation (AF) is the most common arrhythmias managed by emergency physician. In 2005, a chapter setting out best practice for arrhythmia care and sudden cardiac death (SCD) was added to the National Service Framework for Coronary Heart Disease. This highlighted the need for early diagnosis and expert patient support. Methods A nurse led arrhythmia service was set up in 2011. The aim of this service was to develop and improve care pathways, avoid hospital admissions and reduce the length of stay (LOS) as well as providing continuity and support for patients diagnosed with an arrhythmia. Malignant ventricular arrhythmias were excluded. The nurses also managed a caseload of cardio version patients, undertaking pre and post procedure clinics, patient assessment and titration of anticoagulation therapy prior to performing the direct current cardio version (DCCV) itself. The service received referrals for the monitoring of anti-arrhythmic drugs and family screening for SCD. All patients are assessed by the nurse in the emergency room(ER). Depending on the severity of symptoms, the patient would either be discharged home or admitted. All patients would be seen within 24–48 hrs of being discharged. We also compared admission rates and LOS before and after the establishment of the service. All treatment regimes were as per the standardised AF management pathways. Results A total of 1169 patients were seen in arrhythmia service from 2011–2013.Eighty seven percent (1020 patients) were referred from the ER (Table 1). The most common referrals were for atrial fibrillation (77%), atrial Flutter (12%) and palpitations (10%). Thirty three percent of patients with acute AF were discharged from ER on the same day (n = 343). Of those who required admission (n = 677), 36% were discharged within the first 48 h (n = 246). The average LOS for AF was significantly improved compared to the pre Arrhythmia service era (2.6vs 7.3 days). The majority of patients with acute presentation were considered for a rate control strategy and one third of patients were referred for DCCV (n = 249). Majority of patients were discharged back to GP after treatment optimisation (87%), the rest were referred to cardiologist for further management (40% were referred for consideration of radiofrequency ablation, n = 93). There were no reported deaths or major adverse cardiac events (MACE) and the readmission rate was 1%. Abstract 12 Table 1 Referrals from acute area Referrals for DCCV Referrals for monitoring of AADs Referrals for screening of SCD Total = 1169 1020 315 (66 referrals from Out-patient clinic) 56 27 Conclusion The presence of an integrated Arrhythmia Service in the Emergency Room reduces hospital admissions as well as improving access and delivery of patient care. Nurse-led rapid access clinics provides close monitoring of the patients in an ambulatory setting resulting in less admissions and shorter LOS. A pre and post procedure clinics have led to freeing up valuable clinician’s time.

No abstract

Background Stress echocardiography (SE) is a versatile and safe imaging modality used in the evaluation of coronary artery disease. The sensitivity of stress echocardiography for detection of significant coronary disease ranges from 80–90%. The risk of serious adverse events is extremely low with no reported deaths.1 A change in NICE recommendations2 led to a large increase in demand for stress echocardiography. Despite this, SE is still an underutilised modality, due to limited resource and operator availability.3 Contrast echocardiography improves the image quality and diagnostic yield for assessing left ventricular systolic function. It require intravenous administration of the contrast and it can be time consuming, requiring a medical doctor to insert cannula and administer the contrast. Method After the implementation of NICE guidelines (CG95) in 2010, we observed a 40% rise in requests for stress testing. A specialist nurse-led imaging service was introduced in April 2013. The imaging nurse was initially trained to perform the exercise stress echocardiography. After 3 months of further training with direct supervision of an imaging consultant (27 sessions), the nurse was able to perform Dobutamine stress echocardiography (DSE) with indirect supervision (total of 22 sessions). All referrals were screened, and suitability for nurse-led DSE was assessed by a consultant cardiologist. The imaging nurse was also trained to deliver contrast echocardiography; bubble echocardiography and myocardial perfusion scan. We present the data from 1st April to 1st November 2013. All the tests performed by the nurse were reported by a consultant. Results With the introduction of an imaging nurse specialist, we are able to perform 410 imaging tests which would have otherwise been delivered by a consultant or registrar (Table 1). Abstract 137 Table 1 DSE Contrast Echo Exercise stress test Bubble Echo MIBI Total Number 148 235 42 6 30 Adverse eventsAllergic reactionArrhythmiaDeath 0000 2200 1010 0000 0000 Consultant/registrar sessions freed up 22 47 9 1 6 Conclusion Introduction of a cardiac imaging nurse specialist is a safe and cost effective way of expanding the imaging service in a district general hospital. It helps with the freeing up of valuable consultants’ and registrars’ time for reporting images.