A new nurse-led pathway to deliver better patient outcomes post-stroke | Nursing Times

Introduction

Stroke is a leading cause of death and disability in the UK, responsible for approximately 38,000 deaths each year (National Institute for Health and Care Excellence (NICE), 2023), and its burden on individuals, families and the NHS will only increase as the population ages with co-morbidities (NICE, 2019). One in four stroke survivors will experience another stroke (secondary stroke) within five years (NICE, 2019). Based on 1.3 million stroke survivors in the UK alone, this is a staggering 325,000 people who have been, or will be, affected by a stroke yet again (Public Health Scotland, 2023; Department of Health Northern Ireland, 2021). This has led to an increase in the number of stroke-related readmissions to hospitals across the UK (King et al, 2020). This article will explore how nurse practitioners transformed the stroke arrhythmia pathway by improving the remote cardiac monitoring process and creating a nurse-led stroke service.

Remote monitoring devices for stroke patients

Of the more than one million stroke survivors living in the UK, a disproportionate number are living with atrial fibrillation (AF) (Stroke Association, no date). People with AF have a risk of stroke that is around five times higher than those without the condition (Stroke Association, no date). It is now well known that AF-related strokes are often more severe, with higher mortality and greater disability rates than strokes with other causes (Stroke Association, no date). Additionally, effective anticoagulation therapy can decrease the rate of stroke by at least two-thirds in people with AF, this is of course only possible in cases where AF has been identified (Lowres et al, 2019).

Remote patient cardiac monitoring and programming, which are available with some insertable cardiac monitoring systems, allow healthcare teams to remotely monitor patients and remotely reprogram devices, capturing medical data from patients without needing to arrange an in-clinic visit, and transmitting this data electronically to consultants for clinical assessment. Remote patient monitoring technology can identify several cardiac conditions, including AF, by regularly monitoring cardiac changes such as heart rhythm and heart rate. This helped consultants at University College Hospitals NHS Foundation Trust (UCLH) to reduce emergency hospital visits for stroke patients, lessening the pressure on its healthcare systems.

Insertable loop recorders or insertable cardiac monitors (ICMs) – also known as implantable cardiac monitors – are chosen for patients who are suspected to be suffering from arrhythmias or have had a cryptogenic stroke (stroke of an unknown source), including transient ischaemic attack (TIA). The use of long-term cardiac monitoring to support the detection of AF in cryptogenic stroke and TIA patients is now also recommended by both NICE and the European Stroke Association (NICE, 2020; Rubiera et al, 2022; National Clinical Guideline for Stroke for the United Kingdom and Ireland, 2023).

Consequently, ICMs with remote monitoring and programming can help to improve the quality of life for patients recovering from a stroke, while reducing the risk of secondary stroke and minimising unnecessary healthcare costs for the NHS (National Clinical Guideline for Stroke for the United Kingdom and Ireland, 2023).

Piloting a new stroke arrhythmia pathway

Myself, an advanced stroke nurse practitioner at UCLH, and my colleague, nurse practitioner Roberto Macarimban-Inglesant, helped to pioneer a new stroke arrhythmia pathway and referral system at UCLH, to reduce the referral logistics surrounding patient care within the Barts Health NHS Trust local cardiac tertiary centre.

The focus of our pilot was on “door to detection”, and whether it was completed in a timely and efficient way. On a personal level for both of us, it is rewarding to be able to carry out the procedure of ICM insertion in a timely way so our patients can feel reassured that their heart rhythm is being constantly monitored to pick up any potential signs of what the problem may be.

Aside from pioneering the new stroke-led service, we were also the first trained stroke nurses surrounding the implantation of these miniature devices across UK. The ICM insertion can be performed by two or three nurse practitioners (NPs); one NP competent in ICM procedure performs the procedure, and one or sometimes two NPs assist with set-up, programming and documentation. This has transformed the stroke treatment process at UCLH, while still using Barts’ multidisciplinary team capacity, and so ensuring no compromise to cardiac care of the stroke patients.

When we first piloted the new stroke arrhythmia pathway at UCLH, there were no other hospitals or trained stroke nurse practitioners across the UK using this method. This presented some initial structural challenges when determining the number of staff needed to carry out the procedure or the finding of a prespecified room. However, we were greatly supported by Barts’ team who had a more established specialist cardiac care team. Barts invited the UCLH nurse practitioners to observe their existing ICM insertion model and pathway, allowing us to learn more about the process and replicate a lot of their tried and tested practices.

