Reducing Stroke Admissions Across Sunderland
The Sunderland West and Sunderland East Federations (both part of Sunderland CCG) asked us to support their key objective of stroke reduction for patients with atrial fibrillation (AF).
The AF lead, Dr Fadi Khalil, Sunderland CCG Executive GP from the Broadway Medical Practice, along with the CCG medicines optimisation team, made the decision that there was a need to improve anticoagulation levels in primary care for patients diagnosed with AF based on AF NICE (CG180) guidelines and required both an audit and clinical support solution to deliver this.
We provided support through “Enhance Stroke Prevention in AF” an audit service, developed by Oberoi Consulting and funded by a medical education grant from Bayer HealthCare.
This service supported the identification of high risk AF patients who may benefit anticoagulation.
In addition, we recruited a team of local heart rhythm specialist nurses who followed up on the audit results from Enhance SPAF. The nurses provided practical “hands on” support – patient reviews, education and mentorship – to all participating practices.
Clinical staff from each practice were debriefed on next actions following the audit Clinical mentorship from the specialist nurses ensured implementation and long terms embedding of the NICE guidance.
Outcomes
Sunderland East
- 25 patients added to the AF QOF register
- AF prevalence increased to a level 0.53% higher than the England average.
- 15% reduction in patients with a CHADS2>1 or CHA2DS2Vasc >=2 on an anti-platelet.
- 16% reduction in exception coding of AF patients
- 10% (75) additional high risk patients with Atrial Fibrillation and Atrial Flutter were anti-coagulated.
9 out of 10 practices completed the review with a total of 345 patients notes reviewed.
Sunderland West
- 44 patients added to the AF QOF register
- AF prevalence increased to a level 0.28% higher than the England average.
- 25% reduction in patients with a CHADS2>1 or CHA2DS2Vasc >=2 on an anti-platelet.
- 8% reduction in exception coding of AF patients
- 8% (78) additional high risk patients with Atrial Fibrillation and Atrial Flutter patients were anti-coagulated.
13 out of 15 practices completed the review with a total of 331 patients notes reviewed.
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