Data-led decision making

Once the new stroke arrhythmia pathway became more established, myself and Roberto Macarimban-Inglesant, alongside other nurse practitioners, decided to evolve it further. We developed a specialist suspected AF referral process that standardised how the AF patient group was referred to the stroke services. This allowed us to better quantify its data and develop metrics that paved the way for a more efficient stroke arrhythmia care pathway.

We began with a weekly multidisciplinary team triage for discussion of patient referrals. Suitable candidates for ICMs were then referred to a face-to-face pre-assessment appointment. It was this face-to-face appointment that differed from Barts’ pathway. At Barts, consultants referred suitable AF patients, offering an appointment after the screening, and then saw the patients face to face on the day of their cardiac monitoring insertion. Due to the infancy of our pilot study, patients were given an in-person consultation and were able to choose either the Barts care pathway or the UCLH pilot pathway option.

Multidisciplinary support and patient review

When our 14-month pilot at UCLH first began in March 2021, it was widely supported by multidisciplinary teams including cardiology and neurology consultants. From the beginning, we found it reassuring to have stroke consultants present, should they need to step in during the cardiac monitoring insertion. Several nurses had never completed a small surgical procedure independently. As a result, to begin with there were consultants present at every procedure, overseeing the insertion of the cardiac monitoring device.

An important metric of the pilot study was the stroke patient experience. UCLH wanted to collect as much evidence as possible, via pre- and post-cardiac monitoring insertion questionnaires. The stroke patient was seen in the clinic for a pre-assessment consultant review, with an assessment questionnaire before having their procedure. This review was supported by a team from the medical device company who were also on hand to support UCLH with other aspects relating to the cardiac monitoring system and its workflow.

We kept patients for an additional 30 minutes post-insertion, to monitor for signs of any complications, including bleeding, swelling, or pain at the insertion site, before discharging the patients. We also offered patients a choice of another face-to-face consultation or telephone review four to five days post-insertion for a wound review. We gave patients our direct contact details, for which patients were encouraged to call if they had any concerns, reinforcing the new patient-centric pathway model.

Exceeding the expected results

Initially, when we began our UCLH pilot study, our consultant team was asked to refer any suitable candidates. In total, we inserted ICMs in 20 candidates successfully within the pilot period, and detected AF in six patients. The pilot study resulted in an AF detection rate of 30% within the first six months of remote cardiac monitoring, and an average time from pre-assessment to cardiac monitoring insertion at UCLH of 73 days, compared to the previous one year at Barts. This greatly exceeded our expectations and meant that more cases of AF were detected in stroke patients using ICMs than via the standard 12-lead electrocardiogram (ECG) or other short-term devices, such as the Holter monitor. This meant that consultants could treat the necessary patients with anticoagulants, reducing their risk of secondary stroke and hospital readmission. The pilot study proved a clear success and several patients emphasised that, because of the ICM, they felt reassured by being constantly monitored, and were able to return to normal.

The reduction in ICM insertion waiting times and positive patient feedback contributed to the continuation of the service, allowing us to evolve the service past the pilot phase. The recent focus has been on upskilling existing and new stroke advanced nurse practitioners, increasing the team’s capacity and expanding the skill set. At the time of writing (April 2024), a total of 121 patients have been implanted with the ICM device under this care pathway. AF has been detected in 24 of those patients implanted, all of whom were started on anticoagulation medication the same day or the next working day.

Several healthcare decision-makers are now working with UCLH to provide additional resources, having recognised that long-term cardiac monitoring can more effectively detect AF than 12-lead ECGs and other short-term devices, and consequently reduce the risk of secondary strokes.

Myself, Roberto, and the rest of the UCLH stroke team are working continually to improve AF patient detection, referral, and review duration, while increasing the number of nurses trained to insert cardiac monitoring devices. The development of our pilot at UCLH has demonstrated the invaluable role that nurse practitioners hold in stroke patient care. Their willingness to improve treatment and to expand their surgical skills to support ICM insertion has freed up vital resources across UCLH; allowing consultants to focus on patients who require more complex procedures. This has improved many lives and continues to reduce costs across UCLH.

Conclusion

The introduction of a care pathway pilot at UCLH allowed stroke nurse practitioners to undertake advanced skills enabling them to monitor AF in stroke patients by inserting implantable cardiac monitoring devices. The development of this new nurse-led care pathway has offered post-stroke patients greater reassurance about constant health monitoring plus faster access to anticoagulation therapy, and has also freed up vital resources across UCLH.

• Declaration: The pilot was supported by an educational grant from Medtronic